Every finding on record at Goldwater Care Clinton

Based on observation, interview, and record review the facility failed to supervise/monitor three residents (R7,R8,R9) with exit seeking behaviors and failed establish a care plan and initiate interventions for elopement to prevent a cognitively impaired resident from exiting the facility unnoticed. These failures resulted in R7 leaving the facility without staff supervision or knowledge for an undetermined period on the night of 7/5/26. R7 was found by staff at approximately 2:50AM on 7/6/26 lying in the parking lot a few feet from a deep drainage ditch. R7 sustained a sprained ankle with swelling, bruising, and pain. R7 was at risk for serious injury and/or death due to low visibility at night, the proximity of a deep drainage ditch and R7's lack of safety awareness and cognitive impairment. Findings include: The Immediate Jeopardy began on 7/5/26 when R7 left the building unsupervised. (V1), Administrator was notified of the Immediate Jeopardy on 8/13/26 at 3:55PM. The surveyor confirmed by observation, interview and record review the immediacy was removed on 8/13/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and evaluate the measures taken to ensure resident exit alarms are audible on all four wings of the facility.#1. R7's Care Plan dated 7/31/26 includes the following diagnoses: Crohn's Disease, Macular Degeneration, Dementia with Moderate Agitation, Delirium, Insomnia, Muscle Wasting and Atrophy. This care plan includes a problem potential for falls initiated 12/26/25. The care plan includes an intervention dated 6/4/26 stating Sign to be placed on resident walker to remind her to take walker with her when ambulating. There is nothing included in the care plan until 7/7/26 to address R7's history of wandering/exit seeking.On 8/19/26 at 10:53AM V2, Director of Nursing verified there was no care plan or interventions initiated for elopement for R7 until 7/7/26.R7's Minimum Data Set (MDS) dated [DATE] documents R7 is severely cognitively impaired. This MDS documents R7 not exhibiting wandering behavior.R7's (Electronic Monitoring Device) Log for March 2026 documents an electronic monitoring device was placed on R7's ankle on 3/18/26.An elopement assessment was provided by the facility dated 3/18/26 stating (R7) is at risk for elopement at this time. (Electronic Monitoring Device) being placed on (R7). Care plan updated.On 8/19/26 at 10:53AM V2, Director of Nursing stated her expectation is an elopement assessment should be done at least quarterly and at the time of any incident and verified a care plan should have been initiated 3/18/26 and was not.There is no documentation prior to 7/5/26 to indicate R7 was exit seeking.R7's Progress Note dated 7/6/26 at 3:56 AM documents (R7) required frequent redirection throughout the night due to wandering behaviors. (V38, Licensed Practical Nurse) (LPN) instructed staff to perform routine safety checks. During a safety check, the aide discovered the resident was not in her room and immediately notified (V38). Elopement protocol was initiated. (R7) was not located inside the building, and staff searched the exterior grounds where the resident was found lying on the ground. Upon assessment, (R7) had a visibly swollen left ankle and stated she had hit head during the incident. Active ROM (range of Motion) was present in the upper extremities but absent in the lower extremities due to injury. (R7) answered 2 out of 3 orientation questions appropriately. Paramedics were notified at 0250 and arrived to assess the resident. The resident departed with EMS (Emergency Medical Services) at 0300 for further evaluation. POA (Power of Attorney) has been notified, awaiting return call from Manager on call.On 8/12/26 at 10:03AM V38, LPN stated she was not aware how long R7 had been out of the facility, but they found R7 at around 2:30AM lying on the ground outside in the west parking lot close to the fire hydrant. V38 stated (R7) reported (R7) had fallen and hit (R7's) head and (R7) had a swollen discolored right ankle so was sent to the local Emergency Department. (V38) stated (R7) had been exit seeking the entire shift and staff had been redirecting (R7), but the staff didn't document checking her frequently and (V38) could not recall the last time any staff had laid eyes on (R7).On 8/12/26 at 4:10PM V37, Certified Nurse's Aide (CNA) (Agency) stated she was the only CNA assigned to the 31 residents on 400 hall 10:00PM to 6:00AM on the night of 7/5/26. V37 stated It was the night they had fireworks. People were coming back from the fireworks between 9:00PM and 10:00PM. I think (R7) left out the front door during that time. Honestly, I was so busy I hadn't seen (R7) since early in the evening. You can't hear the alarms back on 400 Hall. The staff on 100 Hall can hear the alarms and see they are alarming. V25, Licensed Practical Nurse (LPN) was on 100 Hall that night with V40, Certified Nurse's Aide (CNA) (Agency). I found (R7) missing when I did a bed check at about 2:30AM. When I went to 100 hall to ask for help l saw (V40) sitting at 100 Hall nurse's station with a blanket over her head. (V40) did not get up to help us search.On 8/12/26 at 11:11AM V25, LPN verified he was the nurse on 100 Hall with V40 on 7/5/26. V25 also verified he and V40 monitored the alarms and he had not heard a electric alarm or a door alarm except when people were coming back from the fireworks between 9:00PM and 10:00 PM. V25 also stated V39, Certified Nurse's Aide (CNA) was the one who discovered R7 lying in the parking lot on the west side of the building. On 8/19/26 at 10:53AM V2 Director of Nursing verified Staff working 100 hall on 7/5/26 had the primary responsibility of monitoring the personal electronic monitors and the door alarms and alerting appropriate staff.On 8/12/26 at 10:34AM V39 stated I found (R7) at around 2:45AM lying on the concrete parking lot with a trail of sheets and towels around her. (R7) had a (electronic monitoring device) on her right ankle and her ankle was swollen and turning purple. (R7) was talking to someone we couldn't see. (R7) said 'I was taking the dog out. The man pushed me down and I hit my head when I fell.' (R7) had on pants and a top and her nonslip socks but no shoes. (R7) was between the fire hydrant and the big deep ditch out there. V39 verified (R7) was lying where vehicles could drive over her and if (R7) got to the big deep ditch (R7) would have been injured and very difficult to locate. V39 also stated (R7) did not take her walker. It was in her room.On 8/13/26 at 2:30PM surveyors walked from 400 hall through the front door approximately 800 feet to where (R7) was found on 7/6/26. Along the way R7 had to walk, surveyors observed landscaping [NAME] rocks, bushes, trees, uneven pavement with grass and weeds in cracks, several curbs approximately six inches high. The large drainage ditch near where (R7) was laying was full of dense, thick tall weeds approximately six feet tall. The ditch was a shear drop off from the parking lot of approximately 20 feetOn 8/12/26 at 8:30AM R7 was observed in her room sitting on the side of her bed. R7 was eating breakfast. R7's weight on 7/3/26 is documented as 71.6 pounds. R7 is noted to be less than 5 feet tall. R7 is notably hard of hearing without hearing aids and stated (R7) has bad eyes. R7 stated I want this thing off my ankle. I don't like it. Do you have a pair of scissors? R7 pointed at the electronic device on her ankle. R7 does not recall getting lost outside but stated I think it must have been a long time ago. R7 is anxious and fretful and stated They just leave me in this room, and I want out of here. I think my son doesn't know where I am. They just walk by in the hall, and I sit here and cry. R7 had tears in her eyes as R7 spoke.On 8/12/26 at 11:00AM R7 was observed by the ice cream parlor common area in the front of the building being redirected by staff back to 400 Hall. On 8/13/26 at 9:48am, V42 and V43, Certified Nursing Assistants, (CNA), stated call lights and door alarms produce an audible sound and are displayed on the computer screen behind the nurse's station. V42 and V43 both stated the alarms cannot be heard when staff are down the hallway and away from the nurse's station.On 8/13/26 at 9:56am, V12, LPN and V44, CNA stated staff cannot hear door alarms from any location except the 100 hall. V12 and V44 stated the front door alarms do not alert on the computer screen located on the 400 hall.On 8/13/26 at 10:10am, V2, Director of Nursing, DON and V45, [NAME] President of Operations, were present and activated the front door and electronic monitoring device alarms. Surveyors and V25, LPN, were standing down in the hallway near rooms [ROOM NUMBER] when the alarms were activated. Surveyor and V25 were unable to hear the alarms from this location.On 8/13/26 at 10:30am, V2 and V45 confirmed that the front door alarms cannot be heard by staff when staff are down the hallways and away from the nurse's station.The facility's Code Pink/Missing Resident/Elopement policy revised 11/15/18 states All personnel are responsible for reporting a cognitively impaired resident attempting to leave the premises, orsuspected of missing, to the Charge Nurse as soon as practical. This includes any resident that did notsign out on pass and/or did not notify a staff member of his or her leaving. This policy also states Should an employee discover that a resident is missing from the facility, he or she should:a) Immediately report the missing resident to the Charge Nurse or Nursing Supervisorb) Review the Physician Order to determine if the resident is out on an authorized leave or pass.c) Alert staff by announcing Code Pink over the paging system.d) Inform staff of the name of the missing resident and visualize picture of resident if available.e) Make a thorough search of the building and the premises.f) Notify Administrator and Director of Nursing immediately if resident is not found after thesearch.g) The Administrator and Director of Nursing will evaluate the situation and develop a plan ofaction based on the individual resident.The following steps should occur:1. A nurse should notify the attending physician.2. Notify the resident's legal representative/ responsible party. Determine if friends or family know where the resident may be attempting to go. Contact any individuals who may be helpful in locating resident's possibledestination.3. Notify the sheriff and/or police department and file a missing person report.4. Provide search teams with resident identification information.5. Increase search by a more extensive search of surrounding area (several city blocks).Include areas where residents have a history of spending his or her free time, etc. (etcetera).6. Remain in contact with hospitals, nursing facilities, family members, etc.7. Complete incident report and notify the state agency according to reporting guidelines.8. Document appropriate notations in the medical record.9. Contact morgue if the resident has not been located for 24 hours.The facility's Elopement Device policy updated 9/13/19 states:Purpose: To establish procedures for ensuring personal elopement devices are used in accordance with identified risk, physician orders and to ensure the security system is inspected to identify malfunctions should they occur.Equipment: Battery operated transmitted bracelets Battery operated transmitter anklet Transmitter TesterElectronic Security System Exit Door Key PadsResponsibility: All Facility StaffPolicy: It is the policy of this facility to use elopement alert systems and devices when an assessment has identified the risk of elopement.Procedure:Elopement alert devices will be used as an interventional tool to prevent resident elopements.At the time of application, the expiration date of the battery on the personal device will be documented on a facility-approved form that is kept at the front desk in a binder. Social services will maintain this form.The elopement alert exit door device will be inspected for proper working daily by maintenance and manager on duty:Pushing the numerical code on the exit keypad and waiting for the door to openClosing the door and waiting for the light to indicate the door is secured.The inspection and status of the test will be recorded on a facility-approved log located at the front desk. Maintenance staff and manager on duty will be responsible for maintaining this log.In the event testing reveals a malfunctioning in the exit door security system, maintenance personnel will be notified and a staff member placed at the door to prevent unauthorized exits.The (Electronic Monitoring Device) sensors located at the elevators and front door will be checked daily by maintenance and manager on duty and recorded in the log located at the front desk.a. If any issues with the (Electronic Monitoring Device) systems' functionality or sensitivity occur, maintenance will be notified and a staff member placed at the door to prevent unauthorized exits until issue is corrected.The anklet or bracelet device will be inspected by nursing personnel once each day by:Inspecting the location of the device on the arm or leg.Placing the transmitter tester near the anklet or bracelet to test the battery for proper working order.The functionality of the device on resident arm or leg will be checked daily by social services and manager on duty.In the event the test reveals a malfunctioning personal elopement device, the device will be removed and replaced.The Immediate Jeopardy that began on 7/6/26 was removed on 8/13/26 when the facility took the following actions to remove the immediacy:1. On 7/6/26 the V55, Maintenance Director conducted an audit of all exit doors to ensure alarms and the exit departure device alarm systems were functioning properly. V56, Activity Director/designee will conduct daily audits of all exit doors to ensure alarms and the exit departure device alarm systems are functioning properly.2. On 7/8/26 V2, DON conducted a facility wide assessment of all residents was completed to ensure electronic departure device orders, placement, and care planned interventions are appropriate and added to the resident's care plan.3. On 7/8/26 an audit was completed by the V5, Social Service Director to ensure residents with behaviors of wandering/exit seeking have behavioral interventions that accurately reflect current behaviors, identified triggers, individualized interventions, supervision requirements, and appropriate safety measures. Care plans were compared to behavioral documentation, psychiatric recommendations, incident reports, if any, and physician orders to verify accuracy.4. On 7/6/26 V2 Director of Nursing/Designee, V1 Administrator and Social Service Consultant trained all staff on the facility policy Elopement Device, including but not limited to established procedures for ensuring personal elopement devices are used in accordance with identified risk, physician orders and to ensure the security system is inspected to identify malfunctions should they occur. Staff members who are on FMLA (Family Medical Leave of Absence) or vacation and all agency staff will be in-serviced prior to returning to the facility by V2 Director of Nursing/Designee or V1 Administrator. Started on 7/6/2026 and ongoing.5. On 8/13/26 all staff were in-serviced on the facility's Code Pink policy by V2 Director of Nursing/Designee, V1 Administrator and V57 Social Service Consultant including but not limited to all personnel are responsible for reporting a cognitively impaired resident attempting to leave the premises or suspected of missing. Should an employee observe a cognitively impaired resident leaving the premises or attempting to exit the premises should: attempt to prevent the departure without the use of force, obtain assistance from other staff members, notify attending physician of the attempt to leave the facility, contact legal representative/responsibility party and inform him/her of the incident, make appropriate notations in the resident's medical record, complete a new Elopement Risk Assessment, update the plan of care with appropriate interventions, and review and update the Elopement Risk binder as appropriate. Should an employee discover that a resident is missing from the facility he or she should immediately report the missing resident to the Nursing Supervisor and the Administrator, alert staff by announcing a Code Pink over the paging system, inform staff of the name of the missing resident and visualize picture of resident if available, make a thorough search of the building and the premises, notify the Administrator and Director of Nursing immediately if resident is not found after the search, the Administrator and the Director of Nursing will evaluate the situation and develop a plan of action based on the individual resident. Upon return to the facility the Director of Nursing or Charge Nurse should examine the resident for injuries, contact the attending physician and report findings, notify the legal guardian/responsible party, complete the incident report indicating when resident returned and condition of resident, review policy appropriate entries into the resident's medical record, complete a New Elopement Risk Assessment and update plan of care as appropriate, and review and update Elopement Risk binder. Staff members who are on FMLA or vacation and all agency staff will be in-serviced prior to returning to the facility by V2 Director of Nursing/Designee or V1 Administrator.6. On 7/6/26 all Nursing Staff and the Interdisciplinary team were in-serviced on the facility's Behavioral Health Services Policy by V2 Director of Nursing/Designee, V1 Administrator and the V57 Social Service Consultant. Staff members who are on FMLA or vacation and all agency staff will be trained prior to returning to the facility by V2 Director of Nursing/Designee or V1 Administrator or Social Service Consultant. Started on 7/6/2026 and ongoing.7. On 7/6/26 all licensed and certified nursing staff were educated on the facility's Incident/Accident Policy by V2 Director of Nursing/Designee and V1 Administrator. Staff members who are on FMLA or vacation and all agency staff will be in-service prior to returning to the facility by V2 Director of Nursing/Designee or V1 Administrator. Started on 7/6/2026 and ongoing.8. On 7/6/26 all licensed nurses were educated on the facility's Documentation - Electronic Health Record policy by V2 Director of Nursing/Designee and V1 Administrator. Staff members who are on FMLA or vacation and all agency staff will be in-service prior to returning to the facility by V2 Director of Nursing/Designee or V1 Administrator. Started on 7/6/2026 and ongoing.9. On 7/6/26 all licensed and certified nursing staff were educated on the facility's Physician-Family Notification - Change in Condition policy by V2 Director of Nursing/Designee and V1 Administrator. Staff members who are on FMLA or vacation and all agency staff will be in-service prior to returning to the facility by V2 Director of Nursing/Designee or V1 Administrator. Started on 7/6/2026 and ongoing.10. On 7/6/26 all Interdisciplinary Team Members were educated on the facility's Comprehensive Care Plan policy. This will be on going.11. On 7/6/26 facility staff began working with the Electronic Monitoring Company to correct the following: Monitors at the nurse's station were updated on 8/13/26 to visualize all door alarms on every monitor and the door alarm was changed to police alarm sound on 8/13/26 which is different than the call light chime sound. The Company will install equipment to sound over the PA system to notify of all door alarms sounding and will continue to sound until the door alarm has been reset at the keypad.12. Quality Assurance (QA) meetings were held to discuss the deficiency and the facility action plan on 7/8/26 and 8/13/26.13. V56 Activity Director/designee will conduct audits five days per week for six weeks to ensure electronic departure devices are in place and operational. The Director of Nursing or Administrator will audit five staff members for six weeks to confirm training. A QA tool will be completed to verify this practice has occurred. The QA tool will be completed by the Infection Preventionist/Director of Nursing or designee daily for six weeks. Started 7/7/26 and ongoing.The facility presented an abatement plan to remove the immediacy on 8/14/26. The survey team was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions on 8/14/26, 8/17/26, and 8/18/26 and the survey team accepted the abatement plan on 8/19/26.#2. R8's current Diagnoses List includes the following diagnoses: Chronic Obstructive Pulmonary Disease, Cerebral Vascular Disease, Major Depression, Anxiety, and Heart Disease.R8's Minimum Data Set (MDS) dated [DATE] documents R8 is moderately cognitively impaired but does not exhibit wandering behaviors.R8's Care Plan dated 11/12/25 includes a problem initiated 11/12/25 and documents (R8) is an elopement risk/wanderer related to exit seeking behaviors. (R8) gets agitated when (R8) is unable to go out on (R8's) own and when (family) doesn't come take (R8) out for car rides which triggers (R8's) exit seeking behavior.R8's Progress Note dated 7/28/26 documents Informed by CNA that resident returned to facility last night without wonder guard.R8's Progress Note dated 7/30/26 at 6:59PM documents (electronic monitoring device) replaced to left ankle. There is no documentation to support a plan for increased monitoring was put in place from 7/28/26 until 7/30/26 when the monitoring device was replaced.On 8/18/26 at 3:00PM V1, Administrator verified the facility was out of electronic monitoring devices from 7/27/26 to 7/30/26 and no new interventions were implemented to ensure the safety of R8 until the device could be replaced.On 8/18/95 at 3:00PM V45, Corporate Consultant stated (the facility) should have put R8 on frequent visual checks and/or reached out to sister facilities to replace the monitoring device.On 8/19/26 at 9:00AM V53, Medical Doctor verified if R8 were to leave the facility unsupervised for any length of time it would put R8 at high risk for injury or death.#3. R9's care Plan dated 5/5/26 lists the following diagnoses: Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Osteoporosis, Alzheimer's Disease Late Onset, Type II Diabetes.R9's Elopement Risk assessment dated [DATE] documents Resident is at risk for elopement. (Electronic Monitoring Device) has been put in place on right ankle.R9's Minimum Data Set, dated [DATE] documents R9's Brief Interview of Mental Status (BIMS) was 3 which indicates R9 is severely cognitively impaired.R9's Care Plan dated 7/8/26 documents I am an elopement risk/wanderer related toHistory of attempts to leave facility unattended, Impaired safety awareness related to Alzheimer's Disease.R9's Progress Note dated 7/28/26 documents Was informed by CNA that resident returned to facility last night from home without (electronic monitoring device).R9's Progress note dated 7/30/26 documents (Electronic Monitoring Device) replaced to left ankle.On 8/18/26 at 3:00PM V1, Administrator verified the facility was out of electronic monitoring devices from 7/27/26 to 7/30/26 and no new interventions were implemented to ensure the safety of R9 until the device could be replaced.On 8/18/95 at 3:00PM V45, Corporate Consultant stated (the facility) should have put R9 on frequent visual checks and/or reached out to sister facilities to replace the monitoring device.On 8/19/26 at 9:00AM V53, Medical Doctor verified if R9 were to leave the facility unsupervised for any length of time it would put R9 at high risk for injury or death.

Based on observation, interview, and record review, the facility failed to administer pain medication in accordance with physician orders and failed to ensure transportation to two scheduled pain clinic appointments for two of six residents (R5 and R6) reviewed for medication administration from a sample of 13 residents. Findings include: 1.R6's Electronic Health Record (EHR) documents R6 has multiple diagnoses including Chronic Pain Syndrome 4/30/26 and Rheumatoid Arthritis 1/16/26. R6's Minimum Data Set (MDS) dated [DATE] documents R6 is cognitively intact. R6's EHR contains a physician order dated 4/13/2026 for Oxycodone-Acetaminophen (opioid pain reliever) oral tablet 5-325 milligrams (mg). Give one tablet by mouth every eight hours as needed for pain related to Chronic Pain Syndrome. R6's Order Summary Report documents R6 was readmitted from a local hospital on 6/29/2026 and the order was reinstated. R6's Care plan dated 7/31/2026 documents R6 has the potential for pain with interventions which include administer medications as ordered and notify the physician if pain medications are ineffective. R6's Medication Administration Record dated July 2026 documents the last dose of Oxycodone was given on 7/5/26. On 8/11/2026 at 1:29 PM, R6 rated R6's pain as an eight on a scale of zero to ten with zero being no pain and ten as the worst pain and described the pain as numbing to R6's back. R6 stated R6 had an order for Oxycodone; however, the facility had not had the medication in stock since the beginning of July 2026. R6 stated R6 had been receiving Tylenol (pain reliever) instead, but the Tylenol did not relieve R6's pain. R6 further stated that R6's last two pain clinic appointments in July 2026 had been cancelled because the facility did not have transportation available to take R6 to the appointments. On 8/11/2026 at 1:44 PM, V15, Licensed Practical Nurse (LPN), stated that R6 did not have any Oxycodone in the medication cart. V16, Nurse Practitioner (NP), stated the facility had run out of R6's Oxycodone. V16 further stated that R6 was requesting to change the medication to Hydrocodone (opioid pain reliever) but had missed R6's last two scheduled pain clinic appointments because the facility did not have transportation available. V16 stated V16 left two messages with the pain clinic regarding R6. One on 7/20/26 and one on 7/21/26 and neither call was returned. V16 stated V16 ordered Ibuprofen 600 mg every eight hours as needed for pain for three days on 7/11/26 and on 7/20/26 another order for Ibuprofen 600 mg every eight hours as needed for seven days. R6's Medication Administration Record documents R6 received four doses. On 8/12/2026 at 9:17 AM, when asked whether staff offered R6 non-pharmacological pain interventions, R6 stated, Like a hot pad? No. When asked about menthol topical analgesic, R6 stated that R6 had an order for menthol topical analgesic but staff never offered to apply it. On 8/12/2026 at 1:24 PM, V2, Director of Nursing and Director of Clinical Operations, stated that V2 was not aware R6 had missed R6's pain clinic appointments or was out of R6's pain medication. V2 stated that staff should have contacted V35, Physician, for further orders. On 8/13/2026 at 8:50 AM, R6 stated that when R6 is in pain, R6 becomes nauseated, feels out of R6's body, and just feels weird. R6 stated that being in pain makes R6 feel very sad and angry. On 8/13/2026 at 10:42 AM, V31, Certified Nursing Assistant (CNA), stated that V31 schedules residents' appointments. V31 stated R6's pain clinic appointment scheduled for 7/8/2026 was cancelled because the air conditioner was not working on the facility bus and R6's 7/30/2026 appointment was cancelled because the brakes needed to be repaired on the facility van. V31 verified that the facility had one bus and one van and stated that the van was primarily used for supportive living because it did not have a wheelchair ramp. R6's pain clinic records document on 5/18/2026, R6 was referred to the pain clinic by V16, NP, due to bilateral knee osteoarthritis and low back pain. The pain clinic note dated 6/10/2026 documents that R6 reported bilateral shoulder pain and pain all over. R6 reported that Hydrocodone 7.5/325 mg provided better relief than the Oxycodone 5/325 mg R6 was taking and described R6's pain as bad. The provider documented conservative treatment measures, including heat/ice, back bracing, acupuncture, weight management, and cognitive behavioral therapy as needed. The provider further documented that Hydrocodone 7.5/325 mg, one tablet by mouth four times daily as needed for moderate pain, may be considered after urine drug screening results were obtained. A follow-up appointment was scheduled for 7/8/2026 at 7:45 AM to complete the opiate process. R6's pain observation dated 6/29/2026 at 6:23 PM completed by V15 LPN documents diagnoses of Chronic Pain Syndrome and Rheumatoid Arthritis. The observation documents that R6 was alert and able to answer the pain interview questions. R6 reported that pain occurred frequently, frequently affected R6's sleep, and frequently interfered with R6's day-to-day activities. R6 reported the intensity of pain as moderate. 2. R5's Electronic Health Record (EHR) documents diagnosis including Chronic Pain Syndrome and a Wedge Compression Fracture of T9-T10 Vertebra. R5's Minimum Data Set (MDS) dated [DATE] documents R5 is cognitively intact. R5's MDS dated [DATE] documents R5 has frequent pain that frequently affects sleep and frequently interferes with day to day activities. This MDS documents that R5 rated pain over the last five days as six on a scale of zero to ten with zero being no pain and ten as the worst pain one can imagine. R5's EHR contains a physician's order dated 12/12/25 that documents R5 is contracted with the pain clinic for pain management related to chronic back pain. R5's EHR contains a physician's order dated 6/17/26 for Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams (mg). Give 1 tablet by mouth every six hours as needed for severe pain with a pain assessment every shift initiated on 7/11/26. R5's EHR contains a physician's order dated 6/17/26 for Buprenorphine Transdermal Patch weekly 10 micrograms (mcg) per hour, apply one patch trans dermally at bedtime every seven day(s) for severe pain. R5's Care Plan dated 1/27/26 documents R5 receives pain medication therapy with an intervention to administer analgesic medications as ordered by the physician, monitor and document the effectiveness and side effects of analgesic medications each shift. R5's Care Plan dated 6/12/26 documents R5 has chronic pain with an intervention to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. R5's Care Plan dated 6/12/26 documents R5 has Activities of Daily Living self-care performance deficit with a varying level of assistance needed related to chronic pain syndrome with decreased mobility. R5's EHR contains a progress note dated 7/16/26 that documents R5 reports ongoing pain despite current pain medications; R5 has been wanting to increase dosage but was informed that pain medications are managed by the pain clinic. On 8/11/26 at 11:17 a.m., R5 was observed lying in bed on R5's right side. R5 stated at approximately 9:20 a.m., R5 asked V8, Certified Nursing Assistant (CNA), to notify the nurse that R5 needed pain medication. R5 stated at that time, R5 did not receive a response or hear anything further regarding the request. R5 rated the pain level as 9 on a scale of 0 to 10, with 10 being the worst pain, and described the pain as fluctuating in R5's upper left leg/thigh and hip. R5 was observed grabbing and rubbing the area. On 8/11/26 at 11:43 a.m., V6, Registered Nurse (RN), stated R5 had no pain medication available because R5's Norco should have been ordered the previous day but had not been ordered. V6, RN, stated V6 was not aware that a provider at the pain clinic was managing R5's care and was preparing to contact R5's physician to obtain an order for administration. On 8/11/26 at 1:36 p.m., V8, CNA, stated R5 requested pain medication that morning sometime after breakfast, approximately between 9:00 and 9:30 a.m. V8, CNA, stated V6, RN, was notified immediately of R5's request. R5's August Medication Administration Record (MAR) documents V6, RN administered Hydrocodone-Acetaminophen at 12:07 p.m. on 8/11/26 with the last documented dose at 11:31 p.m. on 8/10/26. On 8/12/26 at 11:38 a.m., V33, Licensed Practical Nurse (LPN) stated R5 receives pain medication, hydrocodone, around the clock and also has a pain patch, which is applied by the night shift. V33 stated there were times when the facility ran out of R5's medication because it was not reordered. On 8/13/2026 at 11:33 a.m., V12, LPN, stated R5 had recently run out of prescribed pain medication due to possible communication or coordination issues between the facility and Pain Clinic. On 8/13/2026 at 11:59 a.m., V2, Interim Director of Nursing (DON) stated there was a process issue involving getting orders for R5's pain medication from the pain clinic. V2 stated nursing staff should have assessed R5 and administered prescribed PRN medication when due and at the request of R5. V2 also stated that staff should follow the emergency medication process when medication is unavailable. V2 added an order to R5's MAR to offer pain medication every six hours per physician's order. The facility's Pain Management Program, dated 11/28/12 and revised 7/6/18, was reviewed. The policy establishes a pain management program intended to effectively manage pain, reduce the adverse effects of unrelieved pain, and develop individualized pain management plans to promote resident comfort, dignity, independence, healing, and overall wellness. The policy directs staff to use the resident's description of the quality, duration, and location of pain to evaluate pain and identify changes. When a resident is unable to describe pain, staff are to assess for physical and behavioral indicators, including grimacing, protective body positioning, changes in vital signs, behavior, and mood.

Based on interview and record review the facility failed to ensure medications were administered as ordered to the correct resident for one of one resident (R3) reviewed for significant medication errors in the sample list of 23. This failure resulted in R3's blood pressure dropping to 60/30, feeling ill and being sent to the emergency room for evaluation and cardiac monitoring. Findings include: R3's Care Plan dated 3/17/2026 documents R3 diagnoses including Coronary Artery Bypass Grafts, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus and Congestive Heart Failure. This Care Plan further documents an admission date of 09/24/2025.R3's Care Plan dated 11/26/2025 documents R3 is at risk for seizures. This Care plan documents an intervention to administer medication and monitor for side effects of medication as ordered.R3's Incident Report dated 7/7/2026 documents an Incident Description: Nurse reported that they (V37) administered this resident (R3) their roommate's (R24's) 0800 medication. Medications (were) Amiodarone (potent antiarrhythmic) 200 milligram (mg) and Duloxetine (antidepressant) 60 mg.R3's Incident Report dated 7/7/2026 documents a Root Cause: Nurse did not utilize the correct resident identifiers when conducting medication administration. Nurse asked (R3) if (R3) was R24 (R3's roommate) in which the resident (R3) responded yes. (R3) is confused to place, time and person.R3's Electronic Medical Record dated 7/7/2024 documents Emergency Triage Assessment reason for visit From (the facility). Brought for vomiting and diarrhea. Nursing staff states that the patient possibly received wrong medication this am. (R3) states that (R3) has had vomiting and diarrhea since about 10:00 am. Multiple Emesis and Diarrhea x 4. (R3) States did have stomach cramps, but that has resolved. Is alert, oriented, skin warm and dry, color good. States they gave me two blue capsules, I don't take those normally. (R3) Is on 4 Lpm (liters per minute of oxygen) NC (nasal canula) chronically.R3's hospital Emergency Department note dated 7/7/2026 documents a History of Present Illness (HPI) (R3) brought in from the local nursing home by EMS after patient was inadvertently given medications meant for another patient by nursing home staff. Wrong medications given were Amiodarone and Fluoxetine. (R3) vomited after (R3) was given the pills and was brought to ED (Emergency Department). Only pertinent complaint the (R3) has is that (R3) feels drowsy. No chest pain or shortness of breath. No abdominal pain or diarrhea. No complaint of headache.R3's Nurses Note dated 7/72026 documents Note from hospital: The medications that were given to the resident inadvertently were not in toxic amounts. Resident may feel drowsy/sleepy today. The effects are expected to completely wear off by tomorrow. Follow-up with your regular doctor in (one) to (three) days time for continued care.R3's Acute Care Note dated 7/7/2026 documents Patient (Pt) incidentally ingested medications (Amiodarone 200mg, Duloxetine 60mg cap) and vomited x 2. Pt's BP was 60/30 but eventually bounced back to 125/60. Pt felt weak and nauseous, intravenous (IV) access established, sent to emergency room (ER) for eval and management. (R3) returned to the facility, still feeling weak but vital signs (VS) (were) stable. Electrocardiogram (EKG) was normal sinus rhythm. Pt denies any chest pain or shortness of breath. On baseline oxygen at 3-4 liters per minute (LPM) nasal cannula.On 7/13/2026 at 3:52 p.m., V37 Licensed Practical Nurse (LPN) confirmed V37 gave R3 another resident's (R24's) medication. V37 stated V37 asked R3 if R3 was R24 Previous Roommate and R3 answered yes and then V37 administered R24's medications to R3. V37 stated V37 realized later on, that the medicines given to R3 were supposed to be for R24. V37 stated V37 should have asked R3 to state R3's name instead of asking R3 if R3 was R24. V37 confirmed R3 became sick soon after ingesting the wrong medicines and R3 was sent to the hospital for further evaluation per V40 Nurse Practitioner's order.On 7/14/2026 at 1:55 p.m., V40 Nurse Practitioner (NP) confirmed V40 was notified by V23 LPN about R3 receiving another resident's (R24's) medications. V40 stated V40 preferred for the nurse to have the residents state their names rather than asking the resident if they were such name. V40 stated for someone who was not taking Amiodarone it will definitely kick the person. V40 stated R3's blood pressure (BP) went down to 60/30 at the time of the incident, although the BP went up to stable reading, V40 stated R3 continued to complaint of feeling sick and V40 was concerned about possible irregular heartbeat that could be caused by the Amiodarone, V40 gave the order to send R3 to the hospital for further evaluation.On 7/14/2026 at 10:35 a.m. V3 Assistant Director of Nursing (ADON) stated they expect the nurses to practice five rights for medication administration. V3 stated they would prefer the nurses to have the resident state their name when identifying the right resident.On 7/14/2026 at 11:19 a.m., V2 Director of Nursing (DON) stated they expect the nurses to practice five rights of medication administration. V2 stated V37 LPN should have asked R3 to state R3's name rather than asking R3 if R3 was R24.The Facility's Policy for Medication Administration General Guidelines dated (undated) documents medication are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. This Policy further documents FIVE rights- Right resident, right drug, right dose, right route and right time, are applied for each medication administration. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration: 1. When the medication is selected, 2. When the dose is removed from the container, and finally 3. Just after the dose is prepared and the medication put away. This policy also documents a procedure for documentation of medication administration: 1. The individual who administers the medication dose records the administration on the resident's Medication Administration Record (MAR) directly after the medicine is given. At the end of each medication pass, the person administering the medication reviewed the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.

