Every finding on record at Goldwater Care Danville

Based on interview and record review, the facility failed to ensure staff used two-person assistance during mechanical lift transfer and failed to inspect mechanical lift slings prior to each use in accordance with facility policy and manufacturer recommendations for one (R1) of three residents reviewed for accidents on a sample list of eight. These failures resulted in R1 falling from a mechanical lift while suspended in the air and sustaining a comminuted, displaced and impacted proximal left humeral fracture (shoulder), and a small subgaleal hematoma (pocket of blood between skull bone and scalp skin). This past non-compliance occurred from 7/1/26 to 7/2/26.Findings include:The facility's policy, Manual Gait Belt and Mechanical Lifts, revised 1/19/18, includes 'Guidelines: 4. Mechanical lift equipment shall undergo routine maintenance checks by the nursing and maintenance staff to ensure that equipment remains in good working order. 5. The transferring needs of residents will be assessed on an ongoing basis and designated into one of the following categories: H - (mechanical lift) with 2 caregivers.'On 7/16/26 at 10:35am, V2, Director of Nursing, confirmed that staff are required to inspect slings prior to each use and that two staff members are required to operate the mechanical lift during resident transfers.The manufacturer's full body sling instruction manual, undated, includes Warning: Carefully inspect the sling before each use for wear and damage to seams, fabric, straps and strap loops. Torn, cut, frayed, or broken slings can fail, resulting in serious personal injury to the user.On 7/15/26 at 2:38pm, V2 confirmed that all staff should be inspecting slings before each use. If there is a problem, the slings should be removed from service and reported to V2. R1's incident report, dated 7/1/26, included, during transfer via mechanical lift staff was transferring resident from wheelchair to bed when mechanical lift sling strap broke. Resident had witnessed fall from machine to floor. Resident observed on ground on top of mechanical lift legs on her left side with face pressed against floor. Legs extended outward. CNA (Certified Nursing Assistant) standing near resident feet. Erythema/bruising noted to right side of face. Deformity of left arm. CNA noted resident struck head on roommate's little table.R1's hospital encounter summary, dated 7/1/26, includes, Reason for visit: Fall - Patient arrives by EMS (emergency medical services) from (Facility) after being dropped while in the (mechanical) lift after strap broke. Pt (patient) did strike head (on Eliquis for a-fib) and c/o (complain of) left arm/shoulder pain.R1's Imaging results, dated 7/1/26, includes, Computed Tomography (CT) Head Impression: small subgaleal hematoma overlying the right frontal convexity, with no evidence of underlying fracture or intracranial hemorrhage. Xray Humerus Left, dated 7/1/26, includes, 'Left shoulder: Comminuted, displaced and impacted proximal left humeral fracture involving the surgical neck and extending to the greater tuberosity.On 7/15/26 at 10:05am, V4, R1's daughter, stated R1 was dropped from the mechanical lift on 7/1/26 while being transferred by one staff member. V4 stated R1 sustained a broken shoulder and cuts and bruises to R1's face. On 7/15/26 at 11:30am, V3, Assistant Director of Nursing, stated V3 was called to R1's room by V5 (CNA). Upon arrival, V3 observed R1 on the floor near the mechanical lift. V3 stated the sling strap had broken while R1 was elevated in the lift, causing the fall. R1 complained of shoulder pain and was sent to the emergency room for evaluation. Upon inspecting the sling, V3 stated the hook that is on the sling had split in half. V3 confirmed R1 had been transferred by only one staff member (V5) and stated facility policy requires two staff for all mechanical lift transfers. On 7/15/26 at 1:30pm, R8, R1's roommate, stated R1 was being transferred in the mechanical lift when something broke, causing R1 to fall. R8 stated the chair was no longer under R1 and R1 struck her head on the table during the fall. R8 stated both R8 and R1 told V5 that two staff members were required for mechanical lift transfers, but V5 insisted V5 could do the transfer alone. R8 stated that when R1 was elevated in the sling, V5 pulled on the sling causing it to break, leading to R1's fall.On 7/17/26 at 9:22am, V5 stated V5 was transferring R1 from the wheelchair using the mechanical lift when the sling broke and R1 fell to the floor, striking her head on R8's table during the fall. V5 confirmed V5 did not inspect the sling before beginning the transfer and confirmed she was alone in the room during the transfer.On 7/16/26 at 9:10am, V1, Administrator, stated V1 expects staff to use two assists for mechanical lift transfers and inspect slings before every use. Prior to the survey of 7/15/26, the facility took the following action to correct the noncompliance: On 7/2/26, A Quality Assurance meeting was held to discuss deficiency and facility action plan for the accident with injury.On 7/2/26, audits were conducted on all slings in service. On 7/2/26, all licensed and certified nursing staff were educated on the facility's Fall Prevention Program Policy, Incident/Accident Policy, and Transfers - Manual Gait Belt and Mechanical Lift Policy.On 7/2/26, all laundry staff were educated on the facility's Mechanical Lift Sling Inspection Log.On 7/2/26, the facility began conducting audits to ensure residents are being transferred with appropriate equipment and appropriate staff.