Based on observation, interview, and record review the facility failed to administer medications as ordered and failed to ensure accurate documentation of controlled medication administration for three of seven residents (R3, R5, R7) reviewed for pharmacy services in the sample list of 23. 1. R7's admission Record documents an admission date of 07/31/2025 with diagnoses including Chronic Pain Syndrome, Generalized Anxiety Disorder, Essential Primary Hypertension, Major Depressive Disorder (Recurrent, Moderate), and Urinary Retention. R7's MDS (minimum data set) with an Assessment Reference Date (ARD) of 05/29/2026, documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R7 is cognitively intact. On 7/13/2026 at 10:38 AM, R7 stated that on 7/4/2026 an unknown nurse was working the evening shift. R7 stated the nurse entered the room to administer medications, and R7 noticed that some medications were missing. R7 stated they brought this to the nurse's attention, and the nurse stated they would check for the medications but did not return. On 7/14/2026 at 12:45 PM, V1 (Administrator) confirmed that the nurse on duty from 6 PM–10 PM on 7/4/2026 was V60 (Agency LPN), and from 10 PM–6 AM was V46 (Agency LPN). On 7/14/2026 at 3:39 PM, V46 stated that on 7/4/2026 was the first shift they worked at the facility, arriving at 10:00 PM. V46 stated V46 received login credentials for the facility's Electronic Health Care Record (EHCR) at approximately 10:30 PM. V46 stated that upon logging into the EHCR, V46 observed that none of the residents on their assigned hall had received their 8:00 PM medications. V46 stated they attempted to administer as many medications as possible but did not wake sleeping residents to give scheduled medications. V46 stated that at 12:00 AM, any remaining medications were marked as sleeping because they felt the medications were too late to administer. V46 stated they entered the charting code seven (7) in the EHCR for any resident considered sleeping. V46 stated they could not recall why R7 received only some of the ordered medications. V46 further stated they would not be surprised if more than half the residents on their assigned hall did not receive their scheduled medications that night. V46 stated they did not request assistance from another nurse or contact a manager for guidance. On 7/15/2026 and 7/16/2026, attempts to contact V60 were unsuccessful. R7's Medication Administration Record (MAR), printed on 7/14/2026, documented the following medications marked as seven (7) (resident sleeping) on 7/4/2026: Thiamine HCl Oral Tablet 100 mg – 1 tablet by mouth at bedtime Buspirone HCl Oral Tablet 5 mg – 5 mg by mouth two times a day Labetalol HCl Oral Tablet 200 mg – 1 tablet by mouth every morning and at bedtime 2. On 7/14/2026 at 10:27 AM, V22 Licensed Practical Nurse (LPN) was reconciling controlled medications. R7's controlled medication count sheet for Hydroco/APAP Tab (Hydrocodone/Acetaminophen-opioid pain reliever) 5-325 mg, give 1 tablet by mouth every 6 hours, was marked as last given on 7/14/2026 at 5:00 AM by V47 LPN. V22 stated controlled medications must be signed on the resident's Controlled Substance Proof of Use sheet and also documented in the resident's Electronic Health Care Record (EHCR). V22 stated that for R7, the dose signed out on 7/14/2026 at 5:00 AM was not charted as administered in the EHCR. V22 stated the last documented administration was on 7/13/2026 at 11:00 AM by V22, confirming no entry for 7/14/2026 at 5:00 AM. 3. On 7/14/2026 at 1:04 PM, V34 LPN presented narcotic log sheets for R3 and R5. V34 stated R5 was administered Tramadol 50 mg, two tablets, on 7/12/2026 at 8:00 AM. V34 confirmed the signature was theirs. Review of R5's electronic Medication Administration Record (EMAR) showed no documentation that the Tramadol dose was administered. V34 stated, I know I should document (on the electronic record), but I get busy and don't chart it as often as I should. 4. On 7/14/2026 at 1:04 PM, V34 LPN presented narcotic log sheets for R3 and R5. V34 further confirmed that R3's Oxycodone HCl(hydrochloride) (opioid analgesic) 5 mg tablet was signed out as administered on 6/29/2026 at 12:15 AM, but the medication was not documented as administered in R3's EHCR. V34 stated they were unable to identify the signature on R3's controlled count sheet. On 7/14/2026 at 2:40 PM, V3 stated nursing staff are expected to sign the controlled medication count sheet and also document in the resident's EHCR when a controlled medication is administered. V3 also stated they were unable to decipher the signature on R3's controlled count sheet. Review of the staffing sheet for 6/29/2026 showed V45 LPN was the nurse on duty for R3. On 7/14/2026 at 2:29 PM, V45 LPN stated they did work the night of 6/29/2026 but could not recall which hall they were assigned. V45 stated that if a controlled medication is administered, staff are required to sign the controlled count log and document the medication administration in the resident's electronic health record. The Facility's Policy for Medication Administration General Guidelines dated (undated) documents medication are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. This Policy further documents FIVE rights- Right resident, right drug, right dose, right route and right time, are applied for each medication administration. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration: 1. When the medication is selected, 2. When the dose is removed from the container, and finally 3. Just after the dose is prepared and the medication put away. This policy also documents a procedure for documentation of medication administration: 1. The individual who administers the medication dose records the administration on the resident's Medication Administration Record (MAR) directly after the medicine is given. At the end of each medication pass, the person administering the medication reviewed the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.

Based on interview, and record review, the facility failed to ensure a resident's right to be free from physical abuse by failing to prevent a resident to resident altercation for two (R6 and R4) of four residents reviewed for abuse on the sample list of 15. Findings include:R4's Minimum Data Set, dated [DATE] documents R4's has Severe Cognitive Impairment.R6's care plan dated 6/11/26 states R6 has the potential to be physically aggressive related to Dementia and adjustment to the facility and an elopement risk/wanderer related to exit seeking, impaired safety awareness related to Dementia, R6 wanders aimlessly, adjustment to new environment.On 7/13/26 at 11:13 AM, V16 Certified Nursing Assistant (CNA) stated on 6/22/26 V16 heard R4 yelling for R6 to leave the bathroom. V16 stated R6 slapped R4's left cheek.On 7/13/26 at 11:30 AM, V15 Licensed Practical Nurse (LPN) stated on 6/22/26 V15 heard R4 screaming get out. When V15 arrived in the room, V16 was already separating R4 and R6.The facility's report to the state agency dated 6/22/26 documents V16 Certified Nurse's aide heard yelling coming from R4's bathroom and responded. This report documents V16 saw R6 inside of R4's bathroom and then seen R6 deliver an open hand slap to R4's left cheek. The facility's policy, Abuse Prevention and Reporting-(State), dated 10/24/22, This facility affirms the right of our residents to be free from abuse.

Based on observation, interview and record review the facility failed to implement fall interventions to prevent a fall for one resident (R12) and failed to adequately assess, monitor and evaluate residents post falls for three of three residents (R2, R12, R14) reviewed for falls in the sample list of 11. This failure resulted in R12 being sent to the hospital and receiving two sutures.Findings include: 1.On 6/23/26 at 11:40PM, R12 was near the dining area in R12's wheelchair. R12 reported R12 fell out of bed the other day and busted R12's head. R12 had to go to the hospital to get stitches. The nurse put a band-aid over the stitches. R12 stated R12's head hurts where the stiches are.R12's Fall note, dated 6/20/26 at 12:32PM, documents R12 fell on 6/20/26 at 9:20AM. R12 was bleeding on the left side of R12's head and was transferred to the local hospital.R12's Fall-Initial Occurrence Note, dated 6/20/26 at 1:01PM, documents R12 fell and had a laceration to R12's forehead requiring R12 to go to the local hospital and receive two sutures. An immediate intervention is not documented to help prevent further falls.R12's Emergency Department Note, with a date of service of 6/20/26, documents R12 had a laceration to R12's forehead after sustaining a fall from R12's bed. It also documents R12 had a Computed Tomography (CT) scan of the head with results indicating R12 had a soft tissue injury to the left forehead.R12's care plan, with an initiation date of 7/23/25, documents R12 is at risk for falls with interventions including but not limited to a scoop mattress and keeping pathway clutter free.R12's Minimum Data Set (MDS), date 4/1/26, documents she is moderately cognitively impaired.R12's Administration Record Report, dated June of 2026, does not document any orders to monitor R12's sutures.R12's Electronic Health Record did not document any post-fall monitoring after R12's fall on 6/20/26.R12's Neurochecks 72-Hr (hour) assessment, dated 6/20/26 at 9:35AM, does not document neurological assessments completed for five of the 4-hour checks and five of the 8-hour checks.On 6/23/26 at 11:43AM, R12's room had two fall mats on either side of the bed. There were towels on floor by foot of bed. R12 mattress was a regular mattress not a scoop mattress. There was a chair in the corner of room and was covered with various unfolded blankets.On 6/23/26 at 11:46AM, V27 (Assistant Director of Nursing) went to R12's room and confirmed R12 did not have a scoop mattress and confirmed there should be a scoop mattress on R12's bed.On 6/23/26 at 12:05PM, V4 (Wound Nurse) stated she had not yet looked at or reviewed R12's sutures or orders for her sutures. Sutures should be monitored daily by staff. V4 confirmed there was no order in R12 Electronic Health Record for the sutures to be monitored daily.On 6/23/26 at 1:20PM, V30 Certified Nursing Assistant (CNA), recalled R12's fall on 6/20/26. V30 stated that morning R12 wanted to have breakfast in bed. When breakfast was brought to R12, R12 decided R12 only wanted coffee. R12 was lying in bed and went to try to get R12's coffee and slipped and fell out of bed.On 6/23/26 at 1:28PM, V2 Regional Nurse/ Interim Director of Nursing stated staff should document a fall in Risk Management. They should get statements from staff present at the time of the fall, complete a fall risk assessment, complete neurological checks if a fall is unwitnessed or the resident hits their head, complete a skin assessment, and 72-hour follow-up charting should be completed every shift. Nurses should be documenting an immediate intervention to help prevent another fall. The interdisciplinary team will review the fall the next business day. Maintenance is part of the interdisciplinary team when it comes to falls. Fall interventions should be maintained at all times. If a resident has sutures, they should have an order to be monitored daily for any signs or symptoms for infection and to make sure they are clean, dry and intact. The staff nurses should put this order in for any resident who has sutures. Any nurse who is notified of a new skin condition of a resident should assess it, document it, and open a Risk Management for it. V2 reviewed R12's Electronic Health Record and confirmed that there is no order for monitoring R12's sutures, an immediate intervention was not documented after R12's fall on 6/20/26, R12's neurological checks were not completed, and R12's 72-hour post-fall monitoring was not completed. 2. On 5/24/26 at 8:30AM, R2's Nurses Note documents R2 was sent to the local hospital for assessment due to an unwitnessed fall. R2's Nurses Note dated 5/24/26 at 11:35AM, documents R2 returned from the local hospital and was negative for any fractures.R2's Risk Management for Unwitnessed Fall, dated 5/24/26 at 8:15AM, documents V22 Licensed Practical Nurse (LPN) was informed by the Certified Nursing Assistant (CNA) that they saw R2 on the floor face down on the mat and R2 was sent to the hospital. R2 had a bruise to R2's upper, center chest measuring 13 centimeters (cm) by 6 cm and was deep purple in color. It does not document any further assessment, predisposing factors, or intervention put into place to prevent another fall.R2's Neuro Checks- 72 HR (Hour) Assessment, with an effective date of 5/24/26 at 1:31PM, does not document R2's neurological assessments being started until 5/24/26 at 7:15PM (7 hours and 50 minutes after returning from the hospital). The initial and first three 15-minute assessments, four 30-minute assessments, first four-hour assessment, and last 8-hour assessment were not completed.R2's Administration Record Report, dated May of 2026, does not document any treatment or monitoring orders for bruises.R2's Administration Record Report, dated June of 2026, documents an order to monitor bruising to R2's upper chest and bilateral lower legs.R2's Progress Notes did not document post fall documentation on 5/25/26. It also did not document any skin assessments or injuries identified after the fall.On 6/23/26 at 8:26AM V22 LPN recalled R2's fall on 5/24/26. V22 reported that the CNA went to the room next to R2's and a few minutes later when the CNA came back to R2's room, R2 was face down on the floor mat next to R2's bed. V22 stated R2 hit R2's head and had some bleeding and bruising to R2's head. V22 assessed R2 and sent R2 to the hospital. V22 cannot recall V22's assessment of R2 after the fall. V22 said the documentation of V22's assessment can be found in the risk management.On 6/22/26 at 12:12PM, V5 CNA stated V5 was working at the time of R2's fall. V5 saw R2 lying on R2's right side on R2's floor mat by the bedside table. V5 went to get the nurse. The nurse checked R2 out. R2 had a little blood by R2's mouth and one of R2's arms that V5 wiped off with a washcloth. When R2 returned from the hospital, V5 did not see any bruising on R2. V5 went to work on a Friday after the fall (5/29/26) and that's when V5 saw the bruising on R2's chest.On 6/23/26 at 9:05AM V23 LPN stated when V23 worked on 5/25/26, V23 had no knowledge of R2's fall on 5/24/26.On 6/22/26 on 11:57AM V1 Administrator provided the Risk Management on R2's fall on 5/24/26. V1 confirmed there was no documentation that the interdisciplinary team reviewed the fall.On 6/23/26 at 1:28PM, V2 Regional Nurse/ Interim Director of Nursing stated staff should document a fall in Risk Management. V2 reviewed R2's electronic medical record and confirmed the risk management was not filled out correctly, the neurological checks were not fully completed, the appropriate assessments were not completed, a skin assessment wasn't completed and all of the 72-hour follow-up was not completed in entirety.3. R14's Fall-Initial Occurrence Note, dated 6/7/26, documents R14 had an unwitnessed fall in R14's bathroom. R14 reported R14 was going to the bathroom, but the floor was slick. No injuries were observed.R14's Care Plan, dated 6/1/26, documents R14 is at risk for falls. An intervention added on 6/7/26 to prevent falls for R14 was skid strips to be placed in front of the toilet.R14's Minimum Data Set, dated [DATE], documents R14 is moderately cognitively impaired.On 6/23/26 at 1:19 p.m., R14 was lying in R14's bed. R14 told writer to ask the staff about R14, because they know more about R14 than R14 does about R14's self. In R14's bathroom there were no skid strips on the floor in front of the toilet.On 6/23/2026 at 2:02PM, V21 LPN stated V21 was working on the day of R14's most recent fall. V21 stated that R14 transferred R14's self and independently went to the bathroom. V21 reported that R14's functional abilities vary from day to day; however, R14 typically calls for assistance when needed and did not do so on the day of the fall. V21 stated V21 was not aware whether skid strips had been installed on the bathroom floor following the incident.On 6/23/26 at 1:28PM, V2 Regional Nurse/ Interim Director of Nursing stated staff should document a fall in Risk Management. V2 stated V2 was unaware of the new intervention of skid strips needing to be put into place for R14 as V2 has been off of work, but maintenance is present at interdisciplinary meetings that occur after falls. V2 stated V2 will reach out to maintenance to ensure that the skid strips are put into place.The facility's Fall Prevention Program Policy, revised 11/21/17, documents a fall risk assessment will be completed after any fall incident, all nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained, and accident/incident reports will be reviewed by the interdisciplinary team.The facility's Neurological Assessment policy, revised 2/16/26, documents neurological assessments will be completed upon a physician's order, when indicated for a change of resident's condition, after all head injuries, and when nursing judgement deems necessary.The facility's Comprehensive care Plan policy, revised 11/17/17, documents the care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving.

Based on interview, and record review the facility failed to ensure that residents and/or their designated financial powers of attorney received individual quarterly resident fund statements, as well as fund statements or receipts upon request for four of four residents (R4, R16, R18, R20) reviewed for personal funds in the sample list of 11. Findings include:R20 reported R20 has twenty dollars in R20's account as R20 keeps R20's own written record of spending. R20 stated R20 does not receive monthly statements. R20 does have a financial Power of Attorney (POA). R16 reported R16 does not receive statements for R16's account. R18 reported R18 has sixty dollars in R18's account and does not get a statement from the facility. R4 stated R4 does not receive monthly or quarterly fund statements. R4, R16, and R18 do not have financial POA's documented.V16 Business Office Manager (BOM) reported that V16 sends resident fund statements to the resident's POA but does not distinguish between a Health Care POA and a Financial POA. V16 acknowledged that V16 does not provide statements directly to alert and oriented residents and had not previously considered doing so. V16 also stated that although V16 prints the quarterly statements, V16 does not keep any documentation or tracking to verify when statements were sent or to whom they were provided.The facility's Resident Funds Policy states that residents and/or their representatives must be provided with quarterly accounting of their personal funds held by the facility, as well as statements upon request. Policy also requires that resident statements reflect debits, credits, and current balances.Review of R4's fund account statement showed deposits from Social Security transferred to the facility for management. The record documented a $200 resident advance on 2/2/2026 and a remaining balance of $280 as of 6/3/2026. There was no documentation showing the statement had been provided to R4 or to an appropriate financial POA.There was no evidence in facility records demonstrating that quarterly fund statements or requested statements were provided to residents or properly designated financial POAs.

Based on observation, interview, and record review, the facility failed to exercise reasonable care in propelling a resident in a shower chair, causing a resident's foot to contact the wall. This failure affects one resident (R2) out of three reviewed for incidents on the sample list of five. Findings include: R2's Census Detail dated 6/4/26 documents R2 was admitted to the facility 12/5/25. R2's Medical Diagnoses list dated 6/3/26 includes Multiple Sclerosis, Major Recurrent Depression, and Polyneuropathy. R2's most recent completed Minimum Data Set, dated [DATE] documents R2 is cognitively intact, dependent upon staff for showers, and transfers into and out of the shower. On 6/3/26 at 11:05 AM, R2 was seated in a wheelchair, fully dressed in street clothing and loose fitting shoes. R2 was well groomed and odor-free. On 6/3/26 at 11:05 AM, R2 stated a Certified Nursing Assistant (CNA)(later identified as V4) had given her a shower and was propelling her out of the shower room on a shower chair. R2 stated the CNA had banged her foot on the wall on the way out of the shower room. R2 stated the CNA called for the nurse (V5) to come look at R2's toe. R2 stated V5 called the Nurse Practitioner (V10) to come look at R2's toe. R2 stated she did not feel anything at first because of her Multiple Sclerosis and Neuropathy, but with all of these people looking at her toe, she decided to look at her toe also. R2 stated she saw her toenail was off and began to feel sick and her toe started hurting. R2 stated she did request to go to the hospital to have the doctor look at her toe but the hospital sent her back to the facility with no concerns. R2 stated the CNA (V4) had been terminated due to the incident. V4 did not return a phone call with a message left requesting an interview. On 6/3/26 at 12:06 PM, V1, Administrator, stated V4 no longer worked at the facility because V4 had resigned. V1 confirmed the incident did occur as described by R2. On 6/3/26 at 1:14 PM, V5, Licensed Practical Nurse, stated the CNA (V4) came to get her to come look at R2's toe. V5 stated when she arrived to R2, the right big toenail was basically off but still partially connected. V5 stated she asked V10 to come look at R2's toe and V10 said it was ok to go ahead and remove the toenail the rest of the way, which V5 stated she did. V5 stated at first R2 said she wasn't having any pain, but then she looked at her toe and kind of freaked out. V5 stated that was when R2 started requesting to go to the hospital despite V5 and V10 telling R2 there was no medical necessity to go to the hospital. V5 stated V10 gave the order to have R2 sent to the emergency room for evaluation. V5 stated R2 was brought back to the facility in less than two hours with no new orders or concerns. The facility's Final Report dated 4/23/26 documents R2 reported the incident on 4/22/26 and the CNA (V4) was suspended at that time pending the outcome of the facility investigation.

Based on interview and record review the facility failed to administer physician ordered medications during the morning medication administration pass on 5/10/26, which resulted in significant medication errors for eight of twelve residents (R1, R2, R3, R4, R5, R6, R7, and R8) reviewed for medications on the sample list of 16. This failure resulted in R5, R6 and R7 to endure and sustain pain and discomfort for an extended amount of time due to not receiving physician ordered narcotic pain medications.Findings include: Findings include:1. R5's Minimum Data Set (MDS) dated [DATE] documents the following: R5's Brief Interview of Mental Status score of 15 out of a possible 15, indicating no cognitive impairment. R5's same MDS documents R5 has routine pain medications, frequent Pain, at a moderate level that occasionally interferes with her activities of daily. R5's Physician Order Sheet dated May 1-31, 2026, documents the following medications orders:Oxycod/APAP (Oxycodone/ Acetaminophen treatment for moderate to severe pain), TAB 5-325MG Give 1 tablet orally every 4 hours (routine) for pain related to Rheumatoid Arthritis Unspecified, Unilateral, Primary Osteoarthritis Left Hip, and Other Forms of Scoliosis, Site Unspecified. The associated Pain assessment scheduled at 8:00 am was not documented as completed.Benazepril HCl Oral Tablet 10 MG (Benazepril HCl), Give 10 mg by mouth one time a day related to Essential Hypertension.R5's Corresponding May 1-31, 2026, Medication Administration Record does not document nurses' initials in the blank boxes, to indicate the above medications were administered on May 10, 2026, during morning medication administration.On 5/22/26 at 10:20 am R5 stated I have a lot of pain every day. On Mother's day (5/10/26) it was extreme. I was hurting on that pain scale thing, 10 out of 10 because I did not get pain medication when it was scheduled. I did not get any of my morning medications. I needed Oxycodone, it is scheduled for breakfast. The other medications I take, I need them, but I was not overly concerned about that. Meds (medications) are late, frequently. I know I will get them when the nurse gets caught up. I needed my oxy (Oxycodone) and had asked the CNA (unidentified). There was no nurse down this hall. The other nurse was busy and never made it over here to give me my meds.R5's Controlled Substance Proof Of Use sheet dated 5/10/26 entry, documents R5 did not have R5's Oxycodone/APAP Tab 5-325 mg removed from the Narcotic supply until the 12:00 pm dose. This confirms there was no 8:00 am dose administered to R5.R5's Care Plan dated 4/19/26 documents the following: Potential for pain related to: osteoarthritis Will have any complaints of pain controlled to acceptable level. I am on pain medication, Date Initiated: 06/24/2025. Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness. 2. R1's Physician Order Sheet dated May 1-31, 2026, documents the following medications orders:Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML (units per milliliter) (Insulin Aspart), Inject 5 (five) units subcutaneously before meals related to Type II Diabetes Mellitus Without Complications.Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 200 - 250 = 3; 251 - 300 = 5; 301 - 350 = 8; 351 - 400 = 10; 401+ = 12u Notify MD (Physician) or NP (Nurse Practitioner) if Blood Sugar is <60 or >400, (less than 60, or greater than 400) subcutaneously before meals related to Type II Diabetes Mellitus Without Complications. No measurement of R1s's blood glucose was recorded on the corresponding Medication Administration Record to determine if the sliding scale insulin was needed 8:00 am on 5/10/26.R1's Blood Sugar Summary sheet documents R1's first blood sugar measurement on 5/10/26 was not completed until after lunch at 2:08 pm (instead of before meals as ordered) and measured 441 mg/dL (milligrams per deciliter). The corresponding Medication Administration record documents R1 received 12 units of insulin based on this measurement. R1's corresponding Progress Notes do not document R1's Physician or Nurse Practitioner were notified that R1's blood glucose measurement was greater than 400. Aspirin Oral Tablet Delayed Release 325 MG (Aspirin), Give 1 tablet by mouth one time a day related to Hemiplegia and Hemiparesis Following Cerebral Infarction, Affecting Left Non-Dominant Side. SIDE (I69.354); Essential Hypertension, Cerebral Infarction, Occlusion and Stenosis of Unspecified Cerebral Artery.Propranolol HCl ER Oral Capsule Extended Release 24 Hour 80 MG (Propranolol HCl), Give 80 mg by mouth one time a day related to Essential (primary) Hypertension.Glipizide Oral Tablet 10 MG (Glipizide), Give 1 tablet by mouth two times a day related to Type II Diabetes Mellitus Without Complications.R1's Corresponding May 1-31, 2026, Medication Administration Record does not document nurses' initials in the blank boxes, to indicate the above medications were administered on May 10, 2026, during morning medication administration.On 5/21/26 at 1:55 pm V12, R1's Family Member stated V12 had great concerns regarding R1's insulin medications not being administered on 5/10/26. V12 stated R1 not getting R1's medications was worrisome.On 5/22/26 at 11:45 am V13, Licensed Practical Nurse (LPN) stated I worked 400 hall on Mother's Day, and stayed over until 9:00 pm. There was no nurse on (working) 100 hall. I had 30 residents of my own (to care for on 400 hall). (V42, Humane Resource Director ) told me I needed to go pass the meds that I could on 100 hall. That was after 1:30 pm. One of the CNA's (Certified Nursing Assistants, unidentified) said (R1) was not feeling well. I did accu-checks (finger stick blood glucose measurement) and insulin for the residents on 100 hall since those are the most important. I took (R1's) accu-check and it was over 400. I gave sliding scale insulin to cover. I did not call the doctor like (as) the order says (directs) to do. We were so busy, I guess it slipped my mind.3. R2's Physician Order Sheet dated May 1-31, 2026, documents the following medications orders.Abilify (Antipsychotic) Oral Tablet 2 MG (Aripiprazole), Give 2 tablet by mouth one time a day related to Delirium Due To Known Physiological Condition.Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 150 - 199 = 2U; 200 - 249 = 4U; 250 - 299 = 6U; 300 - 349 = 8U; 350 - 399 = 10U Notify MD of BS 400<, subcutaneously with meals related to Type II Diabetes Mellitus Without Complications. No measurement of R2s's blood glucose was recorded on the corresponding Medication Administration Record to determine if the sliding scale insulin was needed the morning of 5/10/26.Prednisone Oral Tablet 5 MG (Prednisone), Give 5 mg by mouth two times a day related to Secondary Malignant Neoplasm of Bone.Bicalutamide Oral Tablet 50 MG (Bicalutamide), Give 50 mg by mouth one time a day for Antineoplastics and Adjunctive Therapies.Furosemide Oral Tablet 40 MG (Furosemide), Give 1 tablet by mouth two times a day for diuretic.Spironolactone Oral Tablet 25 MG (Spironolactone) Give 0.5 tablet by mouth one time a day for diuretics.Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG (Metoprolol Succinate), Give 50 mg by mouth one time a day for Hypertension.R2's Corresponding May 1-31, 2026, Medication Administration Record does not document a nurses' initials in the blank boxes, to indicate the above medications were administered on May 10, 2026, during morning medication administration.On 5/20/26 at 1:55 pm R2 stated He has bone cancer and is very weak. R2 stated It is always a bad deal getting my meds. Mother's Day was the worst. There was no nurse, and I did not get my insulin, in the morning. I was not as concerned about my other medications. I was really concerned about my insulin that morning. They didn't even do an Accu-Chek (finger stick glucose measurement check).4. R3's Physician Order Sheet dated May 1-31, 2026, documents the following medications orders:Imatinib Mesylate Oral Tablet 400 MG (Imatinib Mesylate), Give 1 tablet by mouth one time a day related to Chronic Myeloid Leukemia, BCR/ABL Positive, Not Having Achieved Remission.Insulin Lispro (1 Unit Dial) 100 UNIT/ML Solution pen-injector, Inject 5 unit subcutaneously before meals related to TYPE II Diabetes Mellitus With Diabetic Neuropathy, Unspecified.Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro), Inject as per sliding scale: if 150 - 199 = 2U; 200 - 249 = 4U; 250 - 299 = 6U; 300 - 349 = 8U; 350 - 399 = 10U Call MD IF BS (blood sugar/glucose) >400, subcutaneously before meals. Related to TYPE II Diabetes Mellitus with Diabetic Neuropathy, Unspecified. No measurement of R3's blood glucose was documented to determine the dosage of insulin that needed administered the morning of 5/10/26.Bumetanide (strong diuretic) 2 MG Tablet, Give 2 tablet by mouth one time a day related to Chronic Combined Systolic (Congestion) and Diastolic (Congestion) Heart Failure.R3's Corresponding May 1-31, 2026, Medication Administration Record fails to document nurses initials in the blank boxes, to indicate the above medications were administered on May 10, 2026 during morning medication administration.5. R4's Physician Order Sheet dated May 1-31, 2026, documents the following medications orders:Oxcarbazepine (seizure medication) Tablet 600 MG, Give 1 tablet orally one time a day related to Multiple Sclerosis, Unspecified, Polyneuropathy, Unspecified, Unspecified Convulsions.Pregabalin Cap 150 MG, Give 1 capsule orally one time a day for pain related to Multiple Sclerosis, Unspecified, Polyneuropathy. Lamotrigine Tab 25 MG, Give 2 tablets two times a day for seizures related to Unspecified Convulsions.Furosemide Oral Tablet 20 MG, Give 20 mg by mouth one time a day related to Acute Combined Systolic (Congestion) and Diastolic (Congestion) Heart Failure.R4's corresponding May 1-31, 2026, Medication Administration Record does not document a nurse's initials in the blank boxes, to indicate the above medications were administered on May 10, 2026, during morning medication administration.On 5/20/26 at 3:40 pm R4, Resident Council President stated I was very upset on Mother's Day. I am supposed to take pain, seizure and blood pressure medication. Those are important, so that I don't have a heart attack.6. R6's Minimum Data Set assessment dated [DATE] documents a BIMS (brief interview mental status) score of 13 indicating cognitively intact. R6's Physician Order Sheet dated May 1-31, 2026, documents the following medications orders:Norco (narcotic pain medication) Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for Pain - Moderate; Pain - Severe for 14 Days Pain rated 4-10 (on a scale of one to ten, ten being the worst pain).Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate), Give 1 tablet by mouth one time a day related to Unspecified Atrial Fibrillation.Torsemide Oral Tablet 20 MG, Give 2 tablet by mouth one time a day related to Essential (Primary) Hypertension, Pulmonary Hypertension, Unspecified, Systolic (Congestive) Heart Failure, Unspecified. R6's corresponding physician order documents Daily weight Notify MD/NP (Medical Doctor /Nurse Practitioner) if resident has a weight gain of 3lbs in a day or 5lbs in a week, every day shift for CHF (Congestive Heart Failure) Program inform NP of weight gain of 3lbs/day. R6's weight was not documented as measured on 5/10/26.Eslicarbazepine Acetate Oral Tablet 400 MG, Give 1 tablet by mouth one time a day related to Other Seizures.R6's Corresponding May 1-31, 2026, Medication Administration Record does not document nurses' initials in the blank boxes, to indicate the above medications were administered on May 10, 2026, during morning medication administration.On 5/22/26 at 10:30 am R6 stated she did not get her medications on Mother's Day and was concerned about seizure, blood pressure and pain medication. R6 then stated If staff did not want to come in and work, they should have requested off ahead of time, not called in sick on Mother's Day. We are Mothers we should not have to beg for a nurse to give us our meds. Especially if we need pain meds. At that time R6 grabbed her right thigh and stated I fractured this bone around St Patrick's day. I have so much pain in my leg, I can cry sometimes. On Mother's Day, I could not get my meds for anything. It was a horrible experience.R6's Care Plan dated 3/26/26 documents the following: I have a fracture. Date Initiated: 03/26/2026. Administer pain medications as ordered Provide medications for osteoporosis as ordered. Date Initiated: 03/26/20267. R7 Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview of Mental Status score as 14 out of a possible 15 indicating no cognitive impairment.R7's Physician Order Sheet dated May 1-31, 2026, documents the following medications orders:Tramadol HCL (narcotic medication used to treat moderate to severe pain) Tab 50MG, Give 1 tablet orally two times a day for pain related to Primary Osteoarthritis, Left Hand.Eliquis Oral Tablet (anticoagulant) 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day related to Chronic Atrial Fibrillation, Unspecified.Metoprolol Tartrate Tablet 50 MG, Give 50 mg by mouth two times a day related to Essential (Primary) Hypertension, hold for SBP (systolic blood pressure) less than 100 mmHg (millimeters of mercury), PR (pulse rate) of below 60bpm (heart rate /beats per minute). No correlating blood pressure or pulse measurements are recorded the morning of 5/10/26.Losartan Potassium Oral Tablet 50 MG (Losartan Potassium), Give 50 mg, by mouth one time a day related to Essential (Primary) Hypertension.R7's Corresponding May 1-31, 2026, Medication Administration Record does not document nurses initials in the blank boxes, to indicate the above medications were administered on May 10, 2026 during morning medication administration.On 5/20/26 at 3:30 pm R7, stated she missed the administration of medications and she hurt all over.R7 Care Plan dated 3/17/26 documents the following: I have osteoarthritis of the left hand. Date Initiated: 06/23/2025. Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness, Date Initiated: 06/23/2025. Administer medications as ordered, Date Initiated: 06/23/20258. R8's Physician Order Sheet dated May 1-31, 2026, documents the following medications orders:Aspirin 81 Oral Tablet Delayed Release, Give 1 tablet by mouth one time a day for antiplatelet related to Heart Failure Unspecified (and) Essential (Primary) Hypertension.Amlodipine Besylate Oral Tablet 5 MG, Give 1 tablet by mouth one time a day for HTN (Hypertension) related to Essential (Primary) Hypertension.Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG (Metoprolol Succinate), Give 1 tablet by mouth one time a day for HTN (Hypertension).Torsemide Oral Tablet 20 MG, Give 1 tablet by mouth one time a day for Edema related to Heart Failure Unspecified, and Essential (Primary) Hypertension. The correlating MAR for May 2026 documents: Daily weight every day shift related to HEART FAILURE, UNSPECIFIED. The 5/10/26 weight was not documented as completed.R8's Corresponding May 1-31, 2026, Medication Administration Record does not document nurses' initials in the blank boxes, to indicate the above medications were administered on May 10, 2026 during morning medication administration.On 5/27/26 at 10:05 am V30, Nurse Practitioner (NP) for V3, Medical Director (MD) stated Mother's Day I was off, (V3, MD) covers the weekend. On Monday, after Mother's Day, the Director of Nursing (V2) informed me that the residents didn't get the morning medication. She specifically said that there were some residents on the one hall hundred hall (R1-R8 reside on the 100 hall). Insulins, blood pressure medications, anticoagulants, and seizure medication in general, are all considered to be significant medication errors when not administered. These residents (that reside on 100 hall) were monitored closely, once the errors were identified. To my knowledge, there was no negative outcome.On 5/21/26 at 10:10 am V2, Interim Director of Nursing/Regional Nurse Consultant (DON) acknowledged the above significant medication errors were made on Mother's Day 5/10/26, when residents did not receive their insulins and the other significant medication.V2, DON also stated V30 Nurse Practitioner (V3, Medical Director's Co- Provider) was notified Monday 5/11/26 and two additional primary care providers (V36 and V41 Physicians) were also notified of the 100 hall medication errors. V2, Director of Nursing (DON) provided an Electronic (Email-mail), undated, and signed by V2, DON which documents the following: Good evening! In transparency, I wanted to let (V41, Physician) and (V36, Physician) know that we experienced an issue with nurse coverage on Sunday, May 10th for the 6a to 6p shift. At this time when nursing coverage was being obtained, specific residents missed their 8am medications. We did obtain coverage, however, the 8am medications were not able to be administered within the appropriate time frame. I am working on which specific residents and their medications that were not administered for the 8am medication pass. I will send over once completed tomorrow morning. I did not see physician notification in residents' charts as I am auditing. I apologize for the lack of communication. I just returned from vacation. It is a priority to complete the audit and provide the physicians with a full report on their patients. We are working diligently to improve the clinical department. Please let me know if you have any questions or issues. I take your feedback seriously and am committed to building a great relationship with the clinical team and physicians.The facility policy Preparation and General Guidelines dated November 2021 documents the following: MEDICATION ADMINISTRATION-GENERAL GUIDELINES - PolicyMedications are administered as prescribed in accordance with good nursing principles and practices and only by people legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.

Based on record review and interview, the facility failed to ensure an adequate number of licensed nursing staff were in the facility to provide resident care and services. This failure has the potential to affect all 103 residents who reside in the facility.Findings include:The Facility Assessment Tool updated 4/1/26 documents the following: PurposeThe purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being.Staffing plan Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time.The same Facility Assessment Tool documents the facility requires a total number of Licensed Nurses staffed per shift to meet the care needs of the residents:Day shift: 6:00 am -6:00 pm, four Licensed Nurses.Evening Shift: 6:00 pm -10:00pm, four Licensed Nurses.Night Shift: 6:00 pm- 6:00 am, three Licensed Nurses.The facility nurses staff timecards for May 10, 2026, the nursing schedule and the daily work assignment sheet for May 10, 2026 are incongruent and/or illegible, and had to be clarified by interviews by V1, Administrator. In addition to discrepancy noted, according to the multiple interviews below, V4, MDS/LPN worked an undetermined amount of time, and does not enter her time electronically.On 5/20/26 at 11:20 am V1, Administrator reviewed the nurses schedule and daily nurse sheets. V1 stated on Mother's Day the facility had big problems. V1 stated he was on vacation. V1 also stated We knew there were staffing problems. We had two nurses from Agency call off. We also had one of our nurses call off. We were three short. CNA's staffing was ok. (V10, Scheduler) was working diligently to find staff. The DON (V2, Director of Nursing) was already on vacation and did not return until the day after Mother's Day. I know there were two nurses from our sister facility (V7 and V8 Registered Nurses) that came in and worked partial shifts. They came in at 8:00 pm or 8:30 pm. We had issues with staffing from 6:00 pm to 6:00 am and 6:00 am - 6:00 pm. (V4, Licensed Practical Nurse/Minimum Data Set Coordinator Nurse) worked a partial shift. (V4) came in about 9:00 am and worked until about 4:00 pm or 4:30 pm, to help out. It looks like these sheets are a mess with all the call offs. (reviewing illegible day assignment sheet) (V6, Licensed Practical Nurse) worked Memory care a full shift that night. (V9, Licensed Practical Nurse) came in at 7:00 pm. On both shifts we usually have four nurses to meet the needs of the residents. Even with the extra nurses coming in to work we were still short. According to V1's interview, the interviews below and documents reviewed the facility Licensed Nurse Staff hours were short on 6:00 am to 6:00 pm shift, 12 hours on 100 hall, and approximately three hours on 200 /top of 300 hall for a total of approximately 15 hours. The facility Licensed Nurse Staff hours were short and were short approximately five hours, 6:00 pm until 8:30 pm.On 5/20/26 at 1:55 pm R2 stated Is always a bad deal. Getting my meds. Mother's Day was the worst. There was no nurse, and I did not get my insulin in the morning. I was not as concerned about my other medications. I was really concerned about my insulin that morning. They didn't even do an ACCU check.On 5/20/26 at 2:10 pm R1 stated there was not a nurse on duty all day on mother day 5/10/26 which resulted in R1 not receiving her medications.On 5/20/26 at 2:15 pm V16, CNA stated Mother's Day and I worked on 100 Hall with another aide. Several of the residents were upset because none of them got their medications. There was only a nurse on the other hall, that came over in the afternoon. She was there for about 20 minutes. That was really, bad. It shouldn't go that way.On 5/21/26 at 10:10 am V2, Interim Director of Nursing/Regional Nurse Consultant said she was on vacation and was aware there were several nursing shifts open on Mother's Day when she left the Tuesday before Mother's Day. V2 also said she was not aware until Monday that some 100 hall residents did not get their meds. V2 confirmed insulins and other significant medication errors were due nurse staffing issues, when the nurses on duty failed administration of all the residents' medications.On 5/21/26 at 11:50 am V27, Certified Nursing Assistant stated she worked Mother's day with no nurse all day shift on 100 hall. V27 said V4, LPN worked 200 hall and the top of 300 hall, at 9:00 am and left sometime around 4:00 pm, and there was no nurse that worked the rest of that shift.On 5/21/26 at 1:55 pm V12, R1's Family Member said there was not a nurse on 100 hall on Mother's Day, therefore, R1 did not have her blood glucose level checked until later in the day.R1's Blood Sugar tracking sheet records R1's first blood glucose measurement on 5/10/26 was completed at 2:08 pm and measured 441, which required 12 units of insulin.On 5/22/26 at 11:45 am V13, Licensed Practical Nurse (LPN) stated she worked 400 hall on Mother's Day and stayed over until 9:00 pm. There was no nurse on 100 hall. I had 30 residents of my own. On 5/22/26 at 12:15 pm V29, Agency Licensed Practical Nurse (LPN) said she worked the Memory Care unit on the opposite side of the building from the 100-hall unit. V29, LPN said there was no nurse on 100 hall day shift. A CNA called V29, LPN over to the 100 hall, when a resident (R2) to resident (R12) altercation took place in the 100-hall dining room. V29, LPN said she responded to the altercation and did an assessment. While in the process of providing R2 and R12's care, V29 was called back to the Memory Care unit to assess R13 who had a fall. V29 also said that there was a nurse that came in and worked 9:00 am until about 4:00 pm on 200 hall and the top of 300 hall. She left without saying a word, did not count narcotics at the end of her shift and left the medication cart keys on top of the medication carts. V29 also confirmed the medication keys were accessible to residents, staff and visitors at the center nurse's station.On 5/28/26 at 10:00 am V4, Licensed Practical Nurse/Minimum Data Set Coordinator stated she worked a partial shift on Mother's Day. When she came in to work at 9:00 am V4 found the medication cart/narcotic box keys on the top of the 200 hall and 300 hall medication carts, and both med carts were parked at the center (corridor) nurses' station. V4 said there was not a nurse available to count narcotic medications when she came in to work nor when she left the facility. V4 stated she left the medication keys where she found them when she came in to work. V4 also stated she does not punch in electronically for her shift as an MDS Coordinator she just reports her time to V42, Human Resource Director.On 5/21/26 at 10:10 am V2, Interim Director of Nursing/Regional Nurse Consultant (DON) acknowledged the medication omission errors on 100 hall, Mother's Day 5/10/26, resulted from being short of licensed nurse staff. The facilities CMS-802 Matrix dated 5/20/26 documents 103 residents reside in the facility.

Based on observation, interview and record review, the facility failed to complete shift count of residents' narcotic medications and failed to maintain medication room/medication carts keys, in a safe manner to prevent residents, staff and visitors full access to medications, which included narcotic medications. These failures have the potential to affect all 103 residents in the facility.Findings include:On 5/22/26 at 12:15 pm V29, Agency Licensed Practical Nurse (LPN) stated V29 LPN worked on Mother's Day from 6:00 AM to 6:00 PM. V29, LPN said there was only one nurse, V13, Licensed Practical Nurse working when she came to work. V29, Agency LPN also stated there was a nurse (later identified as V4, LPN/MDS Coordinator) that came in and worked 9:00 am until about 4:00 pm, on 200 hall and the top (front area) of 300 hall. V29 LPN stated That nurse left without saying a word. She did not count medications with me and just left the 200 and 300 hall med cart keys in the narc books on the med cart.On 5/28/26 at 10:00 am V4, Licensed Practical Nurse/Minimum Data Set Coordinator (LPN/MDS) confirmed she came in to work about 9:00 am on Mother's Day and there was not a nurse available to count narcotics with her. Narcotic shift count sheets confirmed narcotic medications were not verified to ensure the accuracy on May 10, 2026, night or day shifts. V4 stated she found medication room/ medication cart keys on top of the two med carts, inside narcotic count sheet book, for both the 200 hall and 300 halls. V4 stated Both med (medication) carts were parked at the center (corridor) nurses' station. V4 confirmed the nurse's station is at the center, corridor junction where all resident halls and the main facility entrance to the facility meet. Therefore, all residents, visitors and staff had access to the keys that unlock the medication rooms, medication carts and the narcotic box storage inside the carts. V4 then stated There was still no nurse to count narcotics and give the keys to when I left the facility around 6:00 pm. I left the med (medication) cart keys where I found them when I came in, on top of both 200 and 300 hall carts.During general tours and medication administration pass, 5/20/26-5/28/26, medication carts for 100 hall, 200 hall and 300 hall were intermittently parked at the center nurses station. The center nurses station intersects the main corridor where all resident halls meet, the facility main entrance merges, and the resident common lounge are located. On 5/27/26 at 3:50 pm V2, Interim Director of Nursing, reviewed the Narcotic shift count sheets for 5/10/16 (Mother's Day). V2 confirmed the narcotic shift count sheets were not signed off as completed by two nurses as the facility required. V2 also said V2 was not aware that the narcotic keys were left on top of the medication carts, and she will be adding these failures to the nurse education she provides.The facility CMS 802 Matrix dated 5/20/26 documents 103 residents reside in the facility.The facility policy Medication Storage In The Facility dated November 2021 documents the following: STORAGE OF MEDICATIONS - PolicyMedications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.ProceduresB. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.The facility policy Narcotic/ Controlled Substances- Counting dated as revised November 26, 2017, documents the following:Purpose: 1. To count controlled substances with a partner and to verify the accuracy of the log sheets.2. Knowledge of correct response should an error be discovered in the controlledsubstance count.General Guidelines:Always participate in the counting of the controlled substances at the beginning and ending of your shift. Never say, go ahead without me and I'll sign later. Never leave it to someone else's discretion when you are the one on duty. If you do not observe the medications that you sign as being present, you may be implicated if the medications are later missing.General Procedure for Counting Controlled Substances1. Follow your facility's specific guidelines and use their specific log sheet.2. Obtain sign-out records/logs and keys to the controlled storage compartment.3. Have partner to assist in the count.

Based on interview and record review the facility failed to notify resident family/representatives of missed administration of significant morning medications. This failure affects eight of twelve residents (R1, R2, R3, R4, R5, R6, R7, and R8) reviewed for notification/medications on the sample list of 16.Findings include:R1, R2, R3, R4, R5, R6, R7, and R8's, Medication Administration Records dated May 1-31, 2026, do not document nurses' initials in the blank boxes, to indicate the R1, R2, R3, R4, R5, R6, R7, and R8's medications were administered on May 10, 2026, during morning medication administration.R1, R2, R3, R4, R5, R6, R7, and R8's Progress Notes do not document that family representatives were notified of the medication omission errors.On 5/21/26 at 11:10 am V23, R8's Power of Attorney said the facility did not notify V23 that R8 missed her medications on Mother's Day 5/10/26.On 5/21/26 at 1:55 pm V12, R1's Family Member stated she was not contacted by the facility to inform them that R1 missed her medications on 5/10/26.On 5/21/26 at 5:30 pm V20, R2's Family Member stated There has not been anyone call or tell me there were problems on Mother's Day (5/10/26) with my dad getting any of his medications.On 5/21/26 at 10:10 am V2, Interim Director of Nursing/Regional Nurse Consultant (DON) said that it is standard of practice that the family representatives be notified of medication errors. V2, DON said facility nurses, working the floor are expected to contact the families to inform them of the medication errors, and document the notification in the resident's medical record.The facility policy Physician-Family Notification- Change in Condition dated as revised 11/13/18 documents the following: Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner. Responsibility: Licensed Nursing Personnel / Social Services Guidelines: 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.

Based on interview and record review, the facility failed to provide eight hours of required Registered Nurse staffing coverage per 24-hour period for two of fourteen days reviewed for staffing. This failure has the potential to affect all 105 residents in the facility.Findings include:Facility staffing schedules dated April 14, 2026, through April 28, 2026, document the facility did not have any Registered Nurse working anytime in the facility on April 25, 2026 and April 26, 2026. On 4/29/2026 at 11:04AM, V1 Administrator reported the facility did not have a Registered Nurse working eight hours per day on April 25, 2026, and April 26, 2026.The facility resident census dated 4/28/2026 documents 105 residents reside in the facility.

Based on interview and record review, the facility failed to maintain a resident's right to privacy while being assisted by staff. This failure affects one resident (R1) of three reviewed for privacy in the sample list of three residents. Findings include:R1's Resident assessment dated [DATE] documents R1 is cognitively intact. On 4/29/2026 at 11:31AM, R1 reported direct care staff working on night shift are often on their cell phones and often texting or on a call while they are in R1's room taking care of R1. R1 reported staff will often be on a call using an ear bud or on speakerphone with their phone in their pocket and sometimes they are on a video call but keep the camera pointed towards themselves and not towards R1. R1 reported that some staff will hide in the dining room to use their phones while working. R1 reported these issues do not occur during the daytime. On 4/29/2026 at 1:50PM, V4 CNA reported R1 makes reliable statements and is pretty accurate with what R1 has to say to people. The facility Resident Rights policy (1/4/2019) documents that residents living in the facility have a right to privacy and confidentiality.

Based on interview and record review, the facility failed to provide timely toileting assistance for three residents (R1, R2, R3) of three reviewed for Activities of Daily Living (ADLs) on the sample list of three residents. Findings include:1. R1's Medical Diagnosis sheet dated 4/29/2026 documents R1's diagnoses include Multiple Sclerosis (chronic autoimmune disease of the central nervous system causing numbness, weakness, trouble walking, and vision changes), Chronic Respiratory Failure, Morbid Obesity, Chronic Pain, Overactive Bladder, and Depression.R1's Resident assessment dated [DATE] documents R1 is cognitively intact. The same assessment documents, R1 requires partial/moderate staff assistance to transfer to the toilet and for toileting hygiene. R1's Care Plan dated 3/17/2026 documents R1 has bladder incontinence and requires partial/moderate staff assistance to transfer to the toilet and for toileting hygiene. On 4/28/2026 at 2:40PM, R1 reported sometimes at night when R1 activates R1's call light, a Certified Nurse Aide (CNA) will enter R1's room and shut the call light off but not return and then R1 will have to press the call light again. R1 reported waiting on staff to be assisted to use the bathroom in R1's room when this occurs and reported the situation occurs every week. R1 reported R1 has had toileting accidents while waiting for help and this makes R1 feel not good. On 4/29/2026 at 11:31AM, R1 reported staff can take thirty minutes to respond to call lights.On 4/29/2026 at 1:50PM, V4 CNA reported R1 makes reliable statements and is pretty accurate with what R1 has to say to people. 2. R2's Medical Diagnosis sheet dated 4/29/2026 documents R2's diagnoses include Muscle Wasting and Atrophy, Generalized Anxiety Disorder, and Depression.R2's Resident assessment dated [DATE] documents R2 is cognitively intact. The same assessment documents, R2 requires partial/moderate staff assistance to transfer to the toilet and for toileting hygiene. R2's Care Plan dated 2/23/2026 documents R2 has bowel and bladder incontinence and requires partial/moderate staff assistance to transfer to the toilet and for toileting hygiene. On 4/29/2026 at 2:26PM, R2 reported staff sometimes take 30 minutes at night to answer R2's call light to help with toileting. R2 reported this occurs daily in the facility. 3. R3's Medical Diagnosis sheet dated 4/29/2026 documents R3's diagnoses include Overactive Bladder and Urinary Tract Infection. R3's Resident assessment dated [DATE] documents R3 is cognitively intact. The same assessment documents, R3 requires substantial/maximal staff assistance to transfer to the toilet and partial/moderate staff assistance for toileting hygiene. R3's Care Plan dated 2/12/2026 documents R3 requires substantial/maximal staff assistance to transfer to the toilet and for toileting hygiene. On 4/29/2026 at 2:28PM, R3 reported activating R3's call light a couple of nights ago at 3:00AM to use the restroom and staff didn't arrive for two hours. R3 reports this happens often at night with agency staff. R3 reported staff will sometimes shut off R3's call light and then not return. On 4/29/2026 at 3:40PM, V8 Licensed Practical Nurse (LPN) reported both R2 and R3 make reliable statements and do not have behaviors and do not make false allegations. The facility Call Light policy dated 11/28/2012 documents staff will answer resident call lights in a timely manner.

Based on interview and record review, the facility failed to ensure residents were free from physical abuse for one (R5) of five residents. This failure affected two (R5 and R6) residents on the sample of seven residents. Findings include:R5's record reviews document an admission date of 3/30/2022 with diagnosis of Dementia with Psychosis, Depression, Gastritis, Basal Cell Carcinoma of Skin of Nose, Type 2 Diabetes Mellitus, and Sick Sinus Syndrome with Pacemaker. R5's Minimum Data Set, dated [DATE], documents R5 is cognitively impaired. On 4/13/26 at 10:20am, R5 was unable to be interviewed due to cognitive impairment.On 4/13/26 at 12:08pm, V9 (R5's) family member, stated V9 was informed on 03/24/26 that R5 was struck in the back of R5's head by another resident (R6) while R6 was attempting to hit a staff member. V9 stated the nurse informed V9 that R5 was uninjured but V9 insisted R5 be sent to the local emergency room for evaluation. V9 stated R5 did not have any injuries and returned to the facility. V9 stated that R6 has not been seen since the incident.On 4/14/26 at 10:10am, V3 License Practical Nurse (LPN) confirmed the incident occurred on 3/24/26. V3 LPN stated R6 was experiencing behaviors in the common area of the unit. While another employee was attempting to re-direct R6, R6 attempted to swing and hit that employee and missed hitting R5 on the back of the head. V3 LPN stated multiple employees then were able to remove R6 from the area. R5 was assessed and no injury was found. On 4/14/26 at 10:29am, V5 Certified Nursing Assistant (CNA) stated V5 was on break. V5 CNA returned to the unit and noticed R6 was having behaviors and wanting to go home. All the unit residents were gathered in the common area as staff was attempting to protect the other residents from R6 who was flipping over tables and being violent towards staff. V5 CNA stated V5 was told of R5 being hit but did not witness the incident. V5 CNA stated R5 was acting at R5's baseline, but R5's family wanted R5 sent to the local hospital for examination.On 4/14/26 at 10:46am, V4 Certified Nursing Assistant (CNA) confirmed V4 witnessed R6 attempting to hit another staff member and missed, instead R6 hit R5 in the back of the head. V4 stated R6 was having behaviors and exit seeking.On 04/15/26 at 11:55am, V7 Dietary Manager confirmed R6 did hit R5 in the back of the head, while attempting to hit another staff member. V7 stated R5 has been herself and acting at R5's baseline.On 4/15/26 at 12:30pm, V1 Administrator and V2 Regional Nurse Consultant (RNC), confirmed the incident from 3/24/26 involving R5 and R6. V1 stated R6 was attempting to hit an employee and missed the employee but hit R5 on the back of the head.Record review of the state agency received facility investigation dated 3/26/26 documents on 03/24/2026, R6 was experiencing behaviors. While experiencing behaviors R6 attempted to make contact with a staff member and made contact with peer, R5 instead. Nursing assessment completed. No injuries noted. Record review of local hospital notes dated 3/24/26 at 12:13pm documents patient (R5) presents to emergency room in care of EMS (emergency medical services) from a local nursing home. Patient (R5) was sitting in her wheelchair when another resident struck her in the back of the head. Patient (R5) is alert to her norm (dementia), has no complaints, nothing noted on visual inspection. Abuse Prevention and Reporting policy dated 11-28-16 documents the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment.

Failures at this level required more than one deficient practice statementA. Based on interviews and record reviews the facility failed to ensure follow up medical appointments were scheduled for one (R3) of one resident reviewed for medical appointments in the sample of seven residents.B. Based on interview and record review the facility failed to ensure neurological assessments were completed for one (R5) of one resident reviewed for incidents involving a head injury in the sample of seven residents.Findings include:a. R3's record review documents an admission date of [DATE] and a discharge date [DATE] with diagnosis of Ascites, Cirrhosis, Liver Mass, Dementia, Ascites of Liver and Type 2 Diabetes Mellitus. Further record review documents R3 was admitted to hospice care on [DATE] with the terminal illness Dementia and a Liver Mass. On [DATE] at 10:10am, V15 Hospice Nurse confirmed the facility should have scheduled and transported R3 to a treatment center if paracentesis was needed. V15 confirmed that R3 self-removed R3's drain and that R3's family requested a paracentesis be performed on several occasions.On [DATE] at 11:15am, V14 Nurse Practitioner (NP), confirmed the progress note dated [DATE] stating the hospital would not re-insert the drain, but would perform paracentesis if needed. V14 NP confirmed R3 was diagnosed with a terminal illness and was on hospice and has since expired.On [DATE] at 12:30pm, V2 Regional Nurse Consultant (RNC), confirmed the progress note written by V14 NP in the medical record stated the local hospital would do the paracentesis. V2 RNC stated the hospice company should have scheduled the paracentesis for R3 as the hospice company was managing the care for R3.The nursing progress note dated [DATE] at 01:10am documents the nurse entered resident's (R3's) room and observed the indwelling catheter drain tubing located on the outside of resident (R3). V14 Nurse Practitioner documented on [DATE] at 11:12am a referral for reinsertion of indwelling catheter drain re-inserted. However, as per nursing staff from local hospital, Medical Doctor (MD) declined stating that it is too soon to attempt reinsertion. If R3 needs paracentesis, they will drain R3.On [DATE], R3's record review contained multiple nurses progress notes documenting R3's increase in abdominal girth/ascites. Many of these same note's document R3's family asking when the abdominal indwelling catheter drain can be re-inserted and questioning when R3 will have a paracentesis. b. R5's record review documents an admission date of [DATE] with diagnosis of Dementia with Psychosis, Depression, Gastritis, Basal Cell Carcinoma of Skin of Nose, Type 2 Diabetes Mellitus, Sick Sinus Syndrome with Pacemaker. R5's Minimum Data Set, dated [DATE] documents R5 is cognitively impaired. On [DATE] at 12:08pm, V9 (R5's) family member, stated V9 was informed on [DATE] that R5 was struck in the back of R5's head by another resident (R6) while R6 was attempting to hit a staff member. V9 stated the nurse informed V9 that R5 was uninjured but V9 insisted R5 be sent to the local emergency room for evaluation. On [DATE] at 10:10am, V3 License Practical Nurse (LPN) confirmed the incident occurred on [DATE]. V3 stated R6 was experiencing behaviors in the common area of the unit. While another employee was attempting to re-direct R6, R6 attempted to swing and hit that employee and missed hitting R5 on the back of the head. V3 LPN stated multiple employees then were able to remove R6 from the area, assess R5 and found no injury. On [DATE] at 10:46am, V4 Certified Nursing Assistant (CNA), confirmed V4 witnessed R6 attempting to hit another staff member and missed, instead R6 hit R5 in the back of the head. V4 stated R6 was having behaviors and was exit seeking.On [DATE] at 11:55am, V7 Dietary Manager (DM), confirmed R6 did hit R5 in the back of the head, while attempting to hit another staff member. V7 DM stated R5 has been herself and acting at her baseline.On [DATE] at 12:30pm, V1 Administrator and V2 Regional Nurse Consultant (RNC), confirmed the incident from [DATE] involving R5 and R6. V1 stated R6 was attempting to hit an employee and missed the employee but hit R5 on the back of the head. V2 RNC confirmed the medical record did not contain completed neurological assessments following a known head injury. V2 RNC stated the neurological assessments should have restarted and been completed upon R5's return from the hospital. Record review of the state agency received facility investigation report dated [DATE] documents on [DATE], R6 was experiencing behaviors. While experiencing behaviors R5 attempted to make contact with staff member and made contact with peer, R5 instead. Nursing assessment completed. No injuries noted. Record review of local hospital notes dated [DATE] at 12:13pm documents patient (R5) presents to ER (Emergency Room) in care of EMS (Emergency Medical Services) from local nursing home. Patient (R5) was sitting in her wheelchair when another resident struck her in the back of the head. Patient (R5) is alert to her norm (dementia), has no complaints, nothing noted on visual inspection. There was no fall involved and no loc (loss of consciousness).Neurological assessment policy dated [DATE] documents residents will have neurological assessments completed when they experience a head injury. 1. Neurological assessments will be completed upon a physician's order, when indicated for achange of resident's condition, after all head injuries and when nursing judgement deems necessary.

Based on interview and record review, the facility failed to ensure resident rights were protected when they failed to ensure Advanced Directives were obtained and/or documented for one (R2) of one resident reviewed for advance directives in the sample of nine residents.Findings include:On 4/15/2026 at 11:45am, R2's record review does not contain an Advanced Directive, POLST (Physician Ordered Life Sustaining Treatment) form or a physicians order for life sustaining treatment.R2's record review documents an admission date of 2/2/26 with diagnosis of Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Reduced Mobility, and Type 2 Diabetes Mellitus Without Complications. Minimum Data Set, dated [DATE] documents R2 is cognitively impaired.On 4/15/2026 at 11:50am, V8 (R2's) Power of Attorney, stated V8 had not chosen or signed a POLST (Physician Ordered Life Sustaining Treatment) form for R2.On 4/15/2026 at 12:30pm, V2 Regional Nurse Consultant confirmed there is no physician order for life sustaining treatment or POLST (Physician Ordered Life Sustaining Treatment) form documented in R2's medical record.

Based on observation, interview, and record review the facility failed to protect residents (R1 & R5) from physical abuse from another resident (R2). This failure affected two (R1 & R5) of three residents reviewed for abuse in the sample list of five residents. Findings include:On 3/21/2026 at 8:37 AM, R1 was observed walking down the hallway independently without an assistive device. R1 was clean and well-groomed. R1 then walked around the dining room with other residents still eating. R1 was observed going from one table to another. R1 then sat down on a chair in the dining room. After a few minutes, R1 got up and started to wander around the dining room again while other residents were still eating. R1 was unable to understand what was being asked during the interview due to cognitive impairment. R1's was observed to have a healed wound to right forearm.On 3/21/2026 at 8:40 AM, V2 Certified Nurse Assistant (CNA) stated R1 wanders around and is not able to see very well but usually is not aggressive.On 3/21/2026 at 10:03 AM, V3 Registered Nurse (RN) stated R1 wanders around, sometimes R1 goes to other resident's room. V3 stated R1 has poor vision and sometimes R1 gets into other residents' beds.R1's behavior note dated 2/27/2025 documents that R1 allegedly had a physical altercation with another resident (R2) that resulted in R1 sustaining bruises and a skin tear to right forearm measuring 5cm (centimeters) x 3cm.On 3/21/2026 at 10:13 AM, V6 Licensed Practical Nurse (LPN) stated V6 witnessed R1 and R2 having a physical altercation on the evening of 2/27/26. V6 stated R1 sustained a skin tear from this incident. V6 stated R1 usually has some verbal aggression but not usually physical aggression. V6 stated R2 has verbal aggression towards staff members as well as other residents.On 3/21/2026 at 10:47 AM, V7 Family Member stated the facility notified V7 of the incident occurred on the evening of 2/27/2026 involving R1 having a physical altercation with another resident and R1 sustained a skin tear to R1's right forearm.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively impaired. On 3/21/2026 at 8:37 AM, R2 was sitting in the dining room eating breakfast independently. R2 was clean and well groomed. R2 was quiet and calm at this time.On 3/21/2026 at 9:02 AM, R2 was sitting in R2's wheelchair in R2's room. R2 stated R2 does not have concerns.On 3/21/2026 at 09:09 AM, V4 Certified Nurse Assistant (CNA) stated R2 has a tendency of being aggressive when R2 is frustrated and when over stimulated. V4 stated V4 has never personally witnessed R2 being physical with other residents, but V4 has observed this towards staff members.On 3/21/2026 at 10:10 AM, V5 Activity Aide stated R2 is usually verbally aggressive to both staff and other residents. V5 stated R2 also has physical aggression towards staff members. V5 stated R2 sometimes will attempt to get physical with other residents but staff usually removes R2 before it happens.R2's Nurse's Note dated 2/25/2026 documents R2 had an alleged physical altercation with another resident.R2's Behavior Note dated 2/27/2026 documents R2 had an alleged physical altercation with another resident.R2's Care plan initiated 3/2/2026 documents focus I (R2) have the potential to be physically aggressive r/t (related to) Anger, Dementia, Depression, History of harm to others, and Poor impulse control.R2's Care Plan initiated 8/25/2025 documents focus Problematic manner in which I (R2) act is characterized by ineffective coping; verbal/ physical Aggression related to: Cognitive impairment/physiological changes in brain.R2's Minimum Data Set (MDS) dated [DATE] documents R2's cognition is severely impaired. On 3/21/2026 at 8:55 AM, R5 was observed walking down the hallway independently without an assistive device. R5 is clean and well groomed. R5 then sat on a chair located in the hallway. R5 stated everyone is treating R5 good in the facility. R5 was observed to not able to comprehend the conversation during the interview.On 3/21/2026 at 8:54 AM, V3 Registered Nurse (RN) stated R5 usually will get angry. V3 stated R5 does not usually have physical aggression but mostly verbal.R5's Nurse's note dated 2/25/2026 documents R5 had an alleged altercation with R2.R5's Care Plan date initiated 3/3/2026 documents focus Problematic manner in which I (R5) act is characterized by ineffective coping; verbal/physical Aggression related to: Cognitive impairment/physiological changes in the brain (verbal abuse with staff and residents).R5's Care plan date initiated 3/3/3026 documents focus Problematic manner in which I (R5) act characterized by inappropriate behavior; Hoarding and Rummaging related to: Cognitive impairment onset of Alzheimer's, mood disorder, vascular dementia and anxiety), inability to differentiate btw (by the way) personal and others belongings. Facility's Abuse Prevention and Reporting Policy with revised date 10/24/22 documents the facility affirms the right of residents to be free from abuse. This facility therefore prohibits abuse. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment.

Based on interview and record review, the facility failed to report an allegation of resident-to-resident abuse to the State Agency for two (R2, R5) residents out of three residents reviewed for abuse, on a sample list of five residents.Findings include:R2's Care Plan date initiated 8/25/2025 documents focus Problematic manner in which I (R2) act characterized by ineffective coping; verbal/ physical Aggression related to: Cognitive impairment/physiological changes in brain.R2's Minimum Data Set (MDS) dated [DATE] documents R2's cognition is severely impaired.R5's Care Plan initiated 3/3/2026 documents focus Problematic manner in which I (R5) act characterized by ineffective coping; verbal/physical Aggression related to: Cognitive impairment/physiological changes in brain (verbal abuse with staff and residents).R5's Care plan date initiated 3/3/3026 documents focus Problematic manner in which I (R5) act characterized by inappropriate behavior; Hoarding and Rummaging related to: Cognitive impairment onset of Alzheimer's, mood disorder, vascular dementia and anxiety), inability to differentiate btw (by the way) other's belongings.R5's Nurse's note dated 2/25/2026, V8 Licensed Practical Nurse (LPN) documented R5 had an alleged altercation with R2. This note does not document notifications to the abuse coordinator. On 3/21/2026 at 12:28 p.m. V1 Administrator stated he did not report the incident on 2/25/2026 between R2 and R5 because he was not aware and staff should have reported to him.On 3/21/2026 at 09:09 AM, V4 Certified Nurse Assistant (CNA) stated R2 has a tendency of being aggressive when R2 is frustrated and when over stimulated. V4 stated V4 has never personally witnessed R2 being physical with other residents, but V4 has observed this behavior with staff members.On 3/21/2026 at 10:10 AM, V5 Activity Aide stated R2 is usually verbally aggressive to both staff and other residents. V5 stated R2 also has physical aggression towards staff members. V5 stated R2 sometimes will attempt to get physical with other residents but the staff usually remove R2 before it happens but had not personally witnessed an actual altercation with another resident recently. R2's Care plan initiated 3/2/2026 documents focus I (R2) have the potential to be physically aggressive r/t (related to) Anger, Dementia, Depression, History of harm to others, and Poor impulse control.R2's Care Plan date initiated 8/25/2025 documents focus Problematic manner in which I (R2) act characterized by ineffective coping; verbal/ physical Aggression related to: Cognitive impairment/physiological changes in brain.On 3/21/2026 at 8:54 AM, V3 Registered Nurse (RN) stated R5 usually gets angry. V3 stated R5 does not usually have physical aggression but mostly verbal. V3 stated V3 had not personally witnessed R5 being physically aggressive with another resident recently.Facility's Abuse Prevention and Reporting Policy with revised date 10/24/22 documents when an allegation of abuse has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Public Health shall be informed that an occurrence of potential abuse has been reported and is being investigated.

Based on observation, interview and record review the facility failed to provide supervision in a resident bathroom and the dining room and failed to remove a mechanical lift sling from the wheelchair to prevent falls, and failed to implement fall interventions, complete a fall assessment for five of six residents (R1, R17, R21, R23 and R112) reviewed for accidents on the sample list of 46. These failures resulted in R21 falling in the dining room and suffering a fractured clavicle and laceration to the back of the head when staff were not present supervising, R23 falling and suffering an acute fracture to the tailbone when R23 slid out of the wheelchair after staff failed to remove the mechanical lift sling, and R112 falling in the bathroom and suffering a hematoma to R112's right cheek/neck area and a laceration to R112's cheek requiring adhesive skin closures when staff turned away from R112. Findings include: The facility's Fall Prevention Program Policy dated 11/28/12 with a revision on 11/21/17 documents that the purpose of this policy 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 to provide necessary supervision and assistive devices are utilized as necessary. Guidelines for this policy include methods to identify risk factors, methods to identify residents at risk, use and implementation of professional standards of practice and adherence to manufacturer's recommendation in use of alarm and medical devices and special care equipment. 1.) R21's Minimum Data Set (MDS) dated [DATE] indicates the resident has moderate cognitive impairment and diagnoses of Parkinsonism and Dementia. The MDS further documents that the resident does not have the ability to safely ambulate ten feet due to medical condition and safety concerns. The Nursing Note dated 1/19/26 documents that at 6:35 pm a Certified Nurse Assistant (CNA) called out for help in the 100-hall dining room. Writer responded immediately and observed resident laying on the floor on her right side. Wheelchair was behind her, broom at her side. Resident from dining room witnessed fall and stated resident was standing up trying to sweep the floor, appeared to lose her balance and fall. When asked resident what happened, resident stated I don't know. Visible head wound to right side of head with moderate bleeding noted. Resident complained of right shoulder and right hip pain. Pressure applied to head wound. No further injuries were noted at this time. Resident is on anticoagulant therapy. Medical Doctor (MD) notified and gave order to send to ER for eval/treat. R21's X-ray Report dated 1/19/26 documents an acute fracture of the distal clavicle was identified. R21's Care Plan dated 12/23/25 documents that the resident is at risk for falls related to a history of falls. Interventions include frequent checks on the resident (initiated 12/21/25) and increased supervision during mealtimes (initiated 11/26/25). On 2/10/26 at 10:09 a.m., V8, CNA, stated R21 is confused and has to be monitored very closely and checked at least every 15 minutes if not more. On February 10, 2026, at 10:58 a.m., V25, CNA, stated that she was aware of R21's fall but was unsure whether she was working at the facility when the incident occurred. During the same interview, V25 confirmed that R21 requires monitoring at least every 15 minutes, or more frequently as needed. V25 explained that staff are expected to maintain continuous observation of R21 to ensure her safety. She further stated that staff on the Hall, where R21 resides, make efforts to keep R21 in close proximity to staff at all times, either at the nurse's station with nurses and CNAs or engaged in activities. On 2/10/26 at 11:09 a.m., V26 CNA stated she was not present when R21 fell on 1/19/26, as she left at 6:00 p.m. that day and most residents were still in the dining room. V26 confirmed that R21 was at the dining room table when she left. V26 stated she was later informed that R21 and another resident were in the dining room when R21 got up and attempted to sweep the floor. V26 stated R21 is always confused and requires constant supervision, stating, If I'm going to be honest, staff always have to keep a very close eye on (R21), but sometimes that is very difficult to do when caring for all the other residents too. V26 stated that R21 is able to stand independently and is mobile but very unstable when up. On 2/10/26 at 11:45 a.m., R41 stated he was in the dining room with R21 when she fell. R41 stated that R21 was in her wheelchair, grabbed a broom, and began sweeping. R41 further stated that R21 then got out of her wheelchair and continued sweeping. R41 stated he turned his back for just a second, and when he did, R21 fell. R41 stated there were no staff in the dining room at the time of the fall, only himself and another resident who is cognitively impaired (name unknown). R41 stated staff had not been in the dining room that evening for quite some time and that R21 is often left on her own. R41 added that other residents frequently have to look after R21 and remind her to sit down. R41's MDS dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 14, indicating R41 is cognitively intact. On 2/10/26 at 9:59 a.m., V15, Registered Nurse (RN), stated that R21 falls frequently and that her Care Plan documents the need for close attention from staff. V15 reported there is no specific time frame for frequent checks, but staff are expected to keep an eye on R21. V15 added that if she were working on the floor, R21 would remain with her at all times because she requires one-on-one supervision. V15 also stated she is unsure why R21's Care Plan includes an intervention for increased supervision in the dining room during mealtimes. On 02/10/2026 at 2:36 p.m., V14, Regional Nurse Consultant/Interim Director of Nursing, stated there should always be a staff member present in the dining room to provide supervision for R21 as well as other residents. V14 explained that the timing of checks for R21 depends entirely on her behavior at the time, confirming that there are occasions when R1 requires constant direction. V14 further stated staff should have remained in the dining room until all residents had left. 2.) R23's MDS dated [DATE] documents that the resident is cognitively intact and has diagnoses of Multiple Sclerosis, Demyelinating Disease of the Central Nervous System, Muscle Wasting and Atrophy (multiple sites), Polyneuropathy, and Abnormal Posture. The MDS further documents that R23 is dependent on staff for all aspects of mobility and requires substantial to maximal assistance with bathing. On 2/8/2026 at 10:31 a.m., R23 stated that (on1/31/26) V24, CNA, and V23, Licensed Practical Nurse (LPN), transferred her to the shower chair using a mechanical lift and left the mechanical lift sling beneath her. R23 confirmed that V23 left the room, and V24 did not pick up the mechanical lift straps from the floor before pushing the shower chair. R23 stated the straps became caught in the wheels, causing the chair to come to an abrupt stop and thrusting her forward. R23 reported that she began to slide out of the chair, and V24 called for help. R23 stated V23 returned to the room and was sent to retrieve the mechanical lift while V24 attempted to hold her in the shower chair with her body. R23 stated that before they could get her back into the shower chair with the mechanical lift, she was dropped to the floor. R23 reported experiencing excruciating pain from the fall, was sent to the local emergency department, and was diagnosed with a broken tailbone. The Computed Tomography (CT) Report dated 1/31/26 documents There is angulation at the sacrococcygeal junction (tailbone). This is new in comparison to the prior CT. No additional fractures are appreciated. On 2/09/26 at 11:54 a.m., R94 (R23's former roommate) stated she was present when R23 slid out of the shower chair. R94 stated she did not witness the incident but heard commotion and V24 calling for help. On 2/09/26 at 11:24 a.m., V24 CNA stated that while preparing resident R23 for a shower, R23 slid from the shower chair. V24 stated that earlier, V23 LPN had assisted in transferring R23 into the shower chair using a mechanical lift and then left the room. V24 stated that after V23 exited, R23 requested her bra. V24 stated R23 adjusted herself in the chair and began sliding. V24 confirmed that the mechanical lift sling was still beneath R23 and was slick, contributing to the slide. V24 stated she attempted to hold R23 in the chair using her body and called for help. V24 stated R94, R23's roommate, activated the call light and then entered the hallway with her walker to seek assistance. V24 stated that V23 and another CNA (unknown name) responded, but before they could reposition R23 into the lift, R23 fell to the floor. On 2/10/26 at 8:22 a.m., V23, LPN stated he was the nurse on duty the day R23 slid out of the shower chair. V23 reported that he assisted V24 with transferring R23 into the shower chair, spotting V24 during the mechanical lift transfer, and then left the room. V23 confirmed that the mechanical lift sling was left beneath R23 and stated this was common practice, noting that CNAs typically provide R23's bath with assistance from only one staff member. On 2/11/26 at 9:25 a.m., V20 CNA stated that she works at the facility through an agency but is frequently assigned to R23. V20 stated R23 is dependent on staff for activities of daily living (ADLs) and confirmed that R23 is fully aware of her surroundings, describing her as totally with it. On 2/11/26 at 9:36 a.m., V29, CNA, stated that R23 requires assistance with all activities and prefers to use the Reclining Shower Chair, and be wheeled to the shower room. V29 stated R23 is cognitively aware and is able to make her needs known. On 2/9/26 at 3:20 PM, V14 Interim DON/Regional Nurse Consultant stated she was aware of the incident in which R23 slid out of the shower chair. V14 indicated that, given R23's current condition, two staff members should have been present at all times to complete shower tasks. V14 further stated that the mechanical lift sling should have been removed from beneath R23 before the CNA attempted to move the shower chair. 3.) R112 's diagnosis list (printed 2/11/26) documents that R1's diagnoses include Dementia, Syncope (fainting) and Collapse, Difficulty in Walking, Muscle Wasting and Atrophy, Pain, Cognitive Communication Deficit, Depression, and Anxiety. R112's Resident assessment dated [DATE] documents R1 has severely impaired cognition and requires substantial/maximal staff assistance for transfers, including going from a seated position to a standing position. The same record documents R1 does not have behaviors, delusions, or hallucinations. R112's Fall Risk assessment dated [DATE] Completed 2/10/26 documents R112 is at risk for falls. The facility fall log (11/9/25 thru 2/9/26) documents R112 had an unwitnessed fall in the facility on 12/11/25. The facility provided a fall investigation dated 1/31/26 documenting a fall. The facility Fall Investigation dated 1/31/26 documents staff turned around as R112 stood up from the wheelchair in the bathroom of the resident room and was reaching for the towel bar then fell into the towel bar causing a laceration on the right cheek. The record further documents R112 was transferred to the hospital emergency department via ambulance for evaluation and treatment. R112's Emergency Department Report dated 1/31/26 documents R112 was diagnosed with a Facial Contusion (Acute), Soft tissue swelling of the right infraorbital region of the face with an abrasion noted about 1 centimeter in diameter at the soft tissue swelling site and required computed tomography (CT) radiographic scans to evaluate possible injuries as the physician documented there is the possibility of cervical injury depending on how hard R112's face hit the wall. The Emergency Department Note dated 1/31/26 documents adhesive skin closures were applied to R112's facial wound. The facility Fall Investigation dated 1/31/26 documents V36 (Licensed Practical Nurse) was informed by V35 (Certified Nursing Assistant) that V35 was assisting R112 from the toilet to the wheelchair, V35 stated she turned so that she could back R112 from the bathroom and when V35 turned back around V35 observed R112 had risen from the wheelchair, and was attempting to grab ahold of the towel bar. V35 stated R112 fell into the towel bar. V35 stated R112 did hit her right side of the face on the towel bar causing a laceration and swelling to the right cheek. The same investigation documents V36 entered R112's room and noted R112 laying in a low bed, noting R112's right cheek bleeding from a laceration and swollen. Nursing Progress Notes dated 1/31/26 at 7:30 PM by V36 document R112 complained of some pain to the right cheek area. V36 documents calling the primary care physician and R112 being sent to the emergency room for further evaluation. Further record review does not document a fall risk assessment following the fall dated 1/31/26. R112's Care Plan dated 05/25 was not revised after R112's documented fall on 1/31/26 with a targeted intervention. On 2/8/26 at 11:45am R112 was sitting at the dining room table. R112's right cheek and right neck were discolored yellowish green transitioning into purple from the right infraorbital/cheekbone down to the collar bone. On 2/8/26 at 12:30pm R112's bathroom contained a towel rack above and to the right of the safety grab bar. The left end piece of the towel rack was loose and dislodged. On 2/8/26 at 11:45am V33, Memory Care Coordinator, stated R112 recently had a fall and R112 hit R112's cheek on the towel bar in her bathroom that causing a laceration and bruising and it is now healing. On 2/8/26 at 12:30pm V34, Certified Nursing Assistant, confirmed the towel bar remained in R112's bathroom located at R112's head height and the left end piece of the towel bar was loose and dislodged. V34 stated she was not present at the time of the fall. V34 confirmed R112 did have injuries related to hitting the towel bar upon falling. On 2/9/26 at 10:03am V38, R112 Family, confirmed she received a phone call stating R112 fell in the bathroom and hit R112's cheek on the towel bar and was being transferred to the local emergency room for further evaluation. On 2/9/26 at 12:05pm V15, Minimum Data Set/Care Plan Coordinator (MDS) stated falls are discussed in meetings, the root cause is determined and if a safety concern is identified it is addressed, and the care plan is then updated with a targeted intervention. V15 confirmed R112's care plan was not updated with an intervention following the fall documented on 1/31/26. V15 confirmed the towel bar presented a safety hazard. On 2/9/26 at 12:25pm V14, Regional Nurse Consultant (RNC), stated fall risk assessments are to be completed after a fall. V14 stated there should be 72 hour follow up charting on any resident involved in an incident/accident. V14 confirmed R112's medical record did not contain a fall risk assessment completed after the 1/31/26 documented fall. V14 confirmed R112's medical record did not contain follow up charting after the documented 1/31/26 fall. On 2/9/26 at 12:25pm V1, Admin and V14, RNC, confirmed the fall investigation for R112 dated 1/31/26 did not contain a targeted intervention, the care plan did not contain a targeted intervention, and the towel bar in R112's bathroom presented a safety hazard. On 2/10/26 at 3:50pm V18, Former Director of Nursing, stated V18 did not recall any intervention being put in place for R112's fall on 1/31/26. V18 stated the CNA should not have turned away from R112 when R112 was in the bathroom to walk around the wheelchair. V18 stated if the CNA was facing R112, the CNA would have seen R112 attempting to stand up and been able to redirect R112 to sit down and prevent the injury. On 2/11/26 The Fall Prevention Program/Policy dated 11-28-12 documents the 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. The Program further documents Care plan incorporates: Identification of all risk/issue; Addresses each fall; Interventions are changed with each fall, as appropriate- Preventative measures--Standards: A Fall Risk Assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines. A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. Safety interventions will be implemented for each resident identified at risk. Fall/safety interventions may include but are not limited to: The resident's environment will be kept clear of clutter which would affect ambulation and remove hazards. 4.) R1's fall prevention Care Plan with a revision date of 8/8/25 documents a 6/24/25 intervention to have floor mats on each side of bed. On 2/08/2026 at 9:14 AM, R1 was lying in bed. A fall mat was leaning against the wall by the door. There was not a fall mat in place on R1's right side of the bed on the floor. On 2/08/2026 at 1:36 PM, R1 was lying in bed. A fall mat was leaning against the wall by the door. There was not a fall mat in place on R1's right side of the bed on the floor. On 2/08/2026 at 1:36 PM, V6 Licensed Practical Nurse stated that R1 was supposed to have the fall mat on the floor on both sides of the bed when R1 is in bed. 5.) R17's fall prevention Care Plan with a revision date of 5/19/25 documents R17 is at high risk for falls. This care plan documents a 10/10/25 interventions for activities to provide working task for R17. This care plan also includes a 9/15/25 intervention for a concave mattress and a 10/29/25 intervention for skid strips to be placed by the bed. On 2/10/2026 at 3:12 PM R17 was lying in bed, R17 was lying on a regular mattress and not on a concave mattress. At this time, there were no non-skid strips observed by the bed. On 2/11/2026 at 9:53 AM, V7 Certified Nurse Assistant stated she has worked in the facility since August of this year and has taken care of R17 since starting in the facility. V7 stated she has never seen a concave mattress on R17's bed or non-skid strips on the floor. On 2/11/2026 at 8:49 AM, R17 was sitting in the television room holding a news flyer. R17 was not working on any type of a task at that time. On 2/11/2026 at 10:00 AM, V32 Activity Aide stated R17 occasionally participates in activities. V32 stated she is not familiar with the interventions about a working task for R17. V32 stated they do not always communicate the interventions to her. On 2/11/2026 at 10:04 AM, V1 Administrator stated R17's interventions of the concave mattress and the non-skid strips should have been put into place. V1 stated the intervention about the working task on R17's care plan was not measurable and unclear and that this intervention should be conveyed to the activity staff.

Based on observation, interview, and record review, the facility failed to accurately transcribe an order for Seroquel (antipsychotic), failed to administer an antiparkinsonian medication as recommended prior to meals and failed to ensure medications were taken by the resident for three of 46 residents (R7, R83 and R44) reviewed for medications in the sample list of 46 residents. This failure resulted in exacerbation of R7's behavioral symptoms related to dementia when R7 missed 13 days of R7's antipsychotic due to a transcription error. Findings Include:1.R7's Care Plan updated 11/6/25 documents the following diagnoses: Type II Diabetes, Alzheimer's Dementia, Repeated Falls, and Major Depression.R7's Minimum Data Set (MDS) dated [DATE] documents R7 has no behavioral symptoms.On 2/8/26 at 9:00AM R7 was in his bed watching television (TV). The Surveyor knocked on R7's open door. R7 shouted What and who the H*** are you. The Surveyor introduced self and identified to R7 we are here from IDPH (Illinois Department of Public Health) to talk with residents about the care they receive at the facility. R7 seemed very agitated and shouted Well if you are from the F******(expletive) state get me out of here now. I am being held prisoner. That F******(expletive) B****(expletive) had them arrest me. The Florida state police went into Georgia and arrested me and brought me to Illinois. R7 beat his fists on the bed rail and shook the bed. The Surveyor replied she could see how upset R7 was and would let him get back to his TV. R7 became even louder and continued to pound on the bed with his fists. R7 shouted You F******(expletive) B****(expletive) if you are with the state why can't you get my A**(expletive) out of here and get my money back.On 2/8/26 at 3:00PM V1, Administrator stated we are aware (R7's) behavior is escalating and he has been seen by (a contracted psychiatric provider). V14, Corporate RN and acting DON stated (R7) is very suspicious of his POA (Power of Attorney), he doesn't like women and his behavior related to Dementia is really increasing.R7's Psychiatric Notes dated 12/10/25 by V17, Physician's Assistant (PA) for psychiatric contractor document an order for: Med Changes: Patients diagnosis of Major Depressive Disorder is worsening and unstable at this visit. Increase Sertraline to 100Mg in the AM. Start Trazadone 25Mg at HS (bedtime). Start Quetiapine 25Mg PO (by mouth) every 6 hours PRN (as needed). Continue Quetiapine 50Mg (Daily) for agitation related to Dementia. Continue Memantine 5Mg daily for cognitive decline related to Dementia.R7's Medication Administration Record (MAR) for February and R7's current Physician's Order Sheet document R7's Quetiapine 50Mg was discontinued in error on 1/28/26 and no PRN doses were administered.On 2/9/26 at 2:00PM V14 acting DON verified that the Quetiapine was discontinued in error and R7 had missed doses from 1/28/26 until the surveyor brought this error to the facility's attention on 2/9/26 totaling 13 doses. On 2/10/26 at 12:30PM V17 Psychiatric PA stated It was my intention to continue (R7's) dose of 50Mg Quetiapine daily. (R7) was having increasing agitation and aggressive behavior. It is never a good idea to stop an antipsychotic without tapering and I rarely give a PRN order for antipsychotic especially in a senior, but I spent nearly an hour with (R7), and I really thought it was justified. I do believe that stopping (R7's) quetiapine so abruptly caused (R7's) behavior to escalate even more.The package insert for Seroquel revised January 2022 documents Acute withdrawal symptoms such as insomnia, nausea, and vomiting have been described after abrupt cessation of an atypical antipsychotic drugs including Seroquel.On 2/11/26 at 1:00PM V1, Administrator and V14 Acting Director of Nurses verified R7's behaviors including cursing, isolating, shouting, and refusal of care have increased since R7 has not received the correct dose of Seroquel.On 2/11/26 at 2:00PM V11, Activity Director stated Since the end of January (R7) has not come to activities at all. I have heard him in his room shouting and cursing. I was helping pass trays on Sunday (2/8/26). I took (R7's) tray to him. He pointed at the tray table, and I placed the tray on it and went to get another tray. As I was walking by his room, I heard a commotion and (R7) had knocked his tray off the table and across the room. (R7) is more agitated.2. R83's Care Plan initiated 1/7/26 documents the following diagnoses: Depressive Disorder, History of Fracture of Right Femur with Hip Replacement, and Parkinson's Disease.R83's Minimum Data Set (MDS) dated [DATE] documents R83 as moderately cognitively impaired.On 2/8/26 at 1:00PM V43 (R83's family member) stated When (R83) was ordered the Carbidopa/Levodopa we were told to always give it 30-60 minutes prior to food because high protein food interferes with the absorption of the medication. It is ordered here at 5:00AM, 11:00AM, and 5:00PM. They tell me they have one hour before and one hour after to give his medication. It is sometimes before and sometimes after and sometimes with meals and I think it's causing (R83's) Parkinson's symptoms to get worse.R83's Medication Administration Record (MAR) for February 2026 documents Sinemet Oral Tablet 25-100 MG (Carbidopa-Levodopa) Give 1 tablet by mouth three times a day related to PARKINSON'S DISEASE WITH DYSKINESIA, WITH FLUCTUATIONS. The package insert for Levodopa/Carbidopa 25/100 documents The patient should be advised that a change in diet to foods that are high in protein may delay the absorption of levodopa and may reduce the amount taken up in circulation. Excessive acidity also delays stomach emptying, thus delaying the absorption of levodopa. Iron salts (such as in multivitamin tablets) may also reduce the amount of levodopa available to the body. The above factors may reduce the clinical effectiveness of levodopa or carbidopa-levodopa therapy.On 2/9/26 at 1:30PM V13, R83's primary physician stated The timing 30-60 minutes prior to meals for (R83's) Sinemet is crucial for absorption of this medication. If it isn't given prior to meals high protein food will compete with the medication for absorption. If Sinemet is being given incorrectly I believe this is causing (R83's) increase in Parkinson's symptoms.On 2/8/26 V10, Licensed Practical Nurse verified medications are given within one hour prior or one hour after the time on the MAR. V10 stated I have 35 residents to get meds out to. Have you ever had to do that?On 2/9/26 at 2:15PM V14, Acting DON (Director of Nursing) confirmed R83's medication had been given without regard to meals.3. R44's Minimum Data Set (MDS) dated [DATE] documents R44 is cognitively intact. On 2/10/26 at 10:00AM R44 stated Sunday evening (2/8/26) the agency nurse that was working left all my evening meds on the dresser for the empty bed next to me. I didn't remember I hadn't taken them until (V28), Activity Assistant found them the next day. I missed all my evening meds.R44's MAR documents the medications due at 8:00PM include the following: Amlodipine (antihypertensive) 5Mg twice daily, Atorvastatin (anticholesterol) 40mg at bedtime daily,Lisinopril (antihypertensive) 40 mg at bedtime daily, Senna (laxative) 8.6 mg two tablets at bedtime daily, Eliquis (anticoagulant) 5 mg twice daily, Famotidine (pump inhibitor) 20mg twice daily, Keppra (Antiseizure) 1000mg twice daily, Metoprolol (Beta Blocker) 37.5 mg twice daily.On 2/10/26 at 11:00AM V14, Acting DON verified V28 found R44's 8:00PM medications in a cup. V14 verified the medications were identified as all V14's 8:00PM medications.On 2/10/26 at 11:15AM V1, Administrator verified R11 did not receive any of her 8:00PM medications on 2/8/26 as they were left in a cup sitting on the dresser by an agency nurse.The facility's policy Physician's Orders Entering and Processing revised 1/31/18 states Following a physician's visit, a licensed nurse will check for any orders that require confirmation under: Clinical, Orders, Pending Orders. The orders will be confirmed by the nurse and instructions for the order will be completed.

Failures at this level required more than on deficient practice statement:A .Based on interview and record review the facility failed to complete a thorough admission process including greeting the resident within 15 minutes of arrival, providing access to the call light, notifying the pharmacy of resident's arrival, faxing prescriptions to the pharmacy within two hours, admission assessment including care plan focus, pain observation assessment, and fall assessment with transfer status. This failure affected one of five residents (R7) reviewed for quality of care on the sample list of 30. This failure resulted in R7 experiencing significant physical pain, severe anxiety and feelings of being disregarded by staff.B. Based on interviews and record review the facility repeatedly failed report the results of a Chest X-ray to the physician, which resulted in a four delay in treatment for a resident (R4) with pneumonia. R4 is one of six residents reviewed for infection/treatment on the sample list of 30.Findings include: A. R7's Hospital Discharge After Visit Summary documents that R7 was discharged to the facility on [DATE], status post left total knee replacement surgery. Discharge orders included instructions to call the physician's office for any severe, uncontrolled pain. R7's pain medication orders included Hydrocodone 5/325 mg, take 1–2 tablets by mouth every four hours as needed for moderate or severe pain. Additional pain medication orders included Hydromorphone 4 mg by mouth every four hours as needed for moderate to severe pain; Morphine 15 mg by mouth every 12 hours; and Tizanidine 4 mg, two tablets by mouth every six hours as needed for muscle spasms. R7's medical diagnoses included chronic pain status post motor vehicle injury, morbid obesity, and left knee osteoarthritis status post total knee arthroplasty. R7 was to continue Dilaudid, as she had been taking this medication chronically prior to surgery. R7's undated Hospital Report Note Sheet documents that a report was received from hospital staff indicating R7 is a [AGE] year-old female who underwent a left total knee arthroplasty on 11/13/25. R7 was admitted to the facility for post-surgical pain control. R7 required a gait belt and one-person assist with a walker for transfers and was completely cognitively intact. R7 was taking Dilaudid, Morphine, and Hydrocodone for pain control. Morphine was next due at 9:00 p.m. Controlled substance prescriptions were sent with the hospital discharge packet. R7 was last administered four milligrams of Dilaudid at 4:00 p.m. and was to receive a Hydrocodone tablet prior to transport to the facility. R7 was referred to a pain specialist for pain management and was expected to arrive at the facility after 6:00 p.m. On 12/23/25 at 12:00 p.m., R7 stated she was admitted to the facility on [DATE] at approximately 6:15 p.m. R7 stated she was transported from the hospital to the facility and arrived in her room with a roommate but did not see a facility staff member until after 8:00 p.m. At approximately 8:00 p.m., R7's roommate activated the call light, and V55, Certified Nursing Assistant (CNA), responded. R7 stated she asked V55 to assist her to the bathroom, and V55 instructed her to use her walker and take herself to the bathroom. R7 stated she had not walked independently since surgery and was supposed to have staff walking beside her using a gait belt. R7 stated she was very scared she might fall and injure her new knee and felt very unsteady and unsure of her ability to safely transfer. R7 stated she was already in significant pain because the last time she received pain medication was prior to leaving the hospital. R7 stated that when she walked back from the bathroom, V55 watched her walk but did not assist her or help her get her legs back into bed. R7 stated her bed was broken, the remote did not work, and she was not provided a call light. R7 stated she told V55 she felt that since arriving she had not seen any staff and felt like no one even knew she was there. R7 stated that at approximately 9:00 p.m., V11, Licensed Practical Nurse (LPN), entered the room and told R7 she knew she was there but had not yet made it back to see her. R7 stated V11 did not complete an assessment, ask questions, or assess her surgical knee. R7 stated she told V11 she was in pain and requested pain medication. V11 told her she was unsure whether she had any pain medication available to administer. R7 stated she repeatedly told V11 she was in severe pain and that something did not feel right, but V11 offered no solution. R7 stated V11 left the room and did not return with any pain medication. R7 stated she later took herself to the bathroom again and still did not have access to a call light. After returning to bed, R7 stated she found the call light on the floor next to the bed. R7 stated that approximately two hours later, around 12:00 a.m., she used the call light to request help because she could no longer tolerate the pain and discomfort. R7 stated she felt disregarded and not cared for. R7 stated she was in severe pain and felt she had suffered long enough. She stated no nurse had assessed her, no one was addressing her pain, and she felt forgotten, anxious, and scared something was wrong with her knee because the pain was unbearable. R7 stated that at approximately 12:00 a.m., V12, Licensed Practical Nurse (LPN), entered her room, asked about her pain, and left to determine why she had not received pain medication. V12 returned shortly thereafter, apologized, and informed R7 that her pain medication prescriptions had not been faxed to the pharmacy upon admission and that she would fax them herself. R7 stated V12 informed her that once the pharmacy received the prescriptions, V12 could request a code and access the medications from the emergency medication supply; however, V12 was unsure how long the process would take. R7 stated she was fed up and requested to leave the facility and return to the hospital. V12 contacted emergency medical services, and R7 stated she was transferred to the hospital at approximately 1:30 a.m. on 11/20/25, where she was treated for uncontrolled pain. R7's Nursing Progress Note dated 11/20/25 at 1:10 a.m. documents that R7's prescribed pain medications were not delivered by the pharmacy and were not available through the facility's emergency medication supply. The prescriptions required refaxing, and a new access code was required for medication retrieval. At 1:00 a.m., R7 was tearful, shaking, and stated she could not wait any longer for pain medication, requesting transfer to the emergency room. On 1/7/26 at 3:37 p.m., V12, Licensed Practical Nurse (LPN), stated she was the nurse who cared for R7 overnight on 11/19/25–11/20/25 and sent her to the emergency room. V12 stated she assumed care of R7 at 10:00 p.m. V12 stated she was alerted by an unknown staff member of R7's severe left knee pain multiple times between 11:00 p.m. and 1:00 a.m. and did go to see R7 to address her pain. V12 confirmed R7 was admitted earlier in the evening at approximately 6:30 p.m. and had not received any prescribed pain medications since arrival. V12 stated that a full admission assessment and admission process were not completed for R7. V12 stated R7's controlled substance prescriptions were not faxed to the pharmacy until approximately 1:00 a.m. V12 stated she received only a minimal report on R7, was unfamiliar with her history, and was unable to identify R7's assigned physician. V12 stated that when she first assessed R7 around midnight on 11/20/25, R7 was in extreme pain, visibly upset, shaking, and requesting transfer to the emergency room. On 1/6/26 at 1:54 p.m., V48, Regional Nurse, confirmed nursing staff should have completed the admission process, greeted the resident upon arrival, ensured access to a call light, notified the pharmacy of the resident's arrival, faxed prescriptions within two hours, and completed admission assessments including pain assessment, fall risk assessment, transfer status, and care plan focus. V48 stated staff should have addressed R7's pain before it escalated and acknowledged that failure to do so caused undue stress and pain for R7. B. R4 was discharged from the facility on 12/08/25. R4's most recent diagnoses sheet documents chronic obstructive pulmonary disease with acute exacerbation and pneumonia, unspecified organism. R4's chest X-ray, performed by a private company on 11/13/25, documents the X-ray was completed and reported to the facility on [DATE] at 9:36 p.m. Procedure: Chest, two viewsClinical Information: Cough, congestion, other pulmonary embolism without acute cor pulmonale, and acute systolic congestive heart failure. Significant Findings: No abnormal radiopaque foreign body Cardiac silhouette normal No visible pneumothorax No radiographic evidence of pulmonary edema Opacities in the right lung base Impression:Opacities in the right lung base, which may be due to atelectasis or pneumonia. The facility's Infection Control Log dated November 2025 documents that on 11/17/25, R4 was diagnosed with pneumonia of an unknown organism and was started on antibiotic therapy. R4's Nursing Progress Note dated 11/17/25 at 8:00 a.m. documents: Writer called V45, physician, due to resident R4's chest X-ray results and condition. Resident extremely congested and coughing; vital signs within normal limits. R4's Nursing Progress Note dated 11/17/25 at 10:00 a.m. documents: Office staff from V45 returned call with new diagnosis of pneumonia and new orders for antibiotic therapy for 10 days and DuoNeb treatments as needed. Appropriate parties notified. R4's Medication Administration Record (MAR) dated 11/01/25–11/30/25 documents the following medication:Amoxicillin 675 mg by mouth twice daily for pneumonia, unspecified organism, for 10 days. The MAR further documents R4 did not receive the antibiotic until 11/17/25 at 8:00 p.m., four days after the chest X-ray results were reported to the facility. The MAR also documents: Ipratropium-Albuterol 0.5–2.5 mg/3 mL solution, inhale one vial by mouth every four hours as needed for cough, congestion, and shortness of breath, start date 11/17/25. On 12/30/25 at 1:50 p.m., V2, Director of Nursing/Infection Preventionist, acknowledged that the delay in antibiotic and respiratory treatment for R4's confirmed pneumonia resulted in prolonged infection and symptoms.

Failures at this level required more than one deficient practice statement.A. Based on observation, interview, and record review, the facility failed to effectively supervise a cognitively impaired resident to prevent repeat traumatic falls requiring emergency transfers to the hospital for evaluation and treatment. These falls resulted in R1 sustaining a large head hematoma, skin tear to the knee, and pain in R1's head, neck, back, and pelvis. These failures affect one resident (R1) of three reviewed for falls in the sample of three. B. Based on record review and interview the facility failed to complete a thorough fall investigation to determine root cause of a fall in order to implement a targeted intervention. The facility also failed to assess a resident for the use of side rails, failed to complete neurological assessment post unwitnessed fall, failed to document frequent safety checks post fall, and failed to care plan measurable time intervals for the frequency of safety checks to prevent falls. These failures affect one of three residents (R6) reviewed for falls on the sample of three.Findings include: A. 1. R1's diagnosis list (printed 12/30/2025) documents that R1's diagnoses include dementia, syncope (fainting) and collapse, difficulty in walking, muscle wasting and atrophy, pain, cognitive communication deficit, depression, and anxiety. R1's Resident assessment dated [DATE] documents R1 has severely impaired cognition and requires substantial/maximal staff assistance for transfers, including going from a seated position to a standing position. The same record documents R1 does not have behaviors, delusions, or hallucinations. R1's Fall Risk assessment dated [DATE] documents R1 is at risk for falls. The facility fall log (September–December 2025) documents R1 had an unwitnessed fall in the facility on 9/26/2025. The facility Fall Investigation dated 9/26/2025 documents staff overheard R1 gasp and then found R1 on the floor in the living room of the facility's memory care unit. The same record documents R1 reported hitting R1's head on the floor and complained of head pain. R1 was noted to have redness and swelling to the left side of R1's head. The record further documents R1 experienced a skin tear to R1's knee, complained of knee pain, and was transferred to the hospital emergency department via ambulance for evaluation and treatment. R1's hospital emergency department report dated 9/26/2025 documents R1 complained of neck and pelvis pain while at the hospital and required multiple computed tomography (CT) radiographic scans to evaluate possible injuries. R1's Pain Level Summary dated 9/26/2025 documents R1 did not assess positive for pain in the weeks prior to the 9/26/2025 fall and then scored 7 out of 10 for pain immediately following the fall. R1's Pain Observation dated 9/26/2025 documents R1 experienced new-onset back and neck pain following the 9/26/2025 fall. R1's diagnosis list (printed 12/30/2025) documents that R1's diagnoses include dementia, syncope (fainting) and collapse, difficulty in walking, muscle wasting and atrophy, pain, cognitive communication deficit, depression, and anxiety. R1's Resident assessment dated [DATE] documents R1 has severely impaired cognition and requires partial/moderate staff assistance for transfers, including going from a seated position to a standing position. The same record documents R1 does not have behaviors, delusions, or hallucinations. R1's Fall Risk assessment dated [DATE] documents R1 is at risk for falls. The facility fall log (September–December 2025) documents R1 had an unwitnessed fall in the facility on 12/11/2025. R1's Progress Notes dated 12/11/2025 document R1 had an unwitnessed fall in the facility and was found by staff on the dining room floor of the memory care unit, screaming, Get me up. The same record documents R1 reported hitting R1's head, complained of dizziness and pain, and staff noted a knot and bruising to the left temple area. R1's Progress Notes dated 12/13/2025 document R1 must be supervised closely due to continuing attempts to get up from the wheelchair to walk independently. The facility Fall Investigation dated 12/11/2025 documents V33 (Licensed Practical Nurse) overheard V39 (Certified Nurse Aide) exclaim, (R1) just fell. The investigation documents R1 was not under direct staff supervision at the time of the fall, had impaired safety awareness, and attempted to get up from the wheelchair to walk. The report documents R1 fell onto the dining room floor when the wheelchair rolled backward due to the brakes not being applied. R1 was transferred to the hospital emergency department via ambulance for evaluation and treatment. On 12/30/2025 at 2:20 PM, V39 (Certified Nurse Aide) reported working the night shift on 12/11/2025 when R1 experienced the fall in the memory care dining room. V39 reported R1 repeatedly attempted to get up from the wheelchair and staff redirected R1 to sit down. V39 reported no staff were present with R1 at the time of the fall, as staff were taking residents to their rooms following supper. V39 reported believing R1 fell face down and noted a knot on R1's forehead following the fall. On 12/30/2025 at 2:55 PM, V2 (Director of Nursing) reported R1 does not have intact safety awareness and frequently attempts to self-transfer from the wheelchair. V2 reported not being aware of the presence of auto-locking brakes on R1's wheelchair prior to the 12/11/2025 fall and stated these behaviors had been occurring for a long time. R1's hospital emergency department report dated 12/11/2025 documents R1 had an unwitnessed fall resulting in a medium egg-size forehead hematoma, complained of pain to the forehead and back of the head, and required multiple CT scans to evaluate possible injuries. The same record documents R1 was given one gram of acetaminophen and discharged back to the nursing home with new orders for pain medication (325–650 mg acetaminophen orally every 6–8 hours as needed) and application of ice to the hematoma for 5–15 minutes every few hours. R1's Pain Level Summary dated 12/11/2025 documents R1 did not assess positive for pain in the weeks prior to the fall and scored 8 out of 10 for pain immediately following the fall. R1's Pain Observation dated 12/11/2025 documents R1 experienced facial pain with vocal complaints and facial expressions of pain following the fall. R1's Physician Orders dated 12/31/2025 document an order to monitor bruising of the left eye area until healed. R1's Treatment Administration Record (December 2025–January 2026) documents the forehead hematoma sustained on 12/11/2025 was not resolved as of 1/2/2026. R1's Care Plan (printed 12/30/2025) documents a resolved intervention related to fall risk and impaired judgment. The same record documents the intervention of adding auto-locking brakes to R1's wheelchair. On 12/24/2025 at 1:34 PM, R1 was observed seated in a wheelchair in the memory care living room with an approximately 1.5-inch egg-shaped purple hematoma on the left temple area from the 12/11/2025 fall. The facility Fall Prevention Program policy dated 11/21/2017 documents residents will be assessed for fall risk and appropriate interventions implemented, including supervision and assistive devices. B. R6's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status score of 2 out of 15, indicating severe cognitive impairment. The same MDS documents R6 was totally dependent on staff for bed mobility. There was no Fall Risk Assessment in R6's medical record before or after the fall on 9/5/2025. R6's Fall–Initial Occurrence Note dated 9/5/2025 at 11:03 PM documents R6 had an unwitnessed fall at 8:30 PM in the resident's room. R6 was found lying on the floor mat next to the bed after rolling out of bed. R6 was confused and unable to provide a coherent statement. Vital signs and pain assessment were documented, including a pain level of 5 out of 10. Neurological checks were initiated. No injuries were observed. R6's Unwitnessed Fall report dated 9/5/2025, documented by V60 (previous Director of Nursing), does not document a thorough investigation or identify predisposing environmental, physiological, or situational factors. A CNA witness statement dated 9/6/2025 documents R6 rolled out of bed and the bed was in the lowest position. No Fall Risk Assessment was completed after the 9/5/2025 fall. R6's second fall was inaccurately documented as witnessed. The Witnessed Fall report dated 9/30/2025 documents R6 was already partially out of bed and hanging from the side rail when observed. No CNA was identified, and no witness statements were included. Neurological assessments required for 72 hours were not completed as ordered. Only two assessments were documented. There was no bedside side-rail assessment in R6's medical record. R6 experienced a third unwitnessed fall on 11/19/2025. Although safety checks were ordered, no documentation exists showing they were completed. On 11/20/2025, R6 was transferred to the hospital due to neurological decline and passed away later that morning. On 1/9/2026, V2 (Director of Nursing) reviewed R6's fall investigations and confirmed deficiencies in investigation, assessment, neurological monitoring, care planning, and documentation. The facility Fall Prevention Policy revised 11/21/2017 outlines required assessments, interventions, documentation, and monitoring, including documentation of safety checks when implemented.

Based on interview and record review the facility failed to address a resident's post-surgical pain. This failure affected one of five residents (R7) reviewed for pain on the sample list of 30. This failure resulted in R7 experiencing a significant increase of uncontrolled pain which required hospitalization. This past non compliance occurred from 11/19/25 to 12/19/25. Findings Include: R7's Hospital Discharge After Visit Summary documents R7 was discharged to the facility on [DATE], status post left total knee replacement surgery. Discharge orders included instructions to call the physician's office for any severe uncontrolled pain. R7's pain medication orders included hydrocodone 5/325 mg, take one to two tablets by mouth every four hours as needed for moderate to severe pain; hydromorphone 4 mg by mouth every four hours as needed for moderate to severe pain; morphine 15 mg by mouth every 12 hours; and tizanidine 4 mg, two tablets by mouth every six hours as needed for muscle spasms. R7's medical diagnoses include chronic pain status post motor vehicle injury, morbid obesity, and left knee osteoarthritis status post total knee arthroplasty. R7 was to continue Dilaudid, which she had been taking chronically prior to surgery.R7's undated Hospital Report Note Sheet documents a verbal report was received from the hospital stating R7 is a [AGE] year-old female who underwent a left total knee arthroplasty on 11/13/2025. R7 was admitted to the facility for post-surgical pain control. R7 required a gait belt and one-person assistance with a walker for transfers and was cognitively intact. R7 was taking Dilaudid, morphine, and hydrocodone for pain control. Morphine was next due at 9:00 PM. Controlled substance prescriptions were sent with the hospital discharge packet. R7 last received 4 mg of Dilaudid at 4:00 PM and was to receive hydrocodone prior to transport to the facility. R7 was referred to a pain specialist for pain management and was expected to arrive at the facility after 6:00 PM.On 12/23/2025 at 12:00 PM, R7 reported she was admitted to the facility on [DATE] at approximately 6:15 PM and was already experiencing significant pain at that time. R7 stated no nurse entered her room until approximately 9:00 PM. R7 reported that at 9:00 PM, V11 (Licensed Practical Nurse) entered her room, and R7 informed V11 she was in pain and requested pain medication. According to R7, V11 stated she was unsure whether any pain medication was available. R7 reported she repeatedly stated she was in severe pain and that something did not feel right, but V11 provided no intervention. R7 stated V11 left the room and did not return with pain medication.R7 stated she used her call light at approximately 11:00 PM and informed an unidentified staff member she was in pain; however, no intervention occurred. R7 reported that at approximately 12:00 AM, she again used her call light because she could no longer tolerate the pain and discomfort. R7 stated she felt disregarded and not cared for, was in severe pain, and believed she had suffered long enough without relief. R7 reported no nurse had assessed her or addressed her pain, causing her to feel anxious and fearful that something was wrong with her knee due to the severity of the pain.R7 stated that at approximately 12:00 AM, V12 (Licensed Practical Nurse) entered her room, assessed her pain, and left to determine why pain medication had not been administered. V12 returned shortly thereafter, apologized, and informed R7 her medication orders had not been faxed to the pharmacy upon admission and that she would fax them. V12 explained that once the pharmacy received the prescriptions, a code would be needed to access the medications from the emergency medication supply, but the timeframe was uncertain. R7 stated she requested to be sent back to the hospital due to uncontrolled pain. Emergency medical services were contacted, and R7 was transferred to the hospital at approximately 1:30 AM on 11/20/2025, where she was treated for uncontrolled pain.R7's Nursing Progress Note dated 11/20/2025 at 1:10 AM documents R7's prescribed pain medications were not delivered by the pharmacy and were not available in the emergency medication supply. The prescriptions had to be faxed again, and a new access code was required. At 1:00 AM, R7 was tearful, shaking, and stated she could not wait any longer for pain medication, requesting transfer to the emergency department.On 1/7/2026 at 3:37 PM, V12 (Licensed Practical Nurse) stated she was the nurse responsible for R7's care overnight on 11/19-11/20/2025 and facilitated R7's transfer to the emergency department. V12 stated she assumed care of R7 at 10:00 PM. V12 reported she was notified by unidentified staff members multiple times between 11:00 PM and 1:00 AM regarding R7's severe left knee pain and did assess R7 during that time. V12 confirmed R7 was admitted earlier in the evening at approximately 6:30 PM and had not received any prescribed pain medications since admission. V12 stated the controlled substance prescriptions were not faxed to the pharmacy upon admission and were faxed at approximately 1:00 AM. V12 reported that when she assessed R7 shortly after midnight, R7 was in extreme pain, visibly distressed, shaking, and requesting transfer to the emergency department.On 1/6/2026 at 1:54 PM, V48 (Regional Nurse) confirmed nursing staff should have ensured R7's pain medication prescriptions were available upon admission and, if issues arose, should have contacted the physician for further direction. V48 stated staff should have addressed R7's pain proactively by completing pain assessments, administering ordered pain medications, and implementing non-pharmacological pain management interventions. V48 stated the failure to do so likely caused undue stress and severe pain for R7, who had a history of chronic pain and was a newly post-surgical resident.Prior to the survey date of 1/13/2026, the facility implemented the following corrective actions:On 12/17/2025, the Compliance Assurance Committee developed a plan of correction related to the failures involving R7 on 11/19/2025.On 12/17/2025, all nursing staff received formal training on pain assessments, pain management, admission processes, pharmacy practices, and documentation.On 12/17/2025, all related policies were reviewed and updated as needed.On 12/17/2025, the Quality Assurance Committee held an impromptu meeting to discuss improvement strategies.On 12/19/2025, the Quality Assurance Committee began conducting ongoing audits of all facility admissions to ensure proper admission processes were completed and no related issues occurred.

Based on interview, and record review the facility failed to complete a thorough investigation and implement/develop post fall interventions for three of three residents (R26, R16, R15) reviewed for falls in the sample list of 43. These failures resulted in R26 sustaining a fall requiring sutures and/or staples. Findings Include: 1.) R26's electronic Progress Notes documents the following: 9/8/24 at 5:56 AM, R26 had an unwitnessed fall in his room and was found on the floor with a laceration above the left eye. R26 was sent to emergency room where they glued the laceration and applied adhesive strips to the laceration. 9/18/24 at 7:15 PM, R26 had an unwitnessed fall in his room and was found on the floor laying on his left side. This note by V26 Licensed Practical Nurse documents R26 stated he hit his head and had complaints of left shoulder and hip pain. R26 was sent to emergency room for evaluation and returned with bruising above the left eye and a skin tear above the right eye. 10/13/24 at 3:01 PM, documents R26 was found lying on the floor next to his wheelchair. R26 had a laceration to the top of his head measuring five centimeters in length and was sent to the hospital for evaluation. Progress Note on 10/13/24 at 8:26 PM, document R26 returned to facility with seven sutures and five staples to his forehead. R26's current care plan last revised on 9/17/2024 does not contain any new fall interventions for R26's falls on 9/18/24 or 10/13/24. On 12/4/24 at 1:59 PM, V2 Director of Nursing stated the floor nurse updates care plans after a fall with fall interventions and V2 audits care plans to ensure the interventions are there. V2 confirms no fall interventions were initiated after R26's falls on 9/18/24 and 10/13/24. 37813 2.) R16's Continuity of Care Document printed 12/5/24 includes the following diagnoses: Difficulty Walking, Unsteadiness on Feet, Muscle Wasting/Atrophy. R16's Progress Note dated 11/22/2024 at 10:00AM documents (R16) observed in supine position on floor in hallway. (R16) reports that she lost her balance and fell forwards onto her right knee before positioning herself back onto her buttocks, then to supine position. (R16) denies hitting her head. Neurological signs Within Normal Limits. Range of Motion Within Normal Limits. x3 staff assist and full mechanical lift used to assist resident into bed. Resident voices complaints of pain to Right knee. 5cm x 2cm (centimeter laceration noted to right knee related to fall. Laceration cleansed and pressure applied. Resident sent to (hospital) related to right knee laceration. R16's Progress Note dated 11/22/2024 at 1:20PM documents (R16) returned to facility at this time via Emergency Medical Services transport. Seven intact sutures noted to Right knee. Band-Aid noted to L arm r/t (related to) tdap (tetanus) injection. (R16) denies pain. New orders received for Keflex 500 mg (milligrams) BID (twice a day) x 10 days. New order received for Nurse to remove seven sutures in 10-14 days. R16's Care Plan updated 11/1/24 does not document any new interventions to address the 11/22/24 fall with injury. The facility did not provide documentation a thorough fall investigation was completed nor a root cause of the fall was identified for R16's fall on 11/22/24. On 12/4/24 at 2:15 PM, V2 Director of Nursing stated the floor nurse updates care plans after a fall with fall interventions and V2 audits care plans to ensure the interventions are there. V2 confirms no new fall interventions were initiated after R16's fall on 11/22/24. On 12/4 24 at 2:30PM V1, Administrator confirmed that a root cause analysis was not completed following (R16's) fall 11/22/24. 50322 3.) On 12/2/24 at 10:00 AM, R15 states he had a fall with aide involvement mid-September causing refracture to R15's left femur head at surgical site. R15 states he was impatient waiting for help with transferring and the aide and himself tumbled about 1 week prior to his surgery. R15 states he returned to hospital on 9/23/24 but surgery was delayed 2 days related to facility not holding blood thinner as ordered, then R15 found to have UTI delaying surgery longer. R15 progress note dated 8/15/2024 at 09:08 PM documents R15 self-propelled into room and placed call light on. R15 was notified that the CNA (certified nurse assistant) was with another patient, and it wouldn't be long. R15 heard resident yelling for help. R15 was found kneeling with upper torso on bed, in a praying type of position. MD (medical doctor) and POA (power of attorney) notified. R15's fall assessment dated [DATE] documents R15 care plan was reviewed, and all fall interventions were in place, but does not document new interventions post fall. R15's medical record does not document post fall assessments, fall risk assessments, neurological assessments, or frequent vital signs. R15's hospital records dated 9/23/24 document R15's orthopedic surgeon's physical as follows [AGE] year-old male who is non-ambulatory who had a [NAME]-cervical neck fracture and was doing well post-operatively until an aide fell on top of him. Since that time, he reports increased pain in the operative hip area and severe at times with transfers. He is non-ambulatory baseline. He is seen in the pre-op holding area this morning and his surgery has been canceled due to ongoing UTI along with his Eliquis being continued until Saturday. Past surgical history that includes Hip Fracture Surgery (Left, 6/13/2024). R15's hospital records dated 9/25/24 documents physician notes as follows: recent history of left femoral neck fracture status post closed reduction of intramedullary fixation of the left hip 06/13/2024. Complicated by traumatic displacement of the intramedullary nail. Hip x-ray from 09/20/2024 showed interval loosening/osseous fracture around the femoral head screw with inferior displacement of the femoral head. On 12/03/24 at 1:30 PM V6 RN states that R15 had to have revision surgery from hardware malfunction due to wrong hardware originally placed in R15 hip. Denies any incident where resident and staff member fell prior to revision. V6 does confirm R15 had a fall on 8/15/24 because R15 is impulse and inpatient. Facility failed to provide an investigation from 8/15/24 fall, on 12/3/24 at 2:15PM, V1 administrator, offered a nursing progress note dated 8/15/24. V1 denies knowledge of fall after 8/15/24 for R15 that included staff.

Based on observation, interview, and record review the facility failed to protect a resident's (R2) right to be free from physical abuse by another resident (R1). This failure resulted in R2 experiencing psychosocial harm and fear of R1, and a bruise on R2's arm. This failure affected two of two residents (R1, R2) reviewed for abuse on the sample list of 10. Findings include: The facility's Abuse Prohibition and Reporting policy with a revised date of 11/28/19 documents the purpose of this policy is to protect residents from any kind of abuse. This policy documents, Special attention will be given to identifying behavior that increases the residents potential for abusing self or others or being the victim of abuse. These behaviors would include residents with a history of aggressive behaviors, residents who have behaviors such as; entering other residents rooms, residents with self-injurious behaviors, residents with communication disorders, and those who require heavy nursing care and/or are totally dependent on staff. Appropriate interventions to address identified behaviors will be included on resident care plans, and reviewed as/when change occurs. These interactions will be communicated to the direct care staff. If the incident involves alleged abuse and substantiated evidence indicates that another resident of the facility is the perpetrator of the abuse, then the Administrator shall take all the steps necessary to protect all residents in the facility from abuse until the alleged perpetrator can be evaluated. The facility's initial report dated 9/29/24 at 7:03 PM documents the facility is reporting a possible resident to resident incident the final report will follow. R1's Nurses Notes dated 9/29/24 at 1:07 AM by V8 Licensed Practical Nurse (LPN) documents R1 had been up all night pressing the call light but becoming agitated when staff enter the room. V8 attempted to administer R1's Risperdal (antipsychotic) and R1 grabbed the medication cup and threw it on the floor. V8 documents when she attempted to pick up the medication R1 became aggressive and hostile. R1's Nurses Notes dated 9/29/24 at 4:33 AM by V8 documents V8 was at the nurse's station and heard someone yell help me. V8 documents that she went to R2's room and saw R1 standing over her as R2 was laying on the floor. R1 became aggressive when V8 asked him to leave the room. V8 documents that Emergency Medical Services (EMS) and the police were called. On 10/1/24 at 9:30 AM, R2 stated that she remembers R1 coming into her room and grabbed her arm and pulled hard on it and pulled her onto the floor. R2 stated that R1 has come into her room before. R2 stated that when he comes in her room he gets real loud and the last time he came into her room he sat on her legs in her bed. R2 stated she doesn't want him in her room and stated that she is scared of him. On 10/1/24 at 10:32 AM, V8 stated on 9/29/24 that R1 was restless most of the evening and kept turning on his call light. V8 stated after about the third time of going into his room she offered R1 Risperdal and he grabbed the medication cup out of her hand and threw it on the floor. V8 stated when she tried to pick up the medication cup he came at her. V8 stated he was verbally aggressive and agitated so she left the room. V8 stated around 1:30 AM she heard a female resident yell for help and V8 went to R2's room. V8 stated that V14 Certified Nursing Assistant followed her into R1's room. When she entered R2's room she saw R2 on the floor and R1 was standing over her. V8 asked R1 to leave but he would not leave. V14 went around the back of R1 and over R2's bed to get to R1 and stayed between R1 and R2. V8 stated when V14 got on the floor with R2, R1 lunged at V14. V8 stated that when he went to try to hit V14, V8 wrapped her arms around R1 to try to stop him. V8 stated that more staff came into the room to help. V8 went to call V1 because V8 stated it was an abuse situation and needed to be reported. V8 stated then she called the EMS. V8 when she went back to the room R1 had the other nurse that came to help pinned in the closet doorway. V8 stated that the EMS and the police came shortly after and it took the EMS about 20 minutes to get R1 on the gurney to take him to the hospital for an evaluation. V8 stated that R2 told her R1 came into her room and told her to get up that they had s**t to do and grabbed her arm and pulled her out of bed onto the floor. V8 stated that R2 had bruising to her left arm and said that her left hip was hurting. V8 stated that R2 looked frightened. On 10/1/24 at 11:12 AM, R2 stated that she did feel abused by R1. She said that he sat on her in her bed and then he threw her on the floor. R2 stated that she feels sorry for him (R1) but says she is afraid he (R1) is going to hurt someone. R2 stated that he (R1) should not be here. On 10/1/24 at 2:39 PM, V14 Certified Nursing Assistant (CNA) stated on 9/29/24 they heard someone yelling help and went into R2's room, where the yelling was coming from, and R1 was standing over R2. V14 stated that she made her way behind R1 and around R2's bed and climbed over R2's bed to get onto the floor with R2. V14 stated that R1 came at her and grabbed her arm and tried to choke her. V14 stated that he shoved the nurse into the wall a couple of times also. V14 stated that R2 told her that R1 came into her room and threw her covers off and told her that they had stuff to do and grabbed her arm and pulled her out of bed onto the floor. V14 stated that R2 was shaking and scared and asked if R1 was going to come back into her room. On 9/30/24 at 12:45 PM, R1 was very agitated with staff. R1 yelled at staff, kicked at them, swung his arms at them and pushed V17 Licensed Practical Nurse backwards. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired and he had physical and verbal behaviors directed towards others. R2's MDS dated [DATE] documents R2 is cognitively impaired. R2 repeatedly recalled the event the same each time she was interviewed.

Based on observation, interview, and record review, the facility failed to supervise and provide assistance to a resident (R1) with a known history of falls. This failure resulted in R1 sustaining a facial laceration, dental, and nasal bone fractures. R1 is one of three residents reviewed for falls in the sample of three. Findings include: R1's Physician Order Sheet (POS) dated April 2023 include the following diagnoses: Dementia, Fall, Laceration, Difficulty in Walking and Long-Term Use of Anticoagulants. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as being moderately cognitively impaired, needing supervision when walking with the use of a walker. R1's Care Plan (current) documents a problem area of Fall Risk and includes the following interventions: Fall on 2/21/23 and 4/5/23. Interventions on this same Plan of Care document that staff are to give verbal reminders to R1 not ambulate without R1's walker and to cue and encourage R1. On 4/19/23 at 9:35 am, V4 (MDS/Care Plan Coordinator) confirmed that R1's coding assessment on R1's MDS dated [DATE] indicates that R1 needs direct supervision from staff; That means staff should have their eyes on (R1) when (R1) is up in common areas. (R1) needs to be reminded to use (R1's) walker when ambulating. A facility report dated 4/5/23 documents that R1 was unsupervised by facility staff in the dining room and was found face down on the floor. R1 was transferred to the local emergency roiagnom on this same date for injuries to R1's face. The emergency room Notes dated 4/5/23 document the following: Post- Fall - Head Trauma, Right Knee Injury, Nasal Bone Fracture, Dental Injury, Right Hip Pain, Left Shoulder Pain, Facial Contusion and Facial Trauma (lip laceration). A 4/5/23 Computed Tomography (CT) Scan is referenced in the above emergency room documents R1 has Nasal Bone Fracture and Teeth Fractures. The actual Hospital CT scan of Head without Contrast dated 4/5/23 documents: Reason for Study: Ground Level Fall, landing face first, no loc (loss of consciousness), pain left orbit, left cheek, bridge of nose, and mouth. Findings: There appears to be a minimally displaced left nasal bone fracture and Left Orbital swelling. On 4/18/23 at 2:00 pm R1 was sitting in the common area. R1's front teeth are broken approximately three quarters off. R1's nose is slightly swollen, healing right lip laceration and left facial area is greenish yellow in color. R1 stated Oh, I fell about 5 months ago and I am just beat up. On 4/19/23 at 1:08 pm V3, Regional Consultant, confirmed that R1 was unsupervised by staff in the common area on 4/5/23 and stated that staff should have been there to remind R1 to use R1's walker. V3 also confirmed there are 18 residents on R1's unit and there were three Certified Nursing Assistants working on 4/5/23 and reiterated again there should have been staff in the common area with their eyes on R1.

Based on interview and record review the facility failed to follow facility policy regarding emergency care for falls, resulting in a delay in assessment, physician notification and treatment for a resident. This failure resulted in R200 experiencing unrelieved excruciating pain for approximately 20 hours from a fracture sustained from an earlier fall. R200 had a Markedly Displaced Comminuted and Angulated Intertrochanteric Fracture of the left femur for 24 hours without evaluation/treatment. This failure affects one (R200) of five residents reviewed for falls in the sample of 37. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 1/12/23 at 12:30 PM when R200 fell out of a shower chair during bathing and the facility failed to provide treatment and services to address a serious injury. V3 Regional Consultant was notified of the Immediate Jeopardy situation on 2/2/23 at 3:27 PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 02/07/2023, but noncompliance remains at Level two while the facility continues to in-service staff on providing one-to-one assistance and monitoring for those residents that are dependent on staff for cares, timely assessments, the facility's Emergencies Policy, and care plan revisions to ensure that the appropriate assistance, monitoring, and need for adaptive equipment is identified. Findings include: The facility's policy, with a revision date of 4/3/2018, titled Emergencies documents, It is the policy of this facility to provide emergency care to a resident in need of it. Immediate Care of the Resident- Falls: 1. Check the resident immediately for ability to move extremities, check for bruised areas and or cuts. 2. Check resident's ability to explain what happened; evaluate resident's condition before the fall. 3. Check if, or with anyone who witnessed the accident. Determine, if possible, where, how, when the accident occurred. 4. Check for any apparent dislocation or possible fracture, if any signs of this are noted, stabilize resident until ambulance arrives. 5. Exercise special care in transferring resident, being careful not to do more damage. 6. Notify the Physician. 7. If a head injury has occurred, notify the physician and monitor vital signs and neuro checks at least every 4 hours for twenty-four hours. The facility's policy, with a revision date of 4/2/2019, titled Accidents and Incident Report documents Procedure: A- Provide any necessary emergency care. B- Notify Charge Nurse, who then must promptly notify Physician and Family. D- If there is apparent injury or suspected injury, follow up must continue for at least 72 hours - vital signs, responsiveness, general condition, changes observed in injury sites, etc. R200's care plan documents, Problem Start Date: 09/19/2019 (R200) is at risk for injury due to falling related to generalized weakness, history of fall with injuries, osteoporosis, high blood pressure, cognitive decline from dementia and vitamin D deficiency. Approaches: Encourage to wear nonskid socks when not wearing shoes, Low Bed, Anti-tippers to wheelchair, Ensure that resident is sitting in front of a table with wheels locked when reading in her wheelchair. R200's Electronic Medical Record documents R200's medical diagnoses as Unspecified Dementia, Major Depressive Disorder, Vascular dementia, mild, Dysphagia, Vitamin Deficiency, Hypertension, Osteoporosis, Protein Calorie Malnutrition, Gastro Esophageal Reflux, Pain. History of Right Clavicle Fracture, History of Nondisplaced intertrochanteric fracture of Right Femur, and History of Vertebrae Fracture. On 1/30/23 at 2:45 PM V5 (Certified Nurse Assistant/CNA) stated, After lunch (R200) was in the shower room on the shower bench. I had not given (R200) a shower before. I was in the middle of the shower, (R200) was wet, I pivoted and turned away to move the wheelchair and (R200) slid off the shower bench between the wall and the shower bench. I don't remember which side (R200) was laying on. I know it is the policy to use the (mechanical lift) to get residents up after a fall, but I looked out into the hallway and didn't see anyone to help. I couldn't find help, (R200) was laying on the floor and was wet, so I picked (R200) up and put (R200) back into the wheelchair and then back to bed. I did not have a gait belt. I did not use a gait belt. I reported It to the nurse (V9) after it happened. R200's medical record documents on 1/12/2023 at 1:30 PM by V9 (Registered Nurse/RN) Certified Nurse Aide (V5 CNA) notified writer that while performing residents shower, he had resident sitting on the bench in (R200's) shower and when he went to remove the wheelchair resident slid from the bench to the floor. (notification) sent to Physician. On 1/31/23 at 10:28 AM V10 (CNA) stated, On 1/12/23 I came on shift at 4:00 PM, I did not get in report that (R200) had a fall. Around 4:15 PM (R200) was in bed and looked fine until I turned (R200) on her left side, (R200) then screamed out in pain and was crying grabbing a hold of her left hip area. I stopped and went and got (V9 RN). (V9) came to the room and examined R200, (V9) told me to go ahead and get (R200) up. (R200) continued to cry and scream out in pain when I was getting her out of bed. During the dinner meal (R200) was crying. (R200's) pain seemed to increase as the dinner meal went on. After dinner around 6/6:30 PM I put (R200) back to bed, (R200) screamed out in pain and was grabbing on to the left leg area during any movement I did with her. Around 9:00/9:15 PM I went back in (R200's) room to do a bed check and (R200) was having the same symptoms, R200 was crying out in pain with movement and holding R200's left leg. I was never told by (V9) to not move (R200) or not to get R200 up. On 1/31/23 at 12:50 PM V15 (CNA) stated, I was not in the shower room when (R200) fell . I worked all day until 10 PM that evening. Around 4:15 PM (V10 CNA) came and got me and asked me to come over and see (R200), (R200) was crying out in pain when we tried to roll (R200) in bed, it was not normal for her. Later that evening after supper I went into (R200's) room around 8:00 PM to check on (R200), when I rolled (R200) to change (R200) she was crying out again, I made the comment to her, 'I know your hip hurts and if you need to you can hit me in the face if it hurts.' (R200) was then reaching out trying to swat at my face. (R200) was not verbal, that was her norm. (R200) was in obvious pain. R200's medical record documents an Event report on 1/12/23 at 4:41 PM, Location of fall: Other: Shower room, describe surrounding environment: clear. Was the fall witnessed: Yes, CNA (V5). Pain Assessment: blank, no documentation is completed. Body Assessment: blank, no documentation is completed. Neurological Check: blank, no documentation is completed. Mental Status: blank, no documentation is completed. Possible Contributing Factors: blank, no documentation is completed. Recorded date: 1/12/23 at 4:41 PM, Completed date: 1/12/23 at 4:44 PM. On 1/31/23 at 9:45 AM V11 (Licensed Practical Nurse/LPN) stated, on 1/12/23 I was in my office and sometime between 6:30 to 7:00 PM (V9) came and got me and asked me if I can go put eyes on (R200) because (R200) had a fall earlier in the shift and (V9) was unsure how to check her for shortening or rotation because of (R200's) contractures to the lower extremities. We went in (R200's) room I told (V9) I was not going to move (R200) because of the contractures and that (V9) needed to notify the doctor. (R200) was whimpering. R200's medical record documents on 1/12/2023 at 6:49 PM, resident complaining of left leg pain, sent message and Fax to (V17 Physician) requesting order for x-ray of left leg and hip. R200's fax confirmation sheet signed and dated by V9 (RN) on 1/12/23 at 6:53 PM, documents Resident slid from shower bench to floor around 1:30 PM today. Resident is now complaining of left leg pain, may we get an order for an X-ray of her left hip and leg. On 1/31/23 at 2:00 PM V2 (Director of Nursing) stated, An electronic communication system is used to contact the physician. V2 confirmed, per the facility electronic physician notification system, the first time V9 (RN) notified V17 of R200's fall was at 4:46 PM on 1/12/23. V2 Confirmed another notification was made to V17 at 6:54 PM by V9 (RN) that R200 was complaining of leg and hip pain and asked for an order for a leg and hip x-ray. V17 (Physician) responded back ok at 8:18 PM on 1/12/23. R200's medical record documents on 1/12/2023 at 10:00 PM, Called (mobile x-ray company) to order x-ray, will be out in the morning to obtain x ray. 1/13/2023 at 9:22 AM, (Mobile X-ray Company) in the facility and a x ray complete at this time. Awaiting reports. 1/13/2023 at 12:26 PM, X-ray results received, and findings are as Acute intertrochanteric hip fracture. (V17) notified of x-ray findings and received order to send to Emergency Department for evaluation and treatment. R200's medical record did not document any further assessments or monitoring of R200 from 10:00 PM on 1/12/23 through 9:22 AM on 1/13/23, when the mobile x-ray provider arrived at the facility. On 2/1/23 at 10:50 AM V19 (CNA) stated, I worked with (R200) on 1/13/23, (that morning) I went in to get (R200) dressed and up for breakfast, (R200) was in a lot of pain, (R200) was moaning, it was so out of character for (R200), I told the nurse and was then told (R200) had a fall the day before. The nurse finally gave R200 something for pain about 30 minutes to an hour later. I did not get (R200) up, I left (R200) in bed the remainder of the day until (R200) went to the hospital. (R200) was moaning and saying ouch anytime we did any type of moving, rotating or turning with her that day. R200's emergency room Report documents, admitted : 1/13/23, Nursing home patient with advanced dementia was brought in by Emergency Medical Service because patient fell at nursing home and broke hip. Technique: AP pelvis and additional: Left Hip: there is a superiorly displaced fracture of the left hip, basically in the intertrochanteric region. CT scan of Pelvis, Impression: 1- Markedly displaced comminuted and angulated acute intertrochanteric fracture of the left femur. R200's medical record documents on 01/13/2023 at 5:25 PM, Resident arrived back from hospital at 5:20pm this evening. R200's medical record did not document any further assessments or monitoring of R200's condition from 1/13/23 at 5:25 PM through 1/15/23 at 12:42 AM. The facility's Investigation file documents: on 1/12/23 at 1:30 PM staff was providing (R200) a shower in her bathroom. Staff applied a towel to the bench, then assisted (R200) to the shower bench in the shower. When the CNA pivoted to move the wheelchair away from the immediate area, (R200) slipped on the bench and slid to the floor before the CNA could intervene. (R200) was assisted off the floor by staff, provided with hygiene care and then transferred to bed. When second shift was preparing to get (R200) out of bed for supper, CNAs reported to the nurse that (R200) appeared to be in pain, The nurse assessed (R200) and noted that she appeared to have pain in her left lower extremity, although (R200) could not verbalize her pain experience. On 1/13/22 (mobile x-ray) arrived at 9:22 AM for X-ray. 12:26 PM the x-ray reports came through with impressions that include: left femur x-ray, 1- acute intertrochanteric hip fracture, 2- Old Left pubic fractures, 3- Fixated right intertrochanteric fracture, sent to Emergency Department for evaluation. At the emergency room - CT of head impression: 3- Mild compression fracture of T2, age unknown. AP views of bilateral hips: Impression- 1- old right hip fracture with sliding hip screw, 2- difficult examination of the pelvis with possible fractures of the left pubic arch, 3- Comminuted Intertrochanteric fracture of the left hip. CT of the Pelvis- Impression: 1- Markedly displaced comminuted and angulated intertrochanteric fracture of the left femur. At the time of the incident, the resident was sitting on the shower bench and the shower was on, making the floor other surfaces slippery. The CNA had a towel placed on the bench. The room was well-lit, The CNA reported that wheelchair was placed near the shower for transfer and was in the way of him bathing the resident. As he pivoted to move the wheelchair, the fall occurred. R200 has a history of dementia, major depressive disorder, age related osteoporosis, Vit D deficiency, Hypertension, Diarrhea, Unspecified Severe Protein-calorie Malnutrition, and pain which increase her risk for falls and injuries secondary to falling. Resident is noted to have contractures and limited Range of motion in upper and lower extremities prior to this incident making sitting unsupported difficult. Based on this investigation, the probable root cause of the fall was the resident slipping on the shower bench due to a combination of slippery surfaces and poor trunk and limb control. On 1/31/23 at 8:20 AM V2 (DON) stated, (R200) fell in the shower room on 1/12/23. (R200) had gotten a shower from (V5 CNA). (V5) had sat (R200) on the shower bench in her room, which was not uncommon, (V5) turned his back to get (R200's) wheelchair, either (R200) slid to the floor or (R200) tried to stand up, we don't know because he only saw her sliding down onto the floor. Having the wheelchair closer or not turning back could have helped prevent (R200's) fall. (V5) said she was properly seated on the bench. (R200) has tried to get up from a seated position before. (V5) should have left (R200) on the floor and went and got the nurse to assess first before getting (R200) up. V2 stated, according to documentation, V9 did not immediately assess R200 after the fall. V2 stated, through interviews the first time a nurse was seen in (R200's) room after the fall was at 4:15 PM. V2 confirmed, R200's fall occurred on 1/12/23 around 12:30 PM after lunch, and sometime between the time of the fall and 1:30 PM V5 reported the fall to V9. V9 documented the fall occurrence in R200's progress notes and that the physician was notified. V2 confirmed there was no assessment of R200's condition documented in R200's medical record until 4:41 PM. V2 stated, At some point (V10 CNA) had reported to (V9) that something was going on with (R200) when she had gotten her up. Around 6:49 PM (V11) went in and did an assessment of (R200) with (V9). (V9) later got an order for an x-ray, an X-ray was completed the next day (1/13/23), (R200's) x-ray results showed a left hip fracture, (R200) was sent to the emergency room . V2 stated, The facility's policy for emergency plan is for the nurse to assess the resident before moving them, the nurse then determines if outside treatment is needed, if the resident is not able to get up on their own, then a full mechanical lift is used to get the resident up off the floor. Neuro checks are to be completed then, range of motion, vital signs, and an initial body check. The nurses are then to do neuro checks every four hours for 24 hours after a fall. Pain is assessed every shift, a follow up for 72 hours. V2 confirmed, V9 did not document any type of assessment of R200 until 4:41 PM, R200 was having pain, and R200 was gotten up for supper. V2 DON stated, symptoms that warrant dislocation or fracture are possible rotation, shortening, discoloration or pain. At 11:00 AM V2 stated, (V9) should have notified the ambulance, and sent R200 out to the emergency room . V2 stated, (V9) should have used nursing judgement and sent R200 out to the emergency room . On 1/30/23 at 2:00 PM V1 (Administrator) stated, V5 (CNA) and V9 (RN) were terminated due to not following facility policy and procedures. On 1/31/23 at 4:15 PM, V17 (Physician) confirmed, a fall from a shower bench could have caused the type of fracture R200 sustained. V17 stated, further movement after the fall did not cause further displacement, the fracture of this type occurred with the fall itself, this type of fracture is a very painful one, would cause a lot of pain. The Immediate Jeopardy that began on 1/12/23 was removed on 2/7/23 when the facility took the following actions to remove the immediacy. 1. On 2/7/23 V38 (Regional Nurse) and V37 (Interim Director of Nursing) have in-serviced all direct care staff present in the facility on providing one-to-one assistance and monitoring for those residents that are dependent on staff for cares including but not limited to bathing. The in-service stressed monitoring as well as the importance of immediately reporting any fall, and the importance of not moving a resident post fall, before he/she is assessed by a nurse. Agency Staff will receive an orientation to the facility, Its Policies and Procedures and EHR (Electronic Health Record). Direct care staff will not be allowed to work until they have completed the in-servicing. 2. On 2/2/23 V38 (Regional Nurse) has in-serviced Nursing staff on assessing residents after a fall. The in-service stressed the need for timely assessment including but not limited to having diagnostic x-rays and screening completed timely as well as notification of the resident's physician and family. 3. On 2/7/23 All residents were reviewed to ensure that the facility has properly identified all residents who are dependent on staff for cares including but not limited to bathing. The care plans for all of the residents identified as needing this support and those identified as being at high risk for falls will be reviewed to ensure that the appropriate assistance, monitoring, and need for adaptive equipment is identified. V38 (Regional Nurse) in-serviced Nursing and Direct care staff on those residents identified. 4. On 2/2/23 V38 trained on the facility Emergencies Policy to provide that any resident who experiences a fall where an injury has occurred, or an injury is possible will be sent to the hospital for evaluation. 5. V3 (Regional Consultant) confirmed Quality Assurance will monitor the implementation of the plan.

Based on interview and record review the facility failed to promptly notify the physician of an accident and immediately notify the physician of significant change in condition after an accident for one of seven residents (R200) reviewed for change in condition on the total sample list of 37. This failure resulted in R200 experiencing a delay in treatment for a fracture sustained from a fall. Findings include: The facility's policy, with a revision date of 12/2002, titled Change in Resident's Condition documents, Purpose: Our facility shall promptly notify the resident, and/or resident's representative and his or her attending physician of changes in the resident's condition and/or status. Procedure: 1- The nurse will notify the resident's attending physician when: a- The resident is involved in any accident or incident that results in an injury including injuries of unknown source. b- There is a significant change in the resident's physical, mental or psychosocial status. c- There is a need to alter the resident's treatment significantly. 4- The nurse will record in the residents medical record any changes in the resident's medical condition or status. R200's medical record documents on 1/12/2023 at 1:30 PM by V9 (Registered Nurse/RN) Certified Nurse Aide (V5 CNA) notified writer that while performing residents shower, he had resident sitting on the bench in (R200's) shower and when he went to remove the wheelchair resident slid from the bench to the floor. (notification) sent to Physician. R200's medical record documents an Event report on 1/12/23 at 4:41 PM, Location of fall: Other: Shower room, describe surrounding environment: clear. Was the fall witnessed: Yes, CNA (V5). Pain Assessment: blank, no documentation is completed. Body Assessment: blank, no documentation is completed. Neurological Check: blank, no documentation is completed. Physician notified: Yes, on 1/12/23 at 4:41 PM. R200's medical record documents on 1/12/2023 at 6:49 PM, resident complaining of left leg pain, sent message and Fax to (V17 Physician) requesting order for x-ray of left leg and hip. On 1/31/23 at 10:28 AM V10 (CNA) stated, On 1/12/23 I came on shift at 4:00 PM, I did not get in report that (R200) had a fall. Around 4:15 PM (R200) was in bed and looked fine until I turned (R200) on her left side, (R200) then screamed out in pain and was crying grabbing a hold of her left hip area. I stopped and went and got (V9 RN). (V9) came to the room and examined (R200). (V9) told me to go ahead and get (R200) up. (R200) continued to cry and scream out in pain when I was getting her out of bed. During the dinner meal (R200) was crying. (R200's) pain seemed to increase as the dinner meal went on. After dinner around 6/6:30 PM I put (R200) back to bed, (R200) screamed out in pain and was grabbing on to the left leg area during any movement I did with her. On 1/31/23 at 12:50 PM V15 (CNA) stated, I was not in the shower room when (R200) fell , I worked all day until 10 PM that evening. Around 4:15 PM (V10 CNA) came and got me and asked me to come over and see (R200), (R200) was crying out in pain when we tried to roll (R200) in bed, it was not normal for her. Later that evening after supper I went into (R200's) room around 8:00 PM to check on (R200), when I rolled (R200) to change (R200) she was crying out again. R200's medical record contained a fax confirmation sheet that was signed and dated by V9 (RN) on 1/12/23 at 6:53 PM, that documents Resident slid from shower bench to floor around 1:30 PM today. Resident is now complaining of left leg pain, may we get an order for an X-ray of her left hip and leg. On 1/31/23 at 8:20 AM V2 (Director of Nursing/DON) confirmed, R200's fall occurred on 1/12/23 around 12:30 PM after lunch, and sometime between the time of the fall and 1:30 PM, V5 reported the fall to V9. V9 documented the fall occurrence in R200's progress notes and that physician was notified around 1:30 PM. V2 confirmed there was no assessment of R200's condition documented in R200's medical record until 4:41 PM. V2 stated, At some point (V10 CNA) had reported to (V9) that something was going on with (R200) when she had gotten her up. Around 6:49 PM (V11 Licensed Practical Nurse) ) went in and did an assessment of (R200) with (V9). (V9) later got an order for an x-ray, an X-ray was completed the next day (1/13/23). V2 stated, according to documentation, (V9) did not immediately assess (R200) after the fall. V2 stated, through interviews the first time a nurse was seen in (R200's) room after the fall was at 4:15 PM. On 1/31/23 at 2:00 PM V2 stated, An electronic communication system is used to contact the physician. V2 confirmed, per the facility electronic physician notification system, the first time V9 (RN) notified V17 (Physician) of R200's fall occurrence was at 4:46 PM on 1/12/23. V2 confirmed another notification was made to V17 at 6:54 PM by V9 (RN) that R200 was complaining of leg and hip pain and asked for an order for a leg and hip x-ray. V17 (Physician) responded back ok at 8:18 PM on 1/12/23. V2 stated, symptoms that warrant dislocation or fracture are possible rotation, shortening, discoloration or pain. V2 stated, (V9) should have notified the ambulance, and sent R200 out to the emergency room . V2 stated, (V9) should have used nursing judgement and sent R200 out to the emergency room .

Based on interview and record review, the facility failed to promptly notify a resident's family of a change in condition. This failure affects one of three residents (R1) reviewed for falls on the sample of six. Findings include: R1's Progress Notes dated 11/23/2022 1:29 PM document R1's pain assessment was completed and R1 stated R1's left hip is hurting (R1) and it's a dull pain. There is no documentation V25 (R1's Family) was notified of R1's complaints of left hip pain on 11/23/22. On 1/5/23 at 11:20am, V25 stated V25 was unaware of R1's complaints of left hip pain that began on 11/23/22 until 11/24/22. V25 stated V25 was upset that V25 had not been notified promptly of R1's change in condition. V25 stated the facility is fully aware V25 is to be notified immediately. The facility's Change in a Resident's Condition policy dated 12/2002 documents the facility shall promptly notify the resident and or resident's representative of changes in the resident's condition and/or status. This policy documents the nurse will notify the residence representative when there is a significant change in the residence physical, mental, or psychosocial status.

Based on interview and record review, the facility failed to document thorough post fall investigations. The facility also failed to implement post-fall, fall prevention interventions. These failures affect two of three residents (R1, R2) reviewed for falls on the sample of six. These failures resulted in R1 having three falls during the month of November 2022. R1 was found to have a mildly comminuted fracture of the medial aspect of the superior left pubic ramus with mild displacement and angulation and a non-displaced fracture of the medial aspect of the inferior left pubic ramus. Findings include: 1.) a.) R1's Care Plans dated 4/19/22 document R1 is at risk for falls due to generalized weakness and history of falls. These care plans document R1 may have poor safety awareness related to a diagnosis of Dementia. These care plans include fall prevention interventions including to provide toileting assistance routinely and as needed. R1's Fall Risk assessment dated [DATE] documents R1 is a high risk for falling. R1's Fall Investigation dated 11/13/22 documents R1 has moderate impaired cognition. This investigation documents on 11/13/22 at approximately 11:45am, R1 was witnessed standing in R1's room between the two beds straightening the blankets on R1's bed and before V19 (Certified Nursing Assistant/CNA) could intervene, R1 lost R1's balance and fell . R1 was noted to be incontinent at the time of the fall. R1 was seen in the emergency room with no findings and came back to the facility with orders for Physical and Occupational Therapy for weakness and that these orders were already active. This investigation documents R1 has several considerations that increase R1's risk for falls including a past medical history of Non-traumatic Chronic Subdural Hemorrhage, Muscle Wasting and Atrophy, Dementia, Unspecified Lack of Coordination, Unsteadiness on Feet, Need for assistance with personal care, abnormal posture, pain, muscle weakness, and age-related osteoporosis as well as vitamin B12 deficiency anemia, insomnia, and vitamin D deficiency all of which increase R1's risk for falls and injury related to falls. This investigation documents the probable root cause of the fall was the resident standing to straighten (R1's) bedcovers. This investigation documents staff are to ensure bed is made if R1 is not in bed and to encourage R1 to call for assistance when straightening up R1's bed. R1's fall event report for this fall documents R1 stood up and fell back toward the bed, however R1's progress notes located within this fall event report document R1 leaned forward and fell down. R1 progress notes dated 11/13/2022 document at 1:03 PM the facility received a call from V25 (R1's family) voicing concerns related to R1's fall and V25 had noticed times of increased confusion with R1. This investigation does not document when R1 was last toileted. This investigation also documents R1's bed was already made at the time of this fall. This investigation documents a handwritten witness statement by V19 (CNA) documenting R1 was last seen at 10:00am, sitting in R1's wheelchair with reason of breakfast. This statement documents V19 was the only staff member on the unit at the time of R1's fall. There is no documentation of when R1 was last toileted prior to this fall. There is no documentation of an interview with R4, R1's roommate regarding this fall. On 1/10/22, the facility provided documentation of therapy service dates (evaluation dates and dates of therapy discharge) for R1 which include as follows: Physical Therapy - Evaluation date 4/19/2022 - discharge date [DATE] Evaluation date 10/2/2022 - discharge date [DATE] Occupational Therapy - Evaluation date 4/20/2022 - discharge date [DATE] Evaluation date 10/3/2022 - discharge date [DATE] Speech Language Pathology - Evaluation date 4/21/2022 - discharge date [DATE] Evaluation date 6/9/2022 - discharge date [DATE] There is no documentation R1's orders from R1's emergency room visit due to R1's fall on 11/13/22 for Physical and Occupational Therapy for weakness were active as the facility's investigation documents were. There is no documentation R1 received PT/OT as ordered by the emergency room . On 1/4/23 at 1:05pm, V19 (CNA) stated on 11/13/22 R1 had a fall and was found between resident beds, near the foot of the bed. V19 stated R1 likes to grab at everything including bed sheets and items that are on the floor such as ant bait stations. V19 stated on 11/13/22, R1's bed was made prior to the fall in hopes R1 would not try to fix the sheets. V19 stated V19 could not recall if R1's room call light was on but R4, R1's roommate would alert staff to R1 doing things R1 is not supposed to do and may have turned the light on. V19 stated V19 did not see the fall occur, V19 just found R1 on the floor. V19 stated R1 was incontinent at the time of this fall and that R1 had been toileted some time before breakfast. V19 stated he did not recall taking R1 to the toilet, but R1 had been provided with incontinence care. V19 stated V19 was unable to identify additional staff who were working on the unit at the time of R1's fall but since R1 did not document additional names on R1's written witness statement, the staff were probably agency staff. V19 stated V19 thought maybe R1 was trying to adjust bed sheets because of R1 was located near R1's bed, however V19 was unsure. b.) R1's Fall Investigation documents R1 had a fall on 11/16/22 at 7:30am. This investigation documents R1's cognition as moderately impaired. The investigation documents at approximately 7:30am, R1 was observed sitting on the floor on R1's buttocks in front of R1's wheelchair in the hallway. R1 reported mild left-hand pain with normal range of motion. There was a small bruise noted to the posterior left hand related to a blood draw on 11/13/22. This investigation documents prior to the fall, R1 had last been observed sitting in the hallway and R1 had been dressed and toileted 20 minutes prior to falling. R1 was incontinent of bladder at the time of the fall. R1 stated R1 just stood up and fell . This investigation documents immediate interventions including analgesics, alternate call and increased frequency of visual checks. R1's Investigation Report documents the root cause of R1's fall on 11/16/22 as self-transferring with interventions including staff to assist to the dining room upon rising in the morning and offer snack/beverage as R1 allows and orthostatic vital signs. There is no documentation as to an investigation in to why R1 was attempting to self-transfer. There is no documentation as to investigation in to R1's incontinence at the time of the fall. This investigation documents V19 and V31 (CNAs) were working on the unit at the time of R1's fall. V19's written witness statement dated 11/16/22 documents V19 thinks the fall occurred because (R1) was soaked and tried to stand up and that V19 last observed R1 at 7:00am to get dressed but does not document if R1 was toileted at that time or provided incontinence care. There is no documentation of a witness statement from V31. R1's progress notes dated 11/16/22 at 8:21 AM document Orthostatic vital signs were obtained with a lying blood pressure and pulse and two blood pressures and pulses while sitting. There is no documentation of a blood pressure or pulse while R1 was standing. R1's care plans dated 11/16/22 document R1's risk for falls and that R1 may have poor safety awareness related to Dementia with interventions including Orthostatic Vitals but does not include how often to complete the orthostatic vital signs. On 1/4/23 at 1:05pm, V19 stated V19 was working on the unit R1 resides on 11/16/22 when R1 was found on the floor. V19 stated staff were in the middle of getting residents up. V19 stated V19 was in a room and had come out of the room and found R1 sitting in front of the doorway. R1 was in the hall prior to the fall because the facility tries not to leave R1 alone in the wheelchair in R1's room due to wandering. V19 stated V19 could not recall if V19 got R1 ready that morning. V19 stated R1 is more of a brief change and that R1 was not offered/attempted to be taken to the bathroom for R1 to attempt to use the toilet. V19 stated if R1 was taken to toilet, it was R1 telling staff R1 wanted to be taken to the bathroom to use the toilet. V19 stated, if we took (R1) to the toilet we would have to stay with (R1) because (R1) would get up on R1's own. V19 stated R1 was pretty wet/soaked with urine at the time of this fall. c.) R1's fall investigation documents R1 had a fall on 11/24/22 at 8:43am. This investigation documents R1 is a high risk for falls. This investigation documents on November 24th, 2022, at 8:45 AM R1 was observed on the floor near the sink in R1's room. R1 was complaining of pain to R1's posterior head and R1's left hip. This investigation documents R1's range of motion was within normal limits and all extremities. Due to the use of anti-platelet medication combined with R1's head pain in addition to R1's hip pain the facility was concerned about R1's condition and felt R1 needed to be further evaluated. During R1's emergency room visit and X-ray of R1's hip with pelvis results document a non-displaced fracture of inferior pubic ramus on the right side. This investigation also documents, additionally, the resident has experienced significant weight loss over the past month from 108 pounds on November 8th, 2022, to 102 pounds on November 28th, 2022. This shows a general decline in the resident's condition. This investigation also documents R1 first complained of left hip pain on November 23rd, 2022, and R1's primary care physician was notified and a left hip X-ray was requested via fax. Later that same day the facility followed up with the office on the request for a left hip X-ray with no response to the request for an X-ray being received prior to the fall the following day. This investigation documents on the day of the fall R1 was assisted from bed and provided with morning cares including bruising R1's teeth and continence cares hair care and her face and hands were washed at approximately 7:30 AM. Prior to the incident R1 was last seen at 8:25 AM in her wheelchair in the hall. The wheels to R1's wheelchair were noted to be unlocked and R1 stated R1 was trying to get to the sink when R1 fell . This investigation documents based on the investigation the probable root cause of the fall was R1 self-transferring and standing unassisted to use R1's sink with post fall interventions of providing assistance for R1 to and from meals as R1 allows and to assist R1 to activities after breakfast and cares as R1 allows. R1's Event Report for this fall documents R1 complained of left hip pain following the fall with rotation/deformity of upper left extremity marked as present. Three written witness statements by V31, V32 and V33 (CNA) document R1 was last seen by staff at 8:25 AM that morning in the hallway. Two statements, V32 and V33 (CNA) document R1 was incontinent at the time of the fall. There is no documentation in the investigation that R1 had been taken to/provided assistance to use the toilet, only that R1's brief was clean and had incontinence cares provided. There is no documentation in the investigation related to rotation/deformity of left upper extremity marked as being present on the event for R1's fall on 11/24/22. This investigation documents R1's Hospital History and Physical dated 11/30/22 documents R1 is in distress and ill-appearing. This H&P documents R1 presented to the emergency room with recurrent falls, a right hip fracture as per V25 (R1's Family) which was non-operable. R1 presented to the emergency room and ended up being admitted with poor oral intake, severe dehydration, and dysphagia with right hip pain plus recurrent falls. Additional diagnoses include hypernatremia secondary to dehydration, recurrent falls at the facility. R1's X-ray results of the pelvis and right and left hip dated 12/1/22 document a mildly comminuted fracture of the medial aspect of the superior left pubic ramus with mild displacement and angulation. There is a non-displaced fracture of the medial aspect of the inferior left pubic ramus. These results do not document any right pelvic fractures. On 1/5/22 at 3:00pm, V2 (Director of Nursing/DON) stated V2 thought the fall investigations were being completed thoroughly but there is no documentation of some of the details in the investigations. V2 stated the facility usually just reviews the handwritten witness statements while completing investigations unless there are questions about what is written on the statements, the investigation does not include calling or interviewing witnesses. 2.) a.)R2's Care Plans dated 12/28/22 document R2 has potential for injury from falls related to generalized weakness and a history of falls. R2 may have poor safety awareness due to Dementia and has diagnoses including Parkinson's Disease, Bipolar, and Arthritis. These care plans document the goal is to reduce the risk for major injury related to falls with fall prevention interventions including to encourage and remind R2 to call for assist prior to toileting and for staff to provide toileting assistance routinely and as needed. R2's Fall assessment dated [DATE] documents R2 is a High risk for falls. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact. R2's Fall event form documents R2 had a fall on 12/13/22 at 11:20am. This form documents R2 was self-ambulating from R2's bathroom to R2's bed and lost balance and fell . This form documents R2's call light was on, and an unidentified Certified Nursing Assistant (CNA) was walking to R2's room and heard a crash and found R2 on the floor. R2 complained of pain and had an abrasion to the left shoulder. This form documents immediate measures and interventions taken including to complete neurological checks and observe R2. R2's Progress Notes dated 12/13/22 at 11:20am document R2 was observed sitting on the floor beside the bed. R2's back was resting on the side of bed with legs extended in front of R2. R2 stated R2 was walking from the bathroom with the walker and lost R2's balance and fell . R2 was reminded R2 requires assistance with ambulation. R2 was upset and stated it was the facility staff's fault for not helping R2. There is no documentation regarding the investigation of how long the call light was on. There is no documentation regarding the investigation of if R2 was going to or coming from the bathroom. R2's fall investigation summary for R2's fall on 12/13/22 documents the root cause of this fall as self-transferring with a post fall intervention to place non-skid strips to the right side of R2's bed. This summary does not document why R2 was self-ambulating/transferring. This summary documents, (R2) was planning to self-ambulate to the bathroom although there is no documentation of this statement in the investigation other than the final summary of the investigation. There is no documentation in this investigation as to when R2 had last been assisted or offered to be assisted to the toilet. There is only one witness statement by V31 in R2's investigation although this witness statement documents multiple additional staff members including V19, V31, V34 (CNAs) were working on the unit at the time of R2's fall on 12/13/22. b.) R2's Fall Investigation documents R2 sustained a fall on December 26th, 2022, at 4:40 PM in R2's room. This investigation documents R2's past medical history of a right femur fracture, Parkinson's, unspecified Dementia with Behaviors, syncope and collapse, muscle wasting and atrophy, muscle weakness, difficulty in walking, a history of falling, heart failure, and abnormalities of gait and mobility as well as lack of coordination. At the time of the fall R2 was on aspirin 81 milligrams daily. This investigation documents R2's cognition as cognitively intact with a root cause of R2 slipping out of R2's wheelchair. R2's care plan was updated with post fall interventions including physical therapy to screen for wheelchair position and safety, a cushion secured with (brand name adhesive) to the wheelchair, and that R2's wheelchair was replaced. There is no documentation in this investigation of an assessment of the wheelchair R2 was using at the time of the fall. This investigation documents R2 was last seen by staff sitting in the wheelchair in R2's room. This investigation documents at the time of the fall there was significant bleeding from R2's right forehead. R2 was transferred to the local emergency room and found to have a Subdural Hematoma. R2 was deemed to not be a good candidate for neurosurgical intervention and was transported back to the facility from the local emergency department. When R2 was asked what happened, R2 stated, something is wrong with my wheelchair. (R2) slid out R2 guesses. This investigation documents the probable root cause of the fall was R2 slipping from the wheelchair but does not document why R2 slipped from the wheelchair. This investigation documents R2 was having right sided head pain. This investigation documents hospital discharge instructions with diagnosis including fall, traumatic hematoma of forehead, acute Subdural hematoma, hand laceration, and skin tear. This investigation documents one witness statement from V21 (CNA.) There are no additional witness statements from staff working on the unit R2 resides on at the time of this fall. There is no documentation the state survey agency was notified of the major injury R2 sustained of an acute Subdural hematoma from R2's fall on 12/26/22. R2's Progress Notes dated December 26th at 5:22 PM document V22 (Licensed Practical Nurse/LPN) heard HELP ME being called out while passing pills in the hallway. R2 was found on the floor lying on the right side holding R2's head with R2's left arm. R2 stated R2 thinks something is wrong with his chair and that R2 guesses R2 just slipped out of R2's chair. The emergency room records document a Computed Tomography of the Head exam results dated 12/26/22 that document R2's exam revealed an acute Subdural hematoma along the right temporal and right frontal convexity measuring up to 0.4cm (centimeters) in diameter. Additional emergency room documentation dated 12/26/22 documents R2 sustained a scalp hematoma abrasion that was closed with adhesive closure, a scalp hematoma measuring 5cm by 6cm in diameter, two dorsal superficial skin tears that were closed with adhesive closure and a 2cm laceration to the right ring finger. R2's Investigation for R2's fall on 12/26/22 documents a hospital emergency room report dated 12/29/22 documents R2 returned to the emergency department on December 29th, 2022, with chief complaint of decreasing responsiveness. The emergency department trauma service felt in light of R2's do not resuscitate status there was nothing additional they could offer then continued do not resuscitate and comfort measures. R2's hospital notes document R2 was observed to have extensive facial bruising. These notes document R2 was discharged back to the facility on [DATE] in critical condition. On 1/5/22 at 3:00pm, V2 (Director of Nursing) stated V2 did not report R2's major injury of an Acute Subdural Hematoma with use of Aspirin (Antiplatelet) medication because R2 only went to the emergency department and did not receive further intervention like a drain or sutures. V2 stated V2 just usually reports broken bones or if a resident requires sutures. The facility's Accident and Incident Report policy dated 4/2/2019 documents the objective of the policy is to document all accidents and incidents occurring to resident's, visitors, and employees. This policy documents if the State Survey Agency notification is required, it is the responsibility of the Director of Nursing or Administrator to do so. This policy documents in all cases, there must be an exact description of the accident/incident including witnesses and statements. The Resident Accident & Incident Reports form dated March 2002 documents a blank spreadsheet the facility uses to document the residents incidents and accidents including the possible cause and that the cause was investigated and notifications were made, including a notification to the State Survey Agency. The facility's Emergencies policy dated 4/3/18 documents immediate care of a resident after a fall including to check the residents ability to explain what happened and evaluate the residents condition before the fall. Determine if possible where, how and when the accident occurred. If a head injury has occurred notify the physician immediately for orders to transfer the resident to the emergency room .

Based on observation, interview, and record review the facility failed to ensure proper body alignment during turning and positioning for one (R1) of three residents reviewed for accidents on the sample list of ten. This failure resulted in R1 sustaining a left Humerus fracture. Findings include: On 11/2/22 at 9:34 AM, R1 was lying in bed in a hospital gown. R1 had an arm sling around the left arm. The Nurse's Note dated 10/28/2022 at 5:37 AM, written by V6 (Licensed Practical Nurse) documents, (V5 Certified Nurse's Assistant/CNA) asked writer to come help roll (R1) in bed to get dressed in morning. Upon rolling resident (left) arm got under (R1) and a pop noise was heard. (R1) complained of pain going down (left) arm. Upon assessment resident (left) arm appeared to be swollen at the top of the shoulder. Hand grasp strong bilaterally. Unable to fully assess length of arm due to (R1) refusing to extend arm. R1's Hospital Transfer Report dated 10/28/22 at 11:27 AM, documents, (R1) arrived per (Emergency Medical Services) from (facility) where staff reports (R1) was lying on (left) arm when placed in bed and pop was heard. (R1) was complaining of pain this am. (R1) confused and unable to answer questions at this time. This report documents R1 was diagnosed with a Left Humerus Fracture. On 11/3/22 at 10:51 AM, V6 (Licensed Practical Nurse) stated, (V5 CNA) asked for help turning R1 in bed. V6 stated when turning R1 they tried to cross (R1's) arms, but R1's arm kept dropping to the side. V6 stated R1 has difficulty following directions and we kept crossing R1's arms so R1 wouldn't roll on top of it. V6 stated after we had (R1) halfway over (R1's) arm fell back down and then went under her side and R1 rolled on top of R1's shoulder and we heard a pop noise. R1 complained of pain. R1 was sent to the emergency room and was diagnosed with a left Humerus fracture. V6 stated we should have had three staff to assist her to ensure that R1's arms remained crossed. R1 is an extensive assistance with bed mobility. The facility's undated Turning and Positioning Protocol provided by V2 Director of Nursing documents, 5. Be sure the resident is in good body alignment.

Based on interview and record review the facility failed to assess and seek medical intervention for a significant change in condition for one resident (R1) of three residents reviewed for condition change in a sample list of three residents. This failure resulted in R1 being hospitalized with a blood glucose level of 1200 (milligrams per deciliter) and Diabetic Ketoacidosis. Findings include: R1's Continuity of Care Document printed 10/18/22 includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) dated [DATE] documents R1 was completely cognitively intact. R1's Brief Interview of Mental Status (BIMS) dated 9/14/22 documents R1 scored a score of 15 out of 15. R1's Care Plan includes a problem initiated 9/19/22 which documents (R1) has been displaying verbal behaviors such as yelling/cursing at staff telling them to leave him alone, he has also been displaying rejection of care behaviors such as not allowing CNAs (Certified Nurse Assistants) provide him with daily ADL cares, telling staff that he will let them know when he needs help and that he was not going to allow them to touch him. (R1) has also been displaying more confusion than usual and has been making false accusations toward staff with no truth to the accusations being made. R1's Progress Note dated 9/17/22 at 8:53PM documents (R1) refused to be changed and refused to go to bed. (V6 Licensed Practical Nurse/LPN) encouraged (R1) to let CNAs at least provide peri care to prevent sores and infection. (R1) stated, 'I will not let them. I do not need to be changed right now. They always want to show me disrespect and think they know what's best for me when they don't. I'm my own boss.' (V6) asked (R1) what was wrong and if the CNAs did anything to make him upset. Resident stated, 'No they aren't going to tell me what to do or when to be changed. I am my own person and have been taking care of myself for many years and I don't need them now.' (V6) asked (R1) are you sure you don't want changed. That it would be best to get changed out of wet underwear. (R1) stated, 'No! I will let you know when I need your help.' There is no documentation to support this change in mental status was reported to the physician or a physical assessment was completed by the nurse. R1's Progress Note dated 9/17/22 at 11:58PM documents (V6) was informed by CNA on hall that resident was making statements at him by telling him to go sit on a railroad and let the train hit him. Resident seemed to be confused and started stating, 'You think your sic a bad A** (expletive) and a boss because you have your bike. I do not want care from you.' Writer and another CNA went into resident room and asked (R1) what was the matter and (R1) stated, 'Well I haven't been checked on since after dinner time and this guy thinks he knows it all. I will not let him touch me. I don't like him. He thinks he is the boss, and he is always late to work.' (V6) informed (R1) that (V6) is sorry (R1) feels that way but the CNA is truly trying his best and told resident the reason he hasn't been changed since after dinner is because (R1) has been refusing care. (R1) stated, 'You can change me now, but he is not to touch me.' Writer and other CNA provided care and transferred resident to bed. Resident is lying in bed now calm and cooperative. There is no documentation to support this change in mental status was reported to the physician or a physical assessment was completed by the nurse. R1's Progress Note dated 9/18/22 at 1:56PM documents (R1's) POA (Power of Attorney) was notified of incident that happen 9/17/22. (POA) stated that (R1) normally doesn't act in that manner. R1's Progress Note dated 10/2/22 at 4:49PM documents (R1) did have a slight increase in confusion earlier in the shift. Resident was noted yelling out and being incoherent. There is no documentation to support this change in mental status was reported to the physician or a physical assessment was completed by the nurse. R1's Progress Note dated 10/3/22 at 10:08AM documents (V7 Registered Nurse/RN) assessed (R1) at approximately 08:30AM and noted (R1) to be calling out in pain. Abdomen noted to be distended. Lower abdomen firm. Bowel sounds audible in all quadrants but hypoactive. (R1) having difficulty following commands. (V7) received report from staff members that the resident has been experiencing decline in mental status over the weekend. (V7) re-assessed (R1) at approximately 09:30AM. (R1's) condition not improved. (R1) not following commands or answering questions. POA and (family member) called and notified. Family requests resident to go to emergency department for evaluation. R1's hospital discharge summary dated 10/12/22 documents R1 was hospitalized from 10/3/22 to 10/12/22 with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Hemoglobin A1C (measures average blood glucose over three months) on 10/3/22 is recorded as 14 with the normal levels being under 7. On 10/17/22 at 4:00PM V9 (R1's POA) stated (R1) went to the (local hospital) 10/3/22. (R1's) blood glucose at that time was 1200. (R1) was then transferred to (a hospital with a higher level of care). (R1) was in ICU (Intensive Care Unit) for several days with an insulin drip. (R1's) blood pressure was also very low. (Family members) visited (Nursing home) on Sunday 10/2/22 and they knew something was wrong. (R1) was lethargic and very confused which is nothing like (R1) had been before. On 10/18/22 V2 (Director of Nursing/DON) stated We do use a lot of agency nurses and they are not always aware of the residents baseline cognition and behavior. Any time a resident has a sudden change in cognitive ability or behavior it should be documented and if necessary, the resident should be sent to the emergency room for assessment. (R1) was not ever diabetic before the recent hospitalization . V1 (Administrator) denied having a specific facility policy for notification of a change in condition. On 10/18/22 V1 (Administrator) stated It is our responsibility to make sure when a resident has a change in cognition they are seen by a physician or taken to the emergency room .

Based on interview and record review the facility failed to treat a urinary tract infection for five days for R2 resulting in R2 being transferred to the emergency room to seek treatment. The facility also failed follow a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R1 and R2 experiencing unnecessary avoidable pain in a review for urinary tract infections in a total sample list of three. Findings include: 1.) The facility Infection Control Policy date revised 12/17/19 documents signs of infection include dysuria and bacteriuria. R2's Minimum Data Set, dated dated dated [DATE] documents R2 as cognitively intact. R2's undated face sheet documents a history of urinary tract infections. R2's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's progress notes dated 5/16/22 document R2 complaining of dysuria (discomfort or burning with urination). R2's urine was dipped and resulted with leukocytes (indicator of infection). R2's physician was notified and a request to run a urinalysis and culture and sensitivity was made by the facility. R2's electronic medical record does not document communication between the facility and R2's physician on 5/17/22 or 5/18/22. On 7/5/22 at 1:30PM, V5 (Licensed Practical Nurse/LPN) stated, the delay in hearing from V10 (Medical Doctor) isn't surprising. On 7/6/22 at 10:55, V9 (Registered Nurse) stated, I would say that it is normal for there to be a delay with (V10) getting back to us. (R2) should have had a urinalysis and culture for the urinary tract infection sooner. R2's progress notes dated 5/19/22 at 4:47AM document, Resident continues to (complain of)pain upon urination and lower backpain. MD notified via (text) of resident condition and waiting for order for (urinalysis) and culture. R2's urinalysis dated 5/19/22 documents positive for leukocytes with urine culture pending. R2's progress note dated 5/21/22 at 5:00PM documents, Resident complaining of severe back pain and not feeling well. Resident states she can't wait. Sending resident to (emergency room ) for treatment. R2's emergency room discharge orders dated 5/21/22 document: [MEDICATION(S)] (antibiotic) 500 milligrams by mouth daily for four additional doses, encourage/push water and fluids, recheck urinalysis in six days and see a physician to reassess in one week. On 7/6/22 at 10:25AM R2 stated, When I had my urinary tract infection, I told them I was hurting, and they did nothing for days. I always take [MEDICATION(S)] (pain medication) but that isn't the same kind of pain as a urinary tract infection. I had a lot of pain and finally, I couldn't take it anymore and made them send me to the hospital. That isn't right. On 7/6/22 at 11:20AM, V5 (LPN) stated, V10 (MD) should have answered sooner so that we could get a urine analysis and culture sooner. It is true that once (R2) was started on [MEDICATION(S)], her pain decreased. 2.) R1's Minimum Data Set, dated dated dated [DATE] documents R1 as severely cognitively impaired. R1's undated face sheet documents V6 (Family Member) as R1's Emergency Contact, Legal Guardian, and Responsible for Power of Attorney of Financial and Health Care. R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's progress notes dated 6/16/22 at 11:20AM document [MEDICATION(S)] 1 gram intramuscularly administered in left hip. R1's progress notes dated 6/17/22 document V6 (Family Member/Power of Attorney) expressing concern about intramuscular injections traumatizing R1 (being painful for R1) as soon as V6 was notified of the addition of the medication. R1's June 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's progress notes dated 6/23/22 document, (R2) continues on antibiotics for urinary tract infection. R1's progress notes dated 6/24/22 at 3:09PM document that V7 (Licensed Practical Nurse/LPN) spoke with V6 regarding the stop date for R1's antibiotic. V7 LPN verified the start date was 6/16/22 but did not see a stop date. V7 then contacted V10 (Medical Doctor) and the intramuscular antibiotic was discontinued. On 7/6/22 at 12:00PM, V7 (LPN) stated, I gave (R1's) injection as the (Medication Administration Record) stated to do and later in the day V6 (Family Member/Power of Attorney) called. She asked me how many doses that (R1) had gotten and when I counted it was eight or nine. The daughter told me that she was only supposed to get 7, so I looked in the progress notes and told her that I would have to call the doctor. I called him and he said that he only wanted the 7 doses and to just go ahead and discontinue the drug now. I did and then told the daughter and documented it. On 7/5/22 at 2:00PM, V5 (LPN) stated, Our Director of Nursing asked for the injections even though that's more painful, because (R1's) symptoms were so severe. The facility medication administration policy date revised 2/04 documents, All physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review the facility failed to protect residents from abuse by: failing to recognize an allegation of sexual abuse between staff and a resident, failed to initiate an investigation into the allegation of sexual abuse and failed to remove the alleged perpetrator from continued direct care of a resident for one five residents (R4) reviewed for abuse on the sample list of five. This failure resulted in the V15 Certified Nursing Assistant (alleged perpetrator) continuing to provide personal cares for R4 for 24 shifts with no determination if sexual abuse of R4 by V15 had occurred. This failure also had the potential to affect all 75 residents residing in the facility as V15 continued to work having access to all residents at the facility. These failures resulted in an immediate jeopardy. While the immediate jeopardy was removed on 6/4/21, the facility remains out of compliance at a severity level two while the facility is in the process of implementing re-education components and training related to abuse policies and procedures. Findings include: On 6/1/21 at 12:06 PM, V9 Certified Nurse's Assistant (CNA) stated on Saturday March 27th at 4:00 PM, V9 witnessed V15 CNA performing oral sex on R4. V9 stated V9 immediately reported the incident to V1 Administrator. On 6/2/21 at 1:28 PM, V1 stated on Saturday, March 27th 2021 around 4:00 PM, V9 came to V1's office to report that V15 was found in bed with R4. V1 stated V1 did not do an abuse investigation. V1 stated V1 did ask V15 and R4 what happened and both stated that R9 found R4 and V15 in R4's bed together. V1 stated V1 told V15 that V15 is no longer allowed to provide cares to R4. V1 stated V15 was not suspended pending an investigation. V1 stated V1 did not follow-up with anyone to ensure V15 was not working with R4. The March, April, and May 2021 monthly calendars provided by V19 Scheduler documents R15 worked on the same hallway as R4 on 3/31/21, 4/1/21, 4/2/21, 4/5/21, 4/7/21, 4/8/21, 4/10/21, 4/11/21, 4/13/21, 4/15/21, 4/18/21, 4/19/21, 4/21/21, 4/22/21, 4/23/21, 4/29/21, 4/30/21, 5/3/21, 5/13/21, 5/17/21, 5/21/21, 5/22/21, 5/23/21, and 5/26/21. On 6/2/21 at 2:06 PM, V15 CNA stated after the incident of being found in bed with R4, V15 did work with R4 multiple times and provided personal cares to R4. On 6/2/21 at 10:11 AM, V19 Social Service Director/Scheduler stated V19 is the scheduler for the facility. V19 stated V15 will float and works all the halls in the facility. The facility's Bed Management Sheet provided by V1 documents there are 75 residents residing in the facility. The immediate jeopardy situation was identified on 6/4/21. The immediate jeopardy was identified to have begun on 3/27/21 when V15 sexually abused R4. V1 was notified of the immediate jeopardy on 6/4/21 at 8:20 AM. This surveyor confirmed through observation, interview, and record review the facility took the following actions to remove the immediate jeopardy: 1. V15 was suspended pending an investigation on 6/1/21. 2. V1 was re-trained on the facility's Abuse policy by V23 Regional Director of Operations on 6/4/21. 3. V1 re-trained the facility's Department Heads on the facility's Abuse policy on 6/4/21. 4. The facility's Department Heads re-trained all staff on the facility's Abuse policy on 6/4/21 and ensured no other abuse allegations existed.

Based on interview and record review the facility failed to ensure a resident was free from abuse by staff. Staff witnessed a Certified Nurse's Assistant (CNA) V15 inappropriately interacting with a resident (R4). The facility continued to schedule V15 to provide personal care of R4 on numerous occasions following the abuse incident. This failure affects one of three residents (R4) reviewed for abuse in the sample of five residents. These failures resulted in an immediate jeopardy. While the immediate jeopardy was removed on 6/4/21, the facility remains out of compliance at a severity level two while the facility is in the process of implementing re-education components and training related to abuse policies and procedures. Findings include: On 6/1/21 at 12:06 PM, V9 Certified Nurse's Assistant (CNA) stated on Saturday March 27th at 4:00 PM, V9 walked in to R4's room. V9 stated V15 CNA was in bed with R4. V15 had R4's genitals in V15's mouth. V9 stated V15 jumped up out of R4's bed. V9 stated V9 and V15 had a weird three second pause. V9 stated V9 didn't say anything and that V9 left the room and went straight to V1's (Administrator) office. V9 stated V9 reported what happened immediately to V1. V9 stated V9 told V1 that V15's head was down below R4's waist and R4's pant leg was pulled up enough to have R4's genitals exposed. V9 stated V9 insinuated that V15 was giving R4 oral sex. V9 stated V15 is really focused on R4's care. V15 likes to exclusively claim R4's showers. V9 stated V15 will stay over just to give R4 a shower. V15 makes it a point to take care of R4. V9 stated V15 is still caring for R4 and has been giving R4 showers. V9 stated , I am 100 percent sure that is what V15 was doing. R4's Quarterly Minimum Data Set Assessment form dated 4/23/21 documents R4 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/2/21 at 2:06 PM, V15 stated V15 began working in the facility in December of 2020. V15 stated V15 did not know R4 prior to working in the facility V15 stated that V15 and R4 joke around with each other. V15 stated R4 would tell V15 if R4 had a bad day and V15 took care of R4. V15 stated V15 was on that R4's hall a lot. V15 stated V15 only remembers that day (3/27/21) vaguely, V15 stated V15 was working overtime. V15 stated V15 remembers it being R4's birthday. V15 stated V15 gave R4 a shower because R4 was going to have a visitor that day and we (V15 and R4) wanted to make sure R4 was cleaned and dressed for R4's visit. V15 stated sometime in the afternoon R4 had hit the call light and V15 had answered it. V15 stated V15 gave R4 a urinal and told R4 to hit the light when R4 was done. V15 stated V15 went and got someone else up and R4 turned the light back on. V15 stated V15 reentered room, took the urinal, emptied it, and turned off the call light. V15 stated V15 told R4 that V15 was exhausted. V15 stated R4 and V15 were the only two in the room at that time. V15 stated R4 wiggled over and V15 got into bed with R4 and laid down. V15 stated the privacy curtain was pulled. V15 stated then V9 came in and V15 got up abruptly because V15 knew it could have been perceived as something else. V15 stated people would have thought V15 was doing something more. V15 stated V9 would have been at the foot of the bed when V9 came around the privacy curtain. V15 stated V9 would have seen them in the bed from the feet up. V15 stated they (V15 and R4) weren't covered up. V15 stated V15 had the sheet covering R4 to the waist. V15 stated V9 just stood there looking at them and didn't say anything. V15 stated V15 just looked at V9 and got up and walked past V9 and left the room. V15 stated as V15 was getting another resident up V1 Administrator came and told V15 that V1 needed to talk to me. V15 stated V15 and V1 went to V1's office. V15 stated V1 asked V15 what occurred and V15 told V1 that against V15's better judgement that V15 had laid down in R4's bed. V15 stated V1 told V15 that V15 couldn't be on the hall or take care of R4 again. V15 stated after that day V15 was scheduled on the hall in which R4's resides and V15 has provided cares to R4 since then. V15 stated V15 has also given R4 showers. V15 stated no one told V15 that V15 could care for R4 again but V15 assumed V15 could because V15 was scheduled down there. V15 stated sometimes V15 was the only CNA scheduled on that hallway. V15 stated it would be impossible for V15 not to care for R4 when V15 was scheduled down that hall by herself. V15 stated V15 and R4 are friends and they would talk about music, movies, and cartoons. V15 stated V15 has R4 on two social media applications. V15 stated other staff may perceive our (V15 and R4) relationship as more. V15 stated V15 thinks the other staff may have been suspicious because V15 would offer R4 food such as pizza and diet (soda) out of V15's own money. V15 stated V15 got R4 a bird feeder for R4's birthday because R4 likes watching birds. V15 stated V15 was just trying to make R4 feel special on R4's birthday. V15 stated V15 and V9 have a good working relationship and have had no issues working with each other. On 6/2/21 at 1:28 PM, V1 stated after V9 came in and reported that V15 and R4 were lying in bed together, V1 talked to both R4 and V15. V1 stated V15 and R4 told V1 that they were laying in R4's bed together joking and talking. V1 stated V1 told V15 that it was not appropriate, and that V15 was the care giver and V15 needs to keep it professional. V1 stated V1 told V15 that V15 could absolutely not care for R4 anymore. V1 stated V1 realized laying in bed together was not appropriate so decided to prevent the potential for V15 to cross a boundary with R4. V1 stated going forward V1 didn't want V15 to take care of R4. V1 stated V15 was moved off of the hallway and V1 talked to V19 (scheduler) and had V15 taken off that hallway. V1 stated if V15 was on that hallway, V15 wasn't supposed to take care of R4. V1 stated V1 made it clear that R15 should not be taking care of R4. V1 stated V1 hasn't asked if V15 has been in R4's room or scheduled on that hallway. On 6/2/21 at 10:11 AM, V19 Scheduler stated V19 was told V15 was not allowed to work with R4 at the end of March. V19 stated V19 scheduled V15 on that hallway but assumed V15 was not working with R4. March, April, and May 2021 monthly calendars provided by V19 documents V15 worked on the same hallway as R4 on 3/31/21, 4/1/21, 4/2/21, 4/5/21, 4/7/21, 4/8/21, 4/10/21, 4/11/21, 4/13/21, 4/15/21, 4/18/21, 4/19/21, 4/21/21, 4/22/21, 4/23/21, 4/29/21, 4/30/21, 5/3/21, 5/13/21, 5/17/21, 5/21/21, 5/22/21, 5/23/21, and 5/26/21. On 6/2/21 at 12:57 PM, V13 CNA stated R4 has a friend (V22 Dietary Aide) that had started working in the kitchen. V13 stated V15 would ask V22 questions about R4 prior to R4 being at the nursing home. V13 stated V15 would be in R4's room for long periods of time. V13 stated V15 didn't notice it with other residents, mainly with R4. V13 stated R4 is friendly but it seemed like they (R4, V15) spent more time together. V13 stated V9 is credible and V13 has no reason not to believe what V9 says. On 6/2/21 at 1:28 PM, V22 Dietary Aide stated V22 has worked at the facility since January 27th of 2021. V22 stated V22 knew R4 before employment at the facility. V22 stated V22 and V22's spouse are really good friends with R4. V22 stated V15 talks about R4 a lot. V22 stated V15 would often mention R4 and joke and say things like, you could cook for (R4) and I will take care of (R4). V22 stated V15 wouldn't stop talking about R4. V22 stated she felt the amount she talked about him was weird. V22 stated V15 would call V22 her bestie because of R4 even though V22 had never even talked to V15 outside of work. V22 stated they (R4 and V15) are friends on social media. V22 stated V15 had told V22 that V9 had turned V15 in for messing with R4 but everything was ok. V22 stated V15 was still taking care of R4 after that. On 6/2/21 at 10:57 AM, V18 Licensed Practical Nurse stated a couple weeks ago or longer V9 told V18 about the incident between V9 and R4. V18 stated V18 asked if V9 reported it and V9 said yes. V18 said that V9 walked into R4's room and R15 was laying in bed with R4 talking and R15 jumped out of bed. V18 stated V18 wanted V9 to report it because it is just something that they (staff) don't do. V18 stated V18 would want it investigated to make sure nothing was going on. V18 stated no one asked V18 about the incident until 6/1/21. The immediate jeopardy situation was identified on 6/4/21. The immediate jeopardy was identified to have begun on 3/27/21 when V15 sexually abused R4. V1 was notified of the immediate jeopardy on 6/4/21 at 8:20 AM. This surveyor confirmed through observation, interview, and record review the facility took the following actions to remove the immediate jeopardy: 1. V15 was suspended pending an investigation on 6/1/21. 2. V1 was re-trained on the facility's Abuse policy by V23 Regional Director of Operations on 6/4/21. 3. V1 re-trained the facility's Department Heads on the facility's Abuse policy on 6/4/21. 4. The facility's Department Heads re-trained all staff on the facility's Abuse policy on 6/4/21 and ensured no other abuse allegations existed.

Based on observation, interview, and record review the facility failed to recognize and prevent financial exploitation and the systematic misappropriation/theft by an employee of $30,687.28 from the pooled resident trust fund accounts entrusted to the facility for safekeeping. This failure affected 11 of 12 cognitively impaired residents (R1, R4 through R13) reviewed for misappropriation on the sample list of 17. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a severity level two while the facility is in the process of implementing re-education components and training related to abuse prevention policies and procedures. Findings include: The facility's final investigative report dated [DATE] documents V8 Business Office Manager was arrested and is being investigated for financial exploitation. The Police Department Incident/Offense report dated [DATE] documents V8 was arrested on [DATE] for the offense of Fraud with/Bank ID (identification) Card > (greater than) $150 and Financial Exploitation of Elderly/Disabled. Both of these are listed as felony offenses. On [DATE] at 10:20 AM, V1 Administrator stated the facility began an investigation for misappropriation of resident funds on [DATE] after V9 (R9's Power of Attorney) stated charges on R9's quarterly statement were not approved. V1 stated R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, and R13 all had money withdrawals from their resident funds account without consent. V1 stated the facility can not account for the loss of the money. V1 stated after investigating the facility determined V8 took the money. V1 stated the facility completed a spreadsheet of the unaccounted resident money. V1 stated $30,687.28 was taken from the pooled resident account. V1 stated the money was taken out of eleven individual resident accounts without consent. 1. The facility's undated spreadsheet documents R9 had $24,015.00 taken out of R9's account from [DATE] through [DATE] and there are no receipts for these transactions. On [DATE] at 1:30 PM, V18 Receptionist stated the day after V8 left V18 was looking on the facility's accounting system and noticed R9 had a $700 withdrawal on [DATE] for a college fund. V18 thought it looked suspicious because of the amount and the fact that R9 could not consent to the amount withdrawn. On [DATE] at 12:44 PM, V11 Corporate Accounts Receivable Manager stated V18 notified V1 of some suspicious cash withdrawals out of R9's account. V11 stated V11 started an investigation. V11 stated V11 went back to 2016. V11 stated V9 (R9's family member) called back and stated V9 did not give consent for any of the withdrawals listed on the spreadsheet. On [DATE] at 10:15 AM, R9 was sitting in a reclining wheelchair in the room. R9 was not oriented and did not respond when spoken to. R9's [DATE] quarterly Minimum Data Set assessment documents R9 has severe cognitive impairment. The facility's undated spreadsheet documents $90.00 was spent out of R9's account on [DATE] for hair products and pajamas. On [DATE] at 10:30 AM, there were no new pajamas in R9's room. None of R9's clothing or items appeared in new condition. There was one canister of department store hair mousse on the dresser which appeared old. There were no other hair care products in the room. All the other resident care supplies located in the room were facility stock products. There were no new clothes in R9's closet or drawers. At that time, V22 Activity Director stated there were no items in the room that appeared new and confirmed that the only hair care item in the room that wasn't provided by the facility was a canister of hair mousse. V22 stated V22 has never been shopping for R9. 2. The facility's undated spreadsheet documents R5 had $3756.39 taken out of R5's account from [DATE] through [DATE] and that there are no receipts for these transactions. On [DATE] at 10:12 AM, R5 was sitting in room, R5 stated the facility manages R5's account. R5 stated R5 doesn't get a quarterly statement. R5's Quarterly Minimum Data Set assessment dated [DATE] documents R5 has severe cognitive impairment. On [DATE] at 9:15 AM, V14 (R4 and R5's Power of Attorney) stated the facility called V14 and said they identified problems with R4 and R5's accounts. The facility said that an ex-employee (V8) was suspected and that V8 had been arrested and an investigation is ongoing. V14 stated V14 did not authorize the $3756.39 in withdrawals. The facility's undated spreadsheet documents withdrawals from R5's account from [DATE] to [DATE] for shopping with activities, clothes from a department store, and shirts from an online website. On [DATE] at 10:20 AM, R5 stated R5 has not been shopping or been to a department store. R5 stated R5 has not ordered anything. There was no clothing or items that appeared to be in new condition. There were no department store boxes or sacks or online website boxes in the room. V22 Activity Director stated R5 had not ordered anything from an online website or department store and R5 has not been on shopping trips. 3. The facility's undated spreadsheet documents R4 had $880.00 taken out of R4's account from [DATE] through [DATE] and that there are no receipts for these transactions. On [DATE] at 10:12 AM, R4 was sitting on bed in room. R4 was talking about a train and was confused and not interviewable. R4's [DATE] quarterly Minimum Data Set documents R4 has severe cognitive impairment. The facility's undated spreadsheet documents R4 had withdrawals from [DATE] through [DATE] for shopping with activities, cash for shopping, and a department store order. On [DATE] at 10:20 AM, no new looking items were noted in room, all clothing in the closets and drawers looked worn. At that time, V22 Activity Director stated R4 has not been out of the building to shop and the facility has not shopped for R4. 4. The facility's undated spreadsheet documents R8 had $1,000.00 taken out of R8's account on [DATE] through [DATE] and that there are no receipts for these transactions. These transactions document under description car title change and transfer on both [DATE] and [DATE] of $500 per transaction. On [DATE] at 3:36 PM, V16 ( R8's Family member) stated R8 does not own a car and wouldn't have had a car title to transfer. V16 stated no one asked V16 to allow money to be taken out of R8's account. R8 would be upset and quite aggravated if money was taken from R8's account. V16 stated, (R8) doesn't have that much money to begin with. On [DATE] at 10:15 AM, R8 stated R8 has not had a car for four years. R8 hasn't spent any money to transfer car titles. R8's quarterly minimum data set assessment dated [DATE] documents R8 has severe cognitive impairment. 5. The facility's undated spreadsheet documents R6 had $275.50 taken out of R6's account from [DATE] through [DATE] and that there are no receipts for these transactions. On [DATE] at 4:53 PM, V19 (R6's Family Member) stated the facility had told V19 that there was money spent out of R6's account and that there was no receipts for the items. The facility stated they did not think R6 got the items. V19 stated V19 did not give permission for money to be taken out of the account. V19 stated R6 has been in a facility a long time, would think R6 would be upset if R6 knew money had been taken. V19 stated I would be really upset because it would be a criminal issue. R6's quarterly Minimum Data Set assessment dated [DATE] documents R6 has severe cognitive impairment. The facility's undated spreadsheet documents R6 has withdrawals from [DATE] through [DATE] for shopping with activities at a department store, clothes from a department store and shirt from an online website. On [DATE] at 9:39 AM, V22 Activity Director stated V22 has never shopped online for R6. V22 stated R6 has never been on an activity outing at a department store. V22 stated the activity department has never purchased anything for R6. 6. The facility's undated spreadsheet documents R7 had $200.00 taken out of R7's account on [DATE] and that there is no receipt for this transaction. On [DATE] at 8:32 AM, V15 (R7's Family Member) stated the facility had called V15 and asked if $200 was used for shopping for R7. The facility stated they didn't have a receipt. V15 stated R7 can not make R7's own decisions. V15 stated V15 did not approve for $200 to be used for shopping and that R7 does not have new items. V15 stated R7 would feel terrible if R7 knew money was taken from R7's account and R7 would get really mad. V15 stated V15 has not told R7 because V15 doesn't want R7 to worry. The facility's undated spreadsheet documents R7's account withdrawal for cash for shopping on [DATE]. On [DATE] at 9:39 AM, V22 Activity Director stated the activity department usually shops for the residents. V22 stated the activity department has not shopped for R7. On [DATE] at 12:44 PM, V11 Corporate Accounts Receivable Manager stated V11 audited the cash withdrawals for all residents. V11 stated the withdrawals that did not have a signed receipt are on the spreadsheet. V11 stated, During the audit I identified multiple residents who did not have receipts for money taken. During the audit, we verified the money was not authorized by the family. V11 stated V8 Business Office Manager was able to divert the money by using money out of the cash box, debiting the resident accounts, and then writing facility checks to replenish the money in the box. V11 stated the cash box had a lock and was locked in a drawer in V8's office and V8's office door was also locked. V11 stated there is no way it could have been anyone else but V8 taking the money. V11 stated V11 determined the charges for R9 without receipt started on [DATE]. V11 stated there were four charges for R9 in 2016 without a receipt. V11 stated V11 did not find any other unaccounted money until [DATE]. V11 stated V11 thinks this was when V8 started to steal money from the residents until [DATE]. V11 stated V11 also found that money in the trust fund account belonging to R1, R10, R11, R12, and R13, whom had died in the facility, was taken also. 7. The facility's undated spreadsheet documents R1 had $100.00 taken out of R1's account on [DATE] and that there is no receipt for this transaction. This spreadsheet documents R1 expired on [DATE]. 8. The facility's undated spreadsheet documents R10 had $65.12 taken from R10's account without a receipt on [DATE]. This sheet documents R10 passed away on [DATE]. 9. The facility's undated spreadsheet documents R11 had $132.02 taken from R11's account without a receipt on [DATE]. This spreadsheet documents R11 expired on [DATE]. 10. The facility's undated spreadsheet documents R12 had $243.25 taken from R12's account without a receipt on [DATE]. This spreadsheet documents R12 expired on [DATE]. 11. The facility's undated spreadsheet documents R13 had $20.00 taken from R13's account without a receipt on [DATE]. This spreadsheet documents R13 expired on [DATE]. The Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was determined to have begun on [DATE] when V8 Business Office Manger began to systematically misappropriate funds from resident accounts until [DATE]. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 10:40 AM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: 1. The facility notified the police and the state survey agency for the misappropriation of the resident pooled funds. Completed by Administrator on [DATE]. 2. The facility has been co-operating with the police department investigation since the alleged perpetrator's arrest. Completed by Administrator on [DATE]. 3. The facility audited all trust fund accounts and notified all of the affected resident's families. Completed by Accounts Receivable Manager on [DATE] and [DATE]. 4. All resident's whom had money misappropriated were reimbursed by the facility. Completed by Accounts Receivable Manager on [DATE]. 5. The trust fund account policy was reviewed to ensure it contained appropriate procedures to monitor resident trust fund accounts. Completed by Administrator, Accounts Receivable Manager, and Regional Director of Operations on [DATE]. 6. The facility's corporation will monitor on a monthly basis the withdrawals from the resident pooled accounts to ensure not more than $50 cash is withdrawn and if more than $50 is required than a check will be written to that resident or resident representative. Plan implemented on [DATE] by Administrator, Accounts Receivable Manager, and Regional Director of Operations. 7. The Administrator will review withdrawal entries and reconciliation's to ensure the appropriate staff are carrying out their assigned duties relative to the management and accounting of the resident trust fund. Plan implemented on [DATE] by Administrator, Accounts Receivable Manager, and Regional Director of Operations. 8. The Administrator and Business Office Manager were inserviced to ensure the appropriate safeguards are in place and the appropriate monitoring is being completed. Completed on [DATE] by Accounts Receivable Manager and Administrator.

Based on observation, interview, and record review the facility failed to complete and document weekly skin assessments per facility policy and failed to implement pressure relieving methods to prevent pressure ulcers for one resident (R3) of three residents reviewed for pressure ulcers in a sample of 3 residents. These failures resulted in R3 acquiring 2 pressure ulcers after admission. These pressure ulcers deteriorated to stage IV (four) until R3 was hospitalized for [REDACTED]. Findings include: 1.) R3's physician's orders [REDACTED]. V1 Administrator documented in R3's progress note dated 5/5/18 at 5:00PM resident admitted to us from (local hospital) via transport van. (R3) is aware of limitations and that (R3) is here for short term rehab (rehabilitation) to home program. R3's admission Observation Detail by V4, Licensed Practical Nurse (LPN) dated 5/5/18 at 4:50PM documents No Pressure Sores R3's Braden skin assessment completed by V5, Licensed Practical Nurse (LPN) documents R3 as not at risk. R3's quarterly Braden Skin assessment dated [DATE] by V11, Registered Nurse (RN) documents R3 as Moderate Risk R3's progress note by V12, Registered Nurse (RN) dated 5/28/18 at 1:59AM documents stage 2 pressure ulcer to left heel measures 4.5 cm (centimeters) x 3 cm. Area is dark, no skin opening, border is reddened. R3's progress note by V4, Licensed Practical Nurse (LPN) dated 6/6/18 at 6:01PM documents pressure ulcer to left foot is open and draining serosanguinous fluid. Eschar present. R3's progress note by V12, Registered Nurse (RN) dated 6/20/18 at 4:05AM documents Dressing to left heel done, eschar and smell noted. R3's progress note by V13, Licensed Practical Nurse (LPN) dated 7/2/18 at 5:48PM documents Pressure Ulcer to left heel is unstageable 100% eschar. POA (power of attorney) requesting wound specialist. R3's progress note by V12, Registered Nurse (RN) dated 7/17/18 at 6:56PM documents resident came back from wound clinic with new orders. R3's progress note by V12, Registered Nurse (RN) dated 9/2/18 at 2:53 AM documents dressing to left heel done as ordered. Noted old dressing loosely intact. Upon removal noted several maggots on old dressing. Noted foul smell. R3's progress note by V15, Licensed Practical Nurse (LPN) dated 9/17/18 at 12:53AM documents Dressings changed this shift, heavy drainage noted to left heel, malodorous. Resident voiced discomfort and pain during treatment. 2.) R3's progress note by V12, Registered Nurse (RN) dated 6/15/18 at 6:36AM documents noted pressure ulcer stage 1 on right hip. Measured to the widest 1.9 cm x 1 cm. area is black, surrounding border red, non-blanching, skin intact. R3's progress note by V12, Registered Nurse (RN) dated 7/7/18 at 12:36 AM documents Dressing to right hip done, no active drainage noted, no smell noted, wound bed 100% slough. R3's progress note by V5, Licensed Practical Nurse (LPN) dated 7/16/18 at 1:14 AM documents Area to the back of res (resident) right hip continued, area cleaned and foam dressing applied, some drainage and odor noted. R3's progress note by V14, Licensed Practical Nurse (LPN) dated 8/26/18 at 4:59AM documents Residents dressing changed to right hip, minimal amount of drainage noted. Malodorous. 2.5cm x 2cm. R3's progress note by V5, Licensed Practical Nurse (LPN) dated 9/10/18 at 1:38AM documents Treatment continued to pressure ulcer to (R3's) back, some drainage noted, malodorous. R3's progress note by V12, Registered Nurse (RN) dated 9/16/18 at 12:33AM documents Dressing to right hip done, area with 100 percent slough, smell noted, skin border reddened. R3's progress note by V15, Licensed Practical Nurse (LPN) dated 9/17/18 at 12:53AM documents V6, Medical Doctor (MD) advised to give (R3) Tylenol and send (R3) to the hospital for labs and testing. R3's discharge summary from local hospital dated 9/26/18 at 1:29PM by V17, Medical Doctor (MD) states primary [DIAGNOSES REDACTED]. 3.) On 7/24/18 at 10:45AM during R3's visit to the wound clinic V7 Physician's Assistant (PAC) documented the wound on R3's left heel as Unstageable measuring 5.4 centimeters cm in length by 4.8. cm in width by 0.2 cm in depth with a medium amount of red/brown drainage. At the same visit V 7 documented the wound on R's right gluteus as Stage III (three) with a medium amount of sanguinous drainage. V7 ordered obtain overlay for patient's bed and (specialized) cushion to off-load area at all times. On 9/14/18 during R3's visit to the wound clinic V7 Physician's Assistant (PAC) documented the wound on R3's left heel as Unstageable measuring 5.0 centimeters cm in length by 4 cm in width by 0.4 cm in depth with a medium amount of red/brown drainage. At the same visit V7 documented the wound on R3's right gluteus as Stage III measuring 2.2cm in length by 2.2cm in width by 1.5 cm in depth with a large amount of sanguinous drainage. V7 ordered obtain low air loss mattress for patient's bed and (specialized) cushion to off-load area at all times. On 10/1/18 at 3:00PM V10, R3's family member and power of attorney stated. R3 didn't get any special mattress or overlay for the bed until the day (R3) was hospitalized for [REDACTED]. I brought them (facility staff) the written order from the wound clinic back in (MONTH) but (R3) never got any special mattress. On 10/1/18 at 3:30PM V8, Certified Nursing Assistant (CNA) stated R3 had the regular mattress just like on all of the beds here (at the facility) until (R3) got back from the hospital (9/26/18). We try to turn and reposition (R3) at least every 2 hours, but (R3) is a 2 person lift and by the time we get help it is always more that 2 hours, On 10/2/18 at 10:34AM V1 Administrator stated Until (R3) went to the hospital (9/19/18) (R3) was using a (pressure relief) mattress. The manufacturer's specifications state the clinical indications for this model as Prevention to Stage II (two) (wounds) The wound clinic documented a Stage III to R3's right gluteus as well as an unstageable pressure ulcer on R3's left heel as of 7/24/18. On 10/1/18 between 12:30PM and 3:30PM R3 was in bed on R3's back without benefit of turning or repositioning. On 10/3/18 8:00AM and 10:38AM R3 was in bed on R3's back without benefit of turning or repositioning. On 10/3/18 at 10:40AM V9, Certified Nursing Aide, (CNA) stated yes I know (R3) hasn't been turned since at least 8:00AM. We just haven't gotten to it yet. On 10/2/18 at 9:32AM V3, Assistant Director of Nursing was completing [DEVICE] dressings to R3's left heel and right gluteal wounds. At 9:32AM the low air loss mattress on R3's bed was placed on therapy mode which disables the pressure reducing features of the mattresses so that the resident can be turned easier during a treatment. At 11:00AM V3 discovered that the appropriate dressing supplies were not available to complete the right gluteal wound treatment. V1, Director of Nursing went to the local hospital to get supplies to complete the dressing. V1 returned with the supplies at 12:40PM. During the time between 9:32AM and 1:00PM the pressure reducing properties were disabled since the bed was not taken off therapy mode during that time. On 10/1/18 at 2:00PM V1, Administrator supplied Wound Management documentation for both R3's wounds. There was no documentation on either wound from 7/22/18 until 8/30/18. V1 and V2, Director of Nursing (DON) confirmed that there was no documentation of wound assessments during this time. The facility's policy Pressure Injury Treatment and Protocol revised 7/16 states Weekly Individual treatment report will be done and put on clinical chart. On 10/3/18 at 8:49AM V6, Medical Doctor (MD) stated (R3) has severe [MEDICAL CONDITION], so I can't say with certainty the pressure area to the left heel could have been avoided. However, the area to the right gluteal was certainly caused by pressure and most likely could have been avoided. On 10/3/18 at 11:15AM V7, PAC from the wound clinic stated The first issue we had with (R3's) care was when I ordered the low air loss mattress. (R3) needed that for offloading. R3 had no prior history of pressure ulcers. These wounds could have been avoided if (R3) had been turned and repositioned and the mattress would certainly have slowed down the deterioration of the wounds. As it was (R3) came to the nursing home with intact skin, developed 2 pressure areas which became infected and ended up in the hospital [MEDICAL CONDITION]. The wounds required surgical debridement by a plastic surgeon.

Based on observation, interview and record review, the facility failed to ensure for the Safe Resident Handling of one resident(R1). This failure resulted in R1 being sent to the emergency room with a deep laceration into the muscle of the right leg with contused tissue requiring 18 staples to close the laceration. The facility also failed to implement a plan to prevent injury for residents (R1, R2) and follow care plan to prevent injury for a resident (R3). These failures affect three of three(R1, R2, R3) residents reviewed for incidents with injury in the sample of three. Findings include: The facility's Safe Resident Handling Policy dated (MONTH) 2012 documents that the facility will protect staff and residents from injury and limit the use of manual lifting as much as possible. The policy documents that all residents will be assessed for safe handling and moving, including the resident's ability to participate in transfers, the resident's cognition and behaviors, and the safety of the residents and staff. The policy documents that transfers without mechanical lifts are limited to residents who are able to ambulate or are stable with bearing weight. The lifting strategy may change according to the resident's condition and the instructions are care planned. This policy also documents that a non-mechanical standing device or a mechanical lift may be used instead of a manual lift at the discretion of the certified nurse's aide. 1. The facility incident report dated 6/30/18 documents R1 sustained a laceration requiring treatment (sutures) at the emergency room . The report documents R1 with [DIAGNOSES REDACTED]. The report documents R1 has a BIMS of 4, Brief Interview for Mental Status score of 4 of 15 indicating cognative impairment, and R1 is hard of hearing. R1's Care Plans dated 1/25/16 document R1's Safe Resident Handling Procedures including transfer with wheeled walker, gait belt and assist of one to two staff with cues to stand tall. These care plans also document staff may use full mechanical lift to transfer R1. There was no documentation to prevent further injury to R1 from the 6/30/18 incident. R1's Minimum Data Sets dated 4/10/18 and 7/3/18 document R1 requires extensive assistance of two staff members for transfers. R1's Therapy Daily Treatment Notes documents as follows: 6/20/18- nursing reported to therapy that R1 was not well 6/19/18 and required greater assistance with transfers. 6/21/18- R1 incredibly tired today 6/25/18- R1 continues to be more tired than usual, sometimes requiring more assistance than usual 6/26/18- nursing reported to therapy R1 is especially tired today and requiring greater assistance than usual; requiring and doing fair with stand aid versus stand pivot transfer. 6/28/18- R1 incredibly sleepy today and difficult to rouse. R1 is requiring increased physical assistance for transfers. R1's Resident Progress Notes dated 6/30/18 documents R1 had a large pool of blood under R1's feet and R1's right pant leg was saturated with blood. This note documents R1 had a large deep tear to the outer calf of the right leg and that R1 was sent to the emergency room . R1's emergency room Report dated 6/30/18 signed by V14, emergency room Physician documents R1 presented with a mechanical injury to the right lower extremity lateral aspect. This report documents while R1 was being transferred, R1 got R1's right leg caught on the metal of the wheelchair and the right lateral leg has a L shaped laceration measuring 5cm (centimeter) by 5cm into the deep tissue. This report also documents Wound's Depth, Shape: into muscle, linear, irregular, contused tissue, wound length 10 cm (centimeters) and that the laceration was closed with 18 staples. The hospital Patient Summary dated 7/4/18 documents on 6/30/18 staff stated patient's leg became caught between the bed and wheelchair while transferring (R1). On 7/31/18 at 11:20am, V6, Certified Nursing Assistant (CNA) stated on 6/30/18, V4, CNA and V6 transferred R1 to the wheelchair. V6 stated R1's wheelchair was next to R1's bed and V4 and V6 used a gait belt and assisted R1 to a standing position. V6 stated when R1 is ready to sit, {R1} just sits and R1 lets R1's legs give out and stops bearing weight. V6 stated R1 does this frequently. V6 stated R1's body was a little to the right when R1 stopped bearing weight and plopped down before R1 was positioned correctly in front of the wheelchair. V6 stated R1 bounced off of the wheelchair and hit R1's right side. V6 stated V6 noticed R1's right leg was not positioned properly and that R1's right leg had gotten caught on the hinge of the wheelchair. On 7/31/18 at 11:05am, V5, Licensed Practical Nurse (LPN) stated a CNA of which V5 was unsure of the name of the CNA, had notified V5 there was quite a bit of blood on the floor. V5 stated V5 thought staff had used a non-mechanical standing aid on 6/30/18 to transfer R1. V5 stated from what V5 could see, it looked like R1's leg had gotten caught on the wheelchair during the transfer. V5 stated R1's laceration was pretty deep. On 7/31/18 at 3:55pm, V3, Assistant Director of Nursing (ADON) stated V3 re-enacted R1's incident that had occurred on 6/30/18 with V4 and V6, CNA's. V3 stated from moment to moment, R1 can change R1's response to interactions. V3 stated that neither V4 or V6 notified V3 of R1's frequent legs giving out or plopping in the chair. V3 stated on 6/11/18, V3 had requested therapy to evaluate R1's transfer due to R1's body being bent over during transfers. V3 stated V3 expects staff to use the amount of assistance necessary to complete a safe transfer. V3 stated if the resident can't bear weight or participate in the transfer, the staff should utilize a full mechanical lift to transfer that resident. V3 stated staff had told V3 that R1 was getting weaker and that is when V3 told staff to use a full mechanical lift for R1 if needed. V3 stated staff should use safest mode of transfer for each resident. 2. R2's Event Report dated 6/11/18 documents R2's [DIAGNOSES REDACTED]. This report documents R2's backside of the right calf had a laceration measuring 7.5cm (centimeters) in length. This report documents this was due to a self-inflicted rub on R2's walker. There is no documentation of interventions implemented to prevent potential reoccurrences of skin alterations from R2's walker. On 7/31/18 at 3:55pm, V3, Assistant Director of Nursing (ADON) stated R2 had gotten up independently and went to the bathroom. V3 stated V13, Certified Nursing Assistant (CNA) thought R2 had scratched R2's leg on R2's walker. V3 stated R2 jerks R2's walker around. When asked what intervention was implemented to prevent additional potential skin alterations in relation to R2's walker, V3 stated R2's incident with the skin alteration on 6/11/18 was an isolated incident. 3. R3's Care Plan dated 7/30/2018 documents R3 has [DIAGNOSES REDACTED]. R3's Care Plan documents an approach dated 1/29/2016 to transfer R3 with a non-mechanical standing device, gait belt, and assistance of one staff member. These care plans also include R3 may use full mechanical lift. R3's care plan documents an approach dated 7/12/2018 for R3 to wear protective sleeves to both arms during transfers. R3's Event Report documents on 6/23/2018 R3 received a skin tear to right arm due to the arm of the wheelchair. This report also documents an undated evaluation note documenting that R3 has protective sleeves to wear during transfers. On 6/27/2018 at 10:39 AM, R3's Progress Notes document that R3 was requiring the assistance of two staff members for transfers. This note documents to use a full mechanical lift when R3 is unable to bear weight to stand. R3's Event Report documents on 6/29/2018 R3 received a skin tear to left arm during a transfer with the non-mechanical standing device. Occupational Therapy Notes for R3 dated 7/6/2018 documents that R3 was unable to use left arm to aid self during transfer with the non-mechanical standing device, even with the assistance from unidentified staff. R3's Progress Note dated 7/11/2018 at 4:48 PM documents R3 continues to have weakness in the right hand causing R3 to bump the arm on the non-mechanical standing device during transfers. On 7/31/2018 at 2:20 PM, V11 Certified Occupational Therapy Assistant (COTA) and V12 Certified Nursing Assistant (CNA) attempted to transfer R3 from the wheelchair with a non-mechanical standing device. V11 and V12 applied a gait belt and assisted R3 to a standing position and had to physically hold R3 up with the gait belt due to R3 not bearing own weight to stand up straight. R3 reached with the right hand to grab the cross bar located on the non-mechanical standing device. R3's left hand was contracted and R3 was unable to extend R3's left arm to hold onto the cross bar. R3 was unable to stand upright to allow V11 and V12 to lower the seat pads. R3 had to sit back into the wheelchair and was unable to be transferred after two attempts. R3 was not wearing protective sleeves during the transfer attempts. On 7/31/2018 at 2:35 PM, V9 CNA stated that R3 has limited mobility to left hand and arm, and if not careful R3 has a tendency to bump that arm. V9 also stated that following the skin tear on 6/29/2018 protective sleeves were used for a while and R3 is to wear them for transfers during the night. On 7/31/2018 at 3:55 PM V3, Assistant Director of Nursing (ADON) stated that R3 had been having difficulty with transfers. V3 stated V3 teaches the staff to use the safest means of transfer for each resident. The non-mechanical standing device manufacturer's manual dated with the year of 2007, documents that residents who are qualified to use the device should have adequate arm strength to pull themselves upright and enough leg strength to support themselves upright.

Based on interview and record review, the facility failed to ensure supervision of a resident to prevent a fall that resulted in a right wrist fracture for one of three (R1) residents reviewed for falls in the sample of three. Findings include: R1's Care Plans dated 6/1/18 document R1 is at risk for falls due to deconditioning, weakness, decreased mobility and decreased appetite. These care plans document fall prevention interventions including to offer assist with HS (bedtime) care/check/tidy up/ put items away. These care plans also document R1 requires limited assist of one staff member for activities of daily living and R1 is to be supervised for dressing and transfers. R1's Serious Injury Incident Report documents the facility's investigation for R1's fall which documents R1 transfers and ambulates independently with supervision and that R1 fell trying to put R1's shoe back on while standing and lost R1's balance. This report includes R1's emergency room Report dated 5/31/18 which documents R1 was evaluated for fall with right wrist injury. This report documents R1's X-ray of the right wrist showed a comminuted [MEDICATION NAME] distal right radius fracture; minimal volar angulation; possible impacted ulnar styloid fracture as well. On 6/12/18 at 12:29pm, V5, Certified Nursing Assistant (CNA) stated as V5 walked by R1's room on 5/31/18 before R1's fall, V5 waved to R1 as V5 was ambulating an unidentified resident to another room to provide bedtime cares to the unidentified resident. V5 stated R1 was up by the dresser with R1's walker independently without supervision getting ready for bed independently which is common for R1 to do. V5 stated V5 assisted the unidentified resident with cares. V5 stated he was unsure of the time between V5 seeing R1 up in R1's room to when R1 had fallen. V5 stated V5 had assisted the unidentified resident with bedtime cares prior to finding R1 on the floor in R1's room. V5 stated V5's idea of supervision is when they are taken out to a common area to be supervised. V5 stated there were only 2 CNA's, V5 and V9 working on the unit on 5/31/18 at the time of R1's fall and there were supposed to be three CNA's. V5 stated it is too hectic and hard to supervise all residents who require supervision when working short staffed. On 6/12/18 at 1:13pm, V6, R1's Licensed Practical Nurse (LPN) stated she was unsure of when V6 had last seen R1 prior to R1's fall on 5/31/18. V6 stated it is super busy all the time at the facility and on 5/31/18 when R1 fell , there were only 2 CNA's, V5 and V9 on the unit R1 resides on. V6, stated V6 was responsible for all residents on the unit where R1 resides that is located behind locked double doors as well as another hall and a half due to a staff call off. V6 stated staffing is not safe/not good and puts the residents and nursing staff at risk. V6 stated it is difficult to supervise residents that need it because you are too busy with so many residents and low staff, CNA's and nurses, and CNA's get so busy and are unable to supervise residents as needed. V6 stated V6 was on another hall V6 was assigned to when the fall occurred. On 6/12/18 at 4:00pm, V2, Director of Nursing (DON) stated the investigation V2 completed for R1's fall led to the conclusion R1 was ambulating back to bed from the bathroom without R1's walker independently without supervision, lost a shoe and fell trying to put it back on resulting in the right wrist fracture. V2 stated R1 is pretty confused and R1 is to be supervised while ambulating. V2 stated if staff saw R1 up walking independently without supervision, V2 would expect them to assist the resident they were working with to where they were safe and supervise R1 while R1 was up in the room ambulating. V2 stated if R1 would have been supervised while up ambulating as R1 requires, R1's fall resulting in right wrist fracture could have been prevented. The facility was not able to provide a Fall Prevention policy or protocol.

Based on interview and record review the facility failed to ensure R1 was safely transferred using a sit to stand with two staff member s to assist for one (R1) of three residents reviewed in the sample of three residents reviewed for transfers. The faciliy's failure resulted in R1 sustaining a subarachnoid hemorrhage. Findings include: R1's Physician order [REDACTED]. This same POS also documents [REDACTED]. R1's Brief Interview for Mental Status (BIMS) dated 5/30/16 documents R1's score of 8 indicating R1 as cognitively moderately impaired. R1's pre-fall (6-17-16) Fall Risk assessment dated [DATE] documents a score of 19 indicating R1 is a high fall risk. R1's Care Plan dated 5/25/16 documents R1's mobility as left-sided weakness and Multiple Sclerosis impacting R1's transfers. This same Care Plan also documents the requirement to use the stand aide (sit to stand) with the assistance of two members for transfers for R1. R1's Progress Notes dated 6/17/16 documents (R1's) knees gave out while standing and (R1) fell on to the floor on left side immediate formation of a softball sized hematoma to left side of head. R1's Progress Notes dated 6/20/16 document R1 returned to the facility where R1 resides. R1's Patient Summary dated 6/17/16 from R1's emergency room (ER) visit documents R1 arriving on 6/17/16 at 9:56 AM in critical condition, on an anticoagulant, in pain at left eyebrow area from a mechanical fall at the facility where R1 is staying. The Computed Tomography Report from the ER visit dated 6/17/16 for R1 documents the findings as evidence of a small area of Subarachnoid hemorrhage in the left occipital lobe due to a ground-level fall at the nursing home striking left forehead on concrete (initial encounter). R1's [DIAGNOSES REDACTED]. The ER report dated 6/17/16 for R1 documents R1 arrived with threat for imminent organ system collapse secondary to fall with head injury, on anticoagulation .patient stabilized for transfer to local trauma facility. The Trauma Evaluation History and Physical dated 6/17/16 documents R1 as taking Plavix 75 milligrams (mg) everyday. This same report documents active hospital problem as a fall - on coumadin/plavix (blood thinning medication) and a subarachnoid hemorrhage with a plan to admit to trauma. This report also documents International Normalized Ratio (INR) reversed with Fresh Frozen Plasma (FFP) and Vitamin K. The brain scan without contrast dated 6/18/16 impression documents slight increased size of the probable Subarachnoid blood within a left parietal sulcus .there may be a tiny adjacent parenchymal hemorrhage. On 7/12/16 at 12:07 PM, E3, Certified Nurse Assistant (CNA) stated on 6/17/16 E3 was getting R1's weight and as getting resident back into wheelchair, R1 fell . E3 stated R1 requires the use of a sit to stand for all transfers and has been for a while. E3 stated E3 weighed R1 by herself. E3 stated E3 should have been a two person transfer according to R1's 5/30/16 Care Plan. E3 also stated I should have used the stand aid (sit to stand) and another CNA when weighing the resident (R1) .I made a bad judgement call. On 7/12/16 at 12:37 PM, E2 Director of Nursing (DON) stated on 6/17/16 E3 thought it was okay to weigh R1 with no assist but R1 is supposed to be a stand aide (sit to stand) transfer with two assist. E2 also stated E3 transferred R1 incorrectly and E2 doesn't see how R1 could have fallen if the transfer was done correctly. On 7/13/16 at 3:30 PM E1 Administrator stated E3 was weighing R1 on 6/17/16 in the hallway and R1 sat down before E3 was able to get the wheelchair under R1. E1 stated E1 would expect E3 to follow R1's Care Plan and to use a stand aide, gait belt and two assist (with transfers). E1 stated E3 transferred R1 by E3's self. On 7/14/16 at 2:00 PM, Z1, Physician stated the Subarachnoid Hemorrhage was caused from the fall R1 had on 6/17/16 at 10:02 AM. This failure resulted in R1 falling and sustaining a Subarachnoid Hemorrhage.

Based on record review and interview the facility failed to reassess and implement new safety interventions for wheelchair transporting of R15. This failure resulted in R15 falling out of the wheelchair and sustaining a spinal fracture. R15 is one of twelve residents reviewed for falls in a sample of 24. Findings include: The physician's orders [REDACTED].The Minimum (MDS) data set [DATE] documents R15 requires extensive assistance with two person physical assist for transfers and toilet use. R15's Fall Risk Assessments dated 4/18/14 and 7/22/14 was scored as High Risk for falls. The Physician's Progress Notes titled "Clinic note- Nursing Home" R15's primary physician Z1 documents nursing home visits. On 8/12/14 Z1 documents in the progress note: "I have learned that over the past 3 days the staff has had to feed (R15), that (R15) could not feed herself. ...complaining of being very tired and lethargic...I just feel that (R15) is giving up..." Progress note dated 9/2/14 states "(R15) was seen today, due to multiple symptoms. (R15) has been having a lot of weakness. Very tired, lethargic. Does not have much energy at all...." Progress note dated 9/23/14 reads " I was called by the nurse to come see (R15). (R15) obviously was having an absence seizure. (R15) was staring into space and basically not moving...." The facility's report titled "Event Report" dated 9/24/14 at 11:54 AM documents that "(R15) was in the wheelchair being propelled by E24, Certified Nursing Assistant (CNA). E24 states (R15) fell out of the wheelchair while E24 was taking R15 to the bathroom." The report continues to state, "(R15) was observed laying in the bathroom on (R15's) right side with right arm underneath of herself. (R15's) head was laying in the corner between wall and floor in front of toilet. E24 states that (R15) fell out wheelchair head first....When (R15) was turned over it was noted that (R15) had about 2-3 tablespoons full amount of blood on the floor, and (R15's) hair was semi covered in blood on right side and back. (R15) had a small softball sized raised "goose egg" to right forehead with small abraided area, and then when blood was wiped away from back of head, it appeared that there was a 2 cm (centimeter) laceration to left upper occipital region of head....(R15) complained of numbness and tingling to bilateral hands ....(R15) was sent to emergency room for evaluation." R15's hospital records titled "Discharge Summary" dated 9/30/14 documents the following : "Discharge Diagnosis - Cervical cord compression with bilateral Hand Paresthesia related to fall from wheelchair." R15's careplan dated 7/14/14 states "Discontinue Transfer program: Using stand aide, gait belt and two assist for transfers ..: E3, Director of Nurses (DON) confirmed in interview on 2/6/15 at 10:30 AM R15's condition was declining and becoming weaker. E3 also stated that R15 required the assistance of two staff for transfers and toileting and there was only one staff member assisting R15 when R15 fell on [DATE]. E3 DON stated on 2/6/15 at 4PM "The facility did not have a fall policy."

Based on interview and record review the facility failed to provide supervision while toileting (R8) pursuant to her plan of care. R8 was left unattended in the bathroom, stood and fell and received a fracture of the left 5th metacarpal. R8 is one of thirteen residents reviewed for falls in a sample of 24. Findings include: The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R8 requires extensive assistance with one person physical assist for ambulation and toilet use. R8's Fall Risk assessment dated [DATE] was scored as High Risk for falls. R8's undated Resident Centered Care Information Sheet documents that R8 requires 1 assist for safe resident handling and toileting . E5, Care Plan Coordinator stated on 3/5/14 at 2:15 PM " The Resident Centered Care Information Sheet is part of the interim care plan that is initiated within 24 hours of admission." The facility's report titled "Resident and Incident Report" dated August 2013 documents R8 had a fall on 8/17/13 at 5:40 in the bathroom. The facility's "Event Report" dated 8/17/13 at 5:40 PM documents in the section titled "Notes" reads " Observed (R8) in bathroom on floor laying on her left side with head bleeding from middle forehead laceration. .....(R8) was also observed with small laceration on left 5th digit from ring. (R8) stated she tried to get herself off the toilet ...." Notes continue to document on 8/18/13 at 4PM "(R8) had increased swelling and bruising to her left hand and wrist . (R8) complained of pain....Doctor notified and order for stat (immediate) x-ray for left hand and wrist.... 8/18/13 at 8:39PM Received x-ray results which showed no fracture of the left wrist and a fracture of the left hand at base of the 5th digit...." E2, Director of Nurses confirmed on 3/6/14 at 9:42 AM (R8) was left in the bathroom by herself without assistance because (R8) was using her call light, but did not use the call light, and stood up by herself, fell and sustained the fracture. E2 continued to state residents that are considered high risk for falls and not alert and oriented would not be left in the bathroom unsupervised.

Based on interview and record review the facility failed to provide supervision and stand by assistance by not following the plan of care for R3 and providing appropriate equipment for the wheelchair for R2. R2 and R3 are two residents reviewed for falls in a sample of three. Failure to provide supervision by not following R3's plan of care resulted in R3 falling and sustaining a Right Fractured Hip. Failure to provide foot rests for R2's wheelchair as required resulted in R2 placing her feet down and falling from the wheelchair and sustaining a left forehead laceration requiring 14 sutures. Findings include: 1. The POS (physician's orders [REDACTED]. The MDS (Minimum Data Sheet) dated 12/13/11 states R3 is severely cognitively impaired, requires extensive assistance with two person physical assist for transfers and toileting. The same MDS states R3 is not steady and is only able to stabilize with assistance for balance during transitions and walking. The facility's "Fall Risk Assessments" dated 1/18/12 and 7/12/11 stated R3 is at high risk for falls. The facility's report titled "Event Report" dated 4/5/11 states under section titled "Progress Notes", " ...( R3) was found to be lying in doorway of a room with walker and pants half way down. (R3) was lying on right side with complaints of right leg and back pain. Upon assessment (R3) was unable to fully extend both legs due to (R3) contracting legs...." The report titled "Investigation and Root Cause Analysis" dated 4/5/11 under the section titled "Writer's Account" states ".....Investigation started and it was found that the (E4) CNA (Certified Nurse Assistant) taking care of resident did not assist him to wheelchair or alarm him as was (R3)'s plan of care at the time.......(R3's) plan of care was one assist, mobility per wheelchair , and had alarm in both bed and wheelchair." The same report under the section titled "Root Cause Analysis" states "(R3) plan of care not followed by staff member causing harm." Hospital Record titled "Admission History and Physical" dated 4/8/11 states under the section titled "Assessment and Plan" "Hip fracture, right (4/5/11).." R3's care plan dated 12/22/11 under the section "Problem: Risk for Falls" reads R3 is to be alarmed in w/c (wheelchair) due to increased Parkinson's, loss of safety awareness, and assist of 1 for transfers. The approach date for this intervention was 3/23/2011. On 1/24/12 at 11:35 AM E2, DON (Director of Nurses) stated E4 CNA was discharged from her job because she did not follow R3's plan of care. E2 stated R3 should have been in a w/c with one assist for transfers. E2 stated E4 gave R3 his walker and R3 was walking independently when he fell and received a fractured right hip. 2. The POS dated January 2012 states the following [DIAGNOSES REDACTED]. The MDS states R2 is moderately cognitively impaired, requires extensive assistance with two plus people for transfers and toileting. The same MDS states R2's balance is unsteady and requires human assistance to stabilize. The facility's form titled "Fall Risk Assessment" dated 8/30/11 and 10/3/11 states R2 is at high risk for falls. The facility's form titled "Event Report" dated 12/19/11 under "Progress Notes" states "(R2) was being wheeled back to bed from bathroom when (R2) apparently leaned forward and toppled out of w/c. (R2) hit left side of head on floor and received laceration to left forehead...." The facility form titled "Investigation and Root Cause Analysis" dated 12/19/11 section titled "Root Cause Analysis" states "(R2) feet caught on floor while E5, CNA was pushing (R2) in w/c through doorway." The hospital Report titled "Nursing Home Patients Returning From ER" dated 12/19/11 states under the section titled "Treatments" reads "14 6-0 Ethylene sutures by ER (emergency room ) MD (medical doctor). Bacitracin ointment to wound twice a day." E2 stated 1/24/12 at 12:20 PM R2 was being evaluated by therapy for w/c that would allow her to propel self , the w/c that was being used at that time (12-19-11) had a low seat, lower to the floor and was to have foot rests on the w/c. E2 stated E5, CNA took R2 to the bathroom without the foot rests on the w/c and R2 put her feet down and fell forward out of the w/c. E5 should have put the foot rests on the w/c prior to taking R2 to the bathroom.

Based on interviews, observations and record review, the facility failed to ensure that 3 (R4, R6 and R12) of 11 sampled residents reviewed for passive range of motion (PROM) received appropriate treatment and services, including thorough assessments of risks and contractures, monitoring and accurately completed passive range of motion to prevent further decrease in range of motion. This failure to assess resident's responses to PROM resulted in R4, R6, and R12 having a decline in range of motion. Findings include: 1. R4's Minimum Data Set ((MDS) dated [DATE] identify limited range of motion and contractures bilaterally with Passive range of motion being done. The care plan dated 11/24/10 identifies R4 to have decreased ROM and "at risk for developing contractures." The goal states R4 will experience no further loss of ROM thru next review. Intervention include monitoring/record/report presence of pain, intolerance, or muscle spasm during movement, "Perform PROM to all BLE (Bilateral lower extremities) BID (Twice daily) by CNA's (Certified Nurses Aides). The care plan also indicates she is a mechanical lift. R4 was observed on 1/27/11 at 10:30am to be laying in bed on her left side. Both arms were drawn up to her chest and her knees were drawn up as well. R4's fingers were noted to be tightly curled into the palm of her hand. E8, CNA and E13 Registered Nurse (RN) provided incontinent care rolling her from side to side. Her arms and legs remained drawn up toward her body. E8 then did PROM. She rolled R4 to her back and flexed/extended both arms then moved to her legs which she flexed and extended the hip/knee joint and ankle joint. No further joints were ranges. E8 states "that's as much as we do on her because she doesn't move very well" and is so "stiff." E13, RN was asked if she felt the PROM were done appropriately and responded no. Review of R4's quarterly CONTRACTURE RISK ASSESS - I shows on 3/10/10 that R4 was moderate risk for developing contractures even though she had moderate limitations (20-40%) identifies in addition to moderate hypertonicity. The assessment identifies R4 to be immobile, have very limited functional abilities with confusion. The next quarterly review was dated 6/9/10 and again identifies R4 to be at moderate risk and moderate hypertonicity but has "Present Joint Condition" incomplete. On 11/23/10, the facility completed the next assessment for contracture risk which still shows R4 at moderate risk and an increase in limitations of > (greater than) 40% with "severe/rigid/spastic" muscle tone. This signifies a decline in R4's range of motion. On 1/27/11 at 12:45pm, E12 Licensed Practical Nurse (LPN)/Assistant Director of Nursing identified herself as the restorative nurse. E12 indicate that she does the quarterly Contracture Assessments when she completes her portion of the MDS and agreed that residents with contractures should be identified as a "high" risk. E12 confirmed that no additional measurements and/or further assessments are done to determine extent of contractures or range of motion except the risk assessment that she completes. E12 was questioned about training and and stated she trains CNA's on PROM upon hiring and agreed that inservicing on performing range of motion needs to be done. 2. R12's MDS dated [DATE] identifies that she requires extensive assist of activities of daily living and has limitations of all extremities. The MDS also indicates R12 receives PROM 7 days a week. According to the January 2011 physician's orders [REDACTED]. On 1/26/11 at 2:36pm, E11 and E12 CNA's were asked to do PROMs on R12. Both CNA's stated they usually do them while dressing and bathing the residents. Both had a difficult time identifying which residents on their halls received PROM on a nightly basis. Both CNA's helped change R12's knit top and cued her to straighten her arms out as they did. R12 was unable to straighten her arms out, had contractures of her fingers and kept her legs drawn up unable to spread knees as staff rolled her side to side for incontinent care during this observation. No range of motion was done to any one joint other than changing her shirt. E11 said they do range of motion on her legs when they change her pants or put them on. R12 had contracted hands, elbows, knees. Her socks remained on. According to the CONTRACTURE RISK ASSESSMENT information, R12 was assessed on 4/21/10 to have minimal limitations (< 10%) with moderate hypertonicity or flaccid. This assessment determined R12 was a moderate risk for the development of contractures. The next two CONTRACTURE RISK ASSESSMENTs were dated 7/12/10 and 1/25/11 and also identified R12 to be at moderate risk for contractures with the same limitations. Again, interview with the Assistant Director of Nursing on 1/27/11 at 12:45pm confirms that no further assessments for contractures were done. On 1/28/11 at 9:15am, E2, Director of Nursing confirmed that a risk assessment is to determine residents at risk for contractures and not actually an assessment of existing contractures and/or limitations. E2 also confirmed that no other assessments for contractures is completed at this time. 3. The MDS dated [DATE] identifies R6 to require staff assistance for all activities of daily living including mobility. The MDS also notes R6 to have bilateral limitations of both upper and lower extremities. The care plan dated 7/22/10 indicates R6 has the "Potential for development of contractures d/t (due to) decrease in mobility/ambulation & has limited range of motion to bilateral upper extremities, res (resident) also has foot drop bilaterally." The care plan goal is to maintain her current ROM. The interventions indicate staff are to do PROM to bilateral upper extremities twice daily but fails to include the lower extremities. The second approach is to have a quarterly and prn (as needed) contracture assessment done. The facility failed to address all R6's limitations. The 2010 CONTRACTURE RISK ASSESSMENTS were requested on 1/27/11 and E2 DON was only able to provide one assessment dated [DATE]. E2 confirmed that quarterly assessments were not completed. The assessment provided indicated R6 was only at a "moderate" risk of developing contractures, had moderate limitations on the joints which is identified as 20-40% limitations with moderate hypertonicity or flaccid. R6 has had a decline in range of motion. According to the MDS dated [DATE], R6 had only a partial loss of range in only one foot and partial loss on both legs. No limitations or loss of range was identified for either upper extremities. No further assessments have been done according to E2, DON. R6 was observed throughout the survey to be up in a reclining chair that had leg extensions on. R6 was noted to have severe bilaterally foot drop, contractures of her hand evident when feeding herself with some difficulties and also contractures of her upper arms, primarily elbows also evident when feeding herself. R6 is also a mechanical lift. 4. The facility's policy entitled "Range of Motion" identifies the purpose is to prevent contractures, maintain range of motion, increase joint motion, maintain and build muscle strength, stimulate circulation, prevent deformities and prevent contractures from becoming worse if they are already present. PROM is described as an exercise carried out without the active movement of the muscles within the joint being exercised and stabilize the proximal joint, support the distal joint and move the joint smoothly, slowly and gently through its full range of motion. The joint list includes all joints of the body.

Based on record review and interview, the facility failed to analyze data to identify trends and patterns and perform root cause analysis of falls for 4 of 7 residents sampled for falls (R1, R2, R15, R16). The facility did not develop and implement and individualized interventions to prevent current falls including recurrent falls. This failure resulted in R2 sustaining a right femur fracture;, R1 sustained a fractured hip; and R15 sustained a fractured hip. Findings include: 1. Based on R2's January 2011 physician order [REDACTED]. The MDS dated [DATE] identifies her to have moderate cognitive impairment with short/long term memory deficits. The care plan dated 10/2/10 identifies R2 to be at risk for falls with interventions incliuding no skid foot wear, supervision and assist with transfers/mobility as needed, observe at frequent intervals to ensure safe environment, encourage/educate on use of the call light and keep within easy reach, bed alarm when in bed (9/6/2010) and occupational/physical therapy evaluations as appropriate among others. According to the Incident/accident log, R2 has had multiple falls. She has had falls on 8/11/10, 8/14/10, 8/31/10, 9/5/10 and 10/8/10. E2, Director of Nursing, was asked on 1/27/11 what interventions had been implemented to prevent falls for R2. She said she would check and later came back with a list of interventions that had been tried. Based on the incident report on 8/11/10 R11 told the shower aide that she had fallen in the bathroom hitting her head on the floor. She had a bruise on her left forehead. The incident was not witnessed and was reported by the resident later while getting a shower. The facility implemented an Occupational Therapy evaluation for proper transfer technique, educate R2 to use call light, pressure alarm while in bed and tab alarm while up in wheelchair. The incident report dated 8/14/10 states the Nurse heard R2 crying from her room and found her on the floor holding the back of her head. R2 said she was putting things away when she fell . There was no indication that an alarm was sounding or not to indicate if the chair alarm was effective. R2 was re-educated on the use of her call light. The facility also had Physical therapy evaluate. Based on the incident report on 8/31/10 Nurse stated she was alerted by the Certified Nursing assistant that R2 was on the floor and was already in the toilet room. R2 said she had difficulty sleeping due to her roommate keeping her up and that she fell out of bed. The report does not indicate if the alarm was sounding at the time to alert staff she was up. The facility relocated her to another room. The incident report of 9/5/10 again indicates the nurse was called to R2's room and R2 stated she had fallen while attempting to get into bed. The report fails to indicate whether the alarm was in place and working/functioning or not. The facility also failed to determine why staff were unable to respond to R2's alarm in a timely manner to prevent the fall. On 10/07/10 at 11:00 PM, according to the incident report, R2 called for staff and was found lying in the doorway of the restroom. R2 stated that she had gotten up, used the restroom and was heading back to bed when she just fell . Her walker was parked outside the bathroom. Again, there was nothing documented in the report that indicated whether or not the bed alarm was sounding to alert staff that she had gotten up. On 10/8/10, R2 was diagnosed with [REDACTED]. R2 returned to the facility following a intertrochanteric closed reduction of her right femur. Following her return to the facility, R2's had three additional falls on 11/2/10, 12/23/10 and 1/18/11. All falls occurred in her room and were unwitnessed. The incident reports indicate staff responded to her alarm sounding finding her already on the floor. On 1/28/11 at 9:15am, E18 Certified Nurses Aide (CNA) stated R2 used to be more independent before her fracture and that she does continue to get up unassisted with the alarm sounding 1-2 times per shift. E18 and E19 (CNA) also said the alarm does not deter R2 from getting up stating that she's confused and doesn't really understand what the alarm is anyway. On 1/28/11 at 9:30am, E2, Director of Nursing agreed the facility needs to document whether or not a residents current interventions were in place at the time of falls and assess whether or not they are effective. 2. R1's Minimum Data Set (MDS), dated [DATE], documented an alert resident with extensive assistance of one person physical assistance with transfer and mobility, vision moderately impaired and functional limitation with range in motion for lower extremity (hip, knee, ankle and foot). R1's Care Plan, problem start date 9-20-10, documented, in part, increased risk for falls related to diagnose of left hip fracture. It was also noted to assist R1 as needed. R1's Progress Notes, dated 12-11-10 to 12-27-10, documented R1's continued treatment for [REDACTED]. R1's Event Report, dated 12-18-10, documented R1's diagnoses, in part, as Urinary Tract Infection, Senile Psychosis and Hallucinations. It was also noted R1 was found in her room after an unwitnessed fall. R1 was sent to a local hospital. R1's Progress Note, dated 12-18-10, documented R 1 was admitted for a fractured right hip. R1 stated, on 1-25-11 at 2:00p.m., when asked about her 12-18-10 fall, "I broke my hip at home (left). I stood up here to use walker and broke my hip. I'm legally blind by the State. I can see shadows." R1's Fall assessment dated [DATE], did not document R1 was at risk for falls. R1's Care Plan, did not document interventions to address R1's visual impairment or her increased confusion related to her Urinary Tract Infection prior to her 12-18-10 fall. The facility did not provide an individualized plan addressing R1's fall prevention to include her visually impairment or need for increased assistance and supervision related to her increasing confusion due to her Urinary Tract Infection prior to her 12-18-10 fall. 3. R15's MDS, dated [DATE], moderately impaired cognition with short and long term memory problems, limited assistance of one person physical assistance with mobility, locomotion, toileting and impaired standing and sitting. R15's Care Plan, dated problem start date 8-28-10, documented at risk for falls related to weakness and unsteady gait. R15's Event Reports and Investigation and Root Cause Analysis, dated from 9-6-10 to 1-21-11, documented six falls. On 9-6-10, R15 removed her alarm, attempted self-toileting and was found sitting on the floor at the foot of her bed with her back to her wheelchair. R15's chair moved during self-transfer. On 9-11-10, R15 removed her alarm, attempted self-toileting and was found sitting on the floor. R15's wheel chair rolled away from her during self-transfer. On 9-20-10, R15's alarm was sounding, attempted to stand up when the wheelchair rolled away from her and she fell . R15's Event Report, dated 11-9-10, documented diagnoses, in part, as Dementia, Muscle Weakness, Nonorganic Psychosis and Urinary Tract Infection. It was also noted R15 was finishing toileting, turned on the call light and stood up when staff did not timely respond. E2, Director of Nursing (DON), stated, on 1-27-11 at 10:35a.m., that R15 was not safe to be left alone on toilet. R15's Investigation and Root Cause Analysis, dated 11-9-10, documented staff were re-educated the need for consistent supervision for those residents with alarms. R15's Event Report, dated 11-10-10, documented R15 removed her alarm, attempted self-toileting and was found on the floor with a 1cm laceration to the left side of her head. On 1-21-11, R15 was having trouble propelling herself in her wheel chair. Staff stepped behind the wheel chair and started to propel R15 forward and R15 feel forward and hit her head. R15 was sent to a local hospital for a hematoma to the right side of her head. R15's Care Plan documented "8-28-10 personal alarm to alert staff when (R15) is attempting to get up without help" R15's personal alarm was not addressed until after her third fall which resulted in laceration to the left side of her head. R15's Care Plan documented "1-10-11 DC (discontinue) personal tabs alarm; sensor alarm when in w/c (wheel chair) when in bed." E2, DON, stated, on 1-27-11 at 10:35a.m., that staff had been repeatedly re-educated on alarm placement to ensure R15 could not turn it off. E2 did not state another type of alarm had been provided or assessed as alternative fall prevention measure. R15's Care Plan, dated 8-28-10 to 1-21-11, that R15's wheel chair was not assessed for any anti-rolling system(s) until after R15's 1-21-11 incident which resulted in a hematoma to the right side of her head even though R15 had incurred three falls when her wheel chair moved during self-transfers and one incident of falling from her wheel chair after staff assistance. The facilty did not provide an individualized fall prevention plan that timely identified R 15' s' usage of her alarm and her wheelchair. 4. R16's Care Plan, start dated 12-13-10, documented R16 was at risk for falls related to [DIAGNOSES REDACTED]. with falls on 12-23-10, 1-3-11, and 1-7-11. R16's Event Reports and Investigation and Root Cause Analysis, dated 12-23-10 to 1-7-11, documented three falls. R16's Event Report, dated 12-23-10, documented diagnosis, in part, as Admission Left Neck of Femur Fracture and Dementias. On 12-23-10, staff found R16 on the floor with her alarm sounding, blood pooled in her ear and a laceration to the left ear. On 1-3-11, staff found R16 on the floor with her alarm sounding after attempting self toileting. On 1-7-11, staff found R16 on the floor with her alarm sounding after attempting self transfer. R16's Care Plan, dated 12-23-10, documented "personal alarm to alert staff when resident is attempting to get up without help." The facility did not provide an analysis of the effectiveness of R16's alarm to prevent R16 falls or an individualized interventions to prevent further falls.

Falls A. Based on record review and interview, the facility failed to effectively supervise residents at risk for falls, develop and implement a system to collect and analyze data related to the falls, failed to assess the root causes of the falls, and failed to individualize the care plan to meet the specific needs of the resident in relation to falls, for 2 of 3 (R1, R3) residents reviewed for falls in a sample of 13. This failure resulted in R1 falling multiple times, resulting in a fractured wrist and hip. Additionally, this failure resulted in R3 falling and sustaining a subdural hematoma and multiple skin tears. Findings include: 1. A physician's orders [REDACTED]. A Minimum Data Set, dated dated [DATE], indicates that R1 has long and short term memory deficits and has moderate cognitive impairment. A Care Plan (which is undated), located at the nurses station, indicates R1 is at risk for falls because of weakness, unsteady gait and a history of falling. The Care Plan indicates the following interventions were put into place, on 8/06/08: Encourage resident to void before and after meals, prior to bed and upon rising; Therapy as ordered to improve strength and mobility; Keep bed in lowest position with brakes locked and floor mats; Observe frequently and place in supervised area when needed. The Care Plan indicates the following interventions were put into place on 8/06/09: Pressure alarm while in bed and chair; Offer additional activities at high risk times. Nursing note documentation, indicates R1 fell on the following dates: 2/22/10, 3/11/10, 3/14/10, 3/24/10, 4/2/10, 4/25/10, 5/02/10, 6/17/10, 7/04/10, and 8/25/10. An Event Report, dated 3/14/10 indicates R1 was found on the floor in his room next to the bed. The intervention used to prevent further falls was the use of a bolstered mattress. The current Care Plan documents R1 fell on [DATE] and the intervention implemented was the use of a bolstered mattress. On 8/31/10 at 3:09 pm, E10 (Certified Nursing Assistant) verified that R1 had a bolstered mattress, which had been used recently, but could not confirm if the bolstered mattress was utilized in March of 2010. On 8/31/10 at 10:30am, E7 (Care Plan Coordinator) stated she was uncertain why the bolstered mattress was used as an intervention to prevent falls after the 7/04/10 fall, when it was previously used as an intervention 3/14/10. Fall Event Reports indicate that the following falls were documented, however not fully analyzed as to determine the root cause, nor were there new interventions implemented to prevent further falls: 3/24/10, 4/02/10, 4/25/10, and 5/02/10. The facility was unable to provide documentation of any analysis for the falls R1 sustained on 6/17/10 and 7/4/10. An Event Report, dated 3/24/10, indicates R1 had fallen in the bathroom of his room while attempting to toilet himself. R1 sustained a skin tear to the right elbow after that fall. The 3/24/10 fall was listed on the Care Plan. However, the fall was not comprehensively analyzed and new interventions to prevent further falls were not developed. An Event Report, dated 4/02/10, indicated R1 was found on the floor next to his bed and sustained a 4 x 3 centimeter bruise to the left shin. The 4/02/10 fall was listed on the Care Plan. However, the fall was not comprehensively analyzed and new interventions to prevent further falls were not developed. After R1's undocumented fall, during a transfer on 6/17/10, R1's nursing notes, dated 6/18/10, indicate that R1 had complaints of swelling and bruising to his left wrist. Hospital records, dated 6/18/10, indicate R1 presented to the Emergency Department for evaluation and treatment of [REDACTED]. R1's current Care Plan does not reflect any documentation that this fall occurred. There is no documentation the 6/17/10 fall was analyzed and new interventions to prevent further falls were not developed. An Event Report, dated 8/25/10, indicates R1 was found on the floor of his room at 8:00pm. The Event Report indicates the fall was not witnessed by staff and that R1 complained of right leg pain and had redness to the right forehead. A Hospital x-ray report, dated 8/25/10, documents R1 sustained a Right Hip Fracture, after the fall that night. On 8/31/10 at 10:50am, E8 (Certified Nursing Assistant) stated she was working the evening of 8/25/10 on the hall of R1. E8 (Certified Nursing Assistant) stated E10 (Certified Nursing Assistant) had R1's section of the hall, but "wasn't around". Approximately 8:00 - 8:15pm on 8/25/10, E8 (Certified Nursing Assistant) stated she walked past R1's room and heard a "thump" and then a cry for help. E8 (Certified Nursing Assistant) stated she found R1 alone in his room lying on the floor, alarm sounding, near the wheelchair, with his head up against the wall. E9 (Certified Nursing Assistant), came to R1's room and helped her assess the resident. E8 (Certified Nursing Assistant) stated R1 immediately complained of right hip pain and was sent to the hospital for evaluation. E8 (Certified Nursing Assistant) stated "Normally, they don't put (R1) in his room unless he's going to bed, because he gets into things." E8 (Certified Nursing Assistant) stated, if R1 is up in his wheelchair, they leave him in the hall so he can "interact with staff and isn't alone." On 8/31/10 at 3:09pm, E10 (Certified Nursing Assistant) stated she was caring for R1 the evening of 8/25/10. E10 (Certified Nursing Assistant)left R1 alone in his room, in his wheelchair, on the evening of 8/25/10. E10 stated she left the unit to retrieve supplies from storage and when she returned R1's fall had occurred. E10 (Certified Nursing Assistant) stated she left R1 up in the wheelchair, because in the past he has tried to swing his legs over the side of the bed. 2. A physician's orders [REDACTED]. A Minimum Data Set, dated dated [DATE], indicates that R3 has long and short term memory deficits and has moderate cognitive impairment. A Care Plan (which is undated), located at the nurses station, indicates R3 is at risk for falls because of weakness, unsteady gait and a history of falling. The Care Plan indicates the following interventions were put into place, 3/05/10: Place call light within reach; Encourage to use call light and ask for assistance when needed; Assist (R3) as needed; Proper skid free footwear; Personal Alarm to monitor rising. The Care Plan indicates the following interventions were put into place on 3/10/10: Monitor for adverse side effects of psychotropic medications if ordered; low bed and locked; mats on floor beside bed; bolsters to bed. Nursing note documentation, indicates R3 fell on the following dates: 3/10/10, 3/12/10, 3/15/10, 3/23/10, 3/29/10, 4/01/10, 4/02/10, 4/23/10, 5/03/10, 5/14/10, 5/16/10, 6/09/10, 6/17/10, 6/18/10, 6/22/10, 6/23/10, 7/06/10, 7/11/10, 7/20/10, 7/23/10, and 8/10/10. Fall Event Reports indicate that the following falls were documented, however, not fully analyzed as to determine the root cause and there are not new interventions developed to prevent further falls: 3/12/10, 3/23/10, 3/29/10, 4/01/10, 4/23/10, 5/03/10, 5/14/10, 5/16/10, 6/09/10, 6/17/10, 6/18/10, 6/22/10, 6/23/10, 7/11/10, 7/20/10, and 8/10/10. An Event Report, dated 3/29/10, indicates R3 had fallen in his room. R3 was sent to the hospital, admitted to the Intensive Care Unit, and diagnosed with [REDACTED]. An Event Report, dated 6/09/10, indicates R3 was found on the floor in his room with a left hand injury and taken to the emergency room for evaluation. R3 sustained a 5 centimeter laceration to the left thumb, a 5 centimeter laceration, a 4 centimeter laceration, and a 8 centimeter laceration to the back of the left hand. R3 required steristrips and a splint to the left hand. The 6/09/10 fall was not listed on the Care Plan, not comprehensively analyzed and new interventions to prevent further falls were not developed. On 8/31/10 at 10:30am, E7 (Care Plan Coordinator) stated that she served on the Fall Committee, which currently meets daily. E7 (Care Plan Coordinator) stated they did not always meet on a scheduled basis in the past. E7 (Care Plan Coordinator) stated there were months when the Fall Committee did not meet, when the prior Director of Nursing was at the Facility. E7 (Care Plan Coordinator) confirmed that not all of R1 and R3's falls were analyzed and that there were not new interventions developed to prevent further falls. Elopement B. Based on record review, interview, and observation, the facility failed to effectively supervise 1 of 8 (R5) residents identified with wandering or elopement behaviors, in a sample of 13. The facility failed to have an specific alarm which identifies when a person, who has a personal body alarm, exits the building. Findings include: Facility policy and procedure, titled " Missing Resident " , indicates, under "Procedure: 1.) All exterior doors shall be equipped with a signal that will alert the staff in a resident leaves the building. " Facility " Missing Resident Protocol " , under " Prevention " , indicates " train staff during orientation and on an on-going basis - explain different alarm systems. " A physician's order [REDACTED]. A Care Plan, dated 8/10/10, identifies R5 as a elopement risk and has the following interventions: " (personal body alarm) placed on residents wrist; Notify family and MD (medical doctor) of exit seeking behavior as appropriate; Monitor for an increase in exit seeking; provide diversional activities of her preference during time of exit seeking behaviors. " Nursing notes, dated, 8/14/10 at 2:25pm, document " pt. (patient) found wandering outside the facility .....no obvious injuries or bruising present, full skin assessment performed, no open areas noted. " On 8/30/10 at 1:30pm, E4 (Licensed Practical Nurse) stated, at approximately 9:00am on 8/14/10, she heard the door alarm sound. E4 (Licensed Practical Nurse) stated she went to the front door and saw a man and a resident of the facility sitting outside. E4 (Licensed Practical Nurse) stated she walked out the front door and " looked around " , but saw no one else. E4 (Licensed Practical Nurse) stated, since she saw no one else outside, she assumed the door alarmed because the other resident and family member walked outside. E4 (Licensed Practical Nurse) then returned to the inside of the facility and turned the alarm off. E4 (Licensed Practical Nurse) stated that the personal body alarm and door alarm do not sound different, and there was nothing to alert her to the fact that R5 had left the building. On 8/31/10 at 9:45am, E6 (Certified Nursing Assistant) stated the morning of 8/14/10, she saw R5 sitting in the Library between 8:45am and 9:00am. At approximately 9:30am, E6 (Certified Nursing Assistant) received a telephone call from a local shopping center, indicating that " one of their residents " had been found there. E6 (Certified Nursing Assistant) stated she " had a feeling it was (R5) because she wandered a lot. " E6 (Certified Nursing Assistant), along with E5 (Licensed Practical Nurse), drove over to the local shopping center and picked up R5. E6 (Certified Nursing Assistant) stated it took them approximately 30 minutes to get R5 back inside the facility, and R5 " ran back towards (the shopping center). " E6 (Certified Nursing Assistant) stated R5 was not injured and was constantly monitored after the incident. E6 (Certified Nursing Assistant) stated a pressure alarm was put in her bed and chair to alert staff to any movement, for the remainder of her stay. On 8/31/10 at 9:35am, E5 (Licensed Practical Nurse) stated the morning of 8/14/10, she was at the nurses station when E6 (Certified Nursing Assistant) answered the phone call that R5 was found at a local shopping center. E5 (Licensed Practical Nurse) stated she and E6 (Licensed Practical Nurse) drove over to the shopping center to pick up the resident, who was confused. E5 (Licensed Practical Nurse) stated she did not hear the alarm sound that morning. E5 (Licensed Practical Nurse) stated she had heard reports from other staff, prior to this incident, that R5 was exit seeking. On 8/30/10 at 10:30am, Z1 (Police Sergeant) stated he responded to a call, on 8/14/10 at approximately 9:30am, in the parking lot of a local shopping center. Z1 (Police Sergeant) stated R5 was " obviously confused " and stated she was " going home " , but did not know where home was. Z1 (Police Sergeant) stated, " within minutes of arriving " a vehicle pulled up with two staff members from the facility and escorted R5 to the vehicle. Z1 (Police Sergeant) stated that R5 was originally found at the restaurant across the highway from the facility, but then wandered across the street to the parking lot of the shopping center. On 8/31/10 at 8:45am, Z2 (Family) stated R5 was "bound and determined" to leave the facility, because she told him she "wanted to go home." Z2 (Family) stated R5 is currently living back at her own home, because she did not want to stay at the facility. R5 was unable to be interviewed, as she was discharged from the facility to her own home on 8/16/10. On 8/30/10 at 1:23pm, E3 (Maintenance Supervisor) stated that R5's personal body alarm was functioning the morning of 8/14/10. E3 (Maintenance Supervisor) provided alarm log information, via the computer system, that indicated the front door alarm went off at 9:08am on 8/14/10 and was shut off at 9:13am on 8/14/10. E3 confirmed that all of the facility doors will alarm if an alarm code is not put in prior to exiting. E3 also confirmed that the same alarm sounds if a resident with a personal body alarm exits through a facility door. On 8/30/10 at 10:26am, E1 (Administrator) stated that the door alarms do not differentiate between someone (i.e. visitor or non-confused resident) exiting the building and someone with a personal body alarm, who is an elopement risk, exiting the building. On 8/30/10 at 1:45pm, along with E1 (Administrator), door alarms were checked for verification of working order. When exiting out the front door, the alarm sounded. When exiting out the front door with a personal body alarm, the same alarm tone sounded. The 100 Hall exit door alarmed when opened. When exiting out the 100 Hall exit door with a personal body alarm, the same alarm tone sounded. There is not a way to distinguish, with the alarm tone, between a non-confused resident/visitor leaving the facility and a confused resident, who is an elopement risk, with a personal body alarm, exiting the building.