Based on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services. This failure has the potential to affect all 72 residents within the facility.The Long Term Care Facility Application for Medicare and Medicaid dated 6/7/26 documents 72 total residents within the facility. On 6/7/26 at 1:15PM, V1 Administrator, stated they do not currently have a dietary manager. V1 stated that a new dietary manager will start 6/8/26. V1 stated they do not have a full time in house dietician. The registered dietician visits once a month. On 6/8/26 at 9:15AM, V1 Administrator, stated that the hired dietary manager did not complete the on boarding paperwork so they can not start until that is completed. On 6/9/26 at 8:45AM V1 Administrator stated that the dietary manager is anticipated to start on 6/11/26. On 6/9/26 at 12:38 PM V12 cook stated they do not have a dietary manager and is unsure of how long. Corporate Human Resources oversees the kitchen. Facility Key Personnel dated 4/14/26 documents no dietary manager.

Based on observation, interview, and record review the facility failed to store food and equipment under sanitary conditions in accordance with professional standards for food service safety. This failure has the potential to affect all 72 residents in the facility. Findings include:On 6/9/26 between 12:38PM and 1:20PM, V12 (Cook) gave a tour of the kitchen and food storage areas. In the kitchen, in the freezer there were opened boxes of breaded fish, dinner rolls, and sausage patties that were not sealed. In the refrigerator, there was a container of cottage cheese in a maroon individual bowl with a plastic lid on it that was undated. On the refrigerator seals there was a thick slimy substance with food particles. V12 stated V12 does not have documentation of when the seals were last cleaned. In a kitchen drawer of serving spoons there was food debris in the back, right corner of the drawer. In the kitchen, under the food preparation station, there were cutting boards. The yellow and green cutting boards were wet and had multiple surface-level and deep scratches with small pieces of plastic sticking up from some of the scratches. Near the kitchen door, there was a meat slicer on the bottom shelf that was uncovered and had food debris on it. Under the preparation table, the containers of thickener and sweet and sour sauce had grease residue on them. Both were opened and did not have a date. There was also a box of salt and cream of wheat open with the tab to the container not sealed. In the area where dishes were cleaned and dried, there containers stacked on top of each other with water residue between each container on a rack. Clean dishes were taken from the dishwasher and placed next to a dirty container of bowls with gray water. In the storage area of the basement, two of the three freezers had frost in them. V12 stated V12 did not have documentation of when the freezers were cleaned and defrosted. In the dessert freezer there was an opened and unsealed box of cookies. In another freezer there was an opened and unsealed box of frozen vegetables.On 6/9/26 between 12:38PM and 1:20PM, during the tour, V12 confirmed that the fish, dinner rolls, sausage patties, cookies, frozen vegetables, salt, and cream of wheat should have been sealed. The cottage cheese, thickener, and sweet and sour sauce should have been dated. The drawer with the spoons and the seal around the refrigerator should be cleaned. The cutting boards were not used today, but the sanitization of these boards may be ineffective due to the scratches. The meat slicer should be cleaned and covered. The containers were used to hold condiments and they should be re-washed since they were not dried properly before stacking them on top of each other. V12 stated the dirty dishes have been through the dishwasher and need to be re-washed since they did not come all the way clean. V12 confirmed that dirty dishes should not be next to clean dishes. V12 reported the freezer was suppose to be defrosted and cleaned monthly.The Long Term Care Facility Application for Medicare and Medicaid dated 6/7/26 documents 72 total residents within the facility.The facility's Food Storage Policy ,dated 2020, documents all food items will be labeled and freezers must be defrosted regularly.

Based on interview and record review the facility failed to hold quarterly Quality Assurance Performance Improvement (QAPI) meetings with all required members. This failure has the potential to affect all 72 residents in the facility. Findings include: The facility's QAPI plan dated 2026 documents The Quality Assessment and Assurance (QAA) Committee reports to the executive leadership and governing body and is responsible for meeting on a quarterly basis or more often if necessary to coordinate and evaluate QAPI program activities and develop and implement corrective actions for identified quality deficiencies. This plan documents V11 as the facility's Medical Director and part of the QAA Committee. The facility's QAPI Meeting sign in sheets dated 6/30/25, 7/24/25, 8/28/25, 9/23/25, 9/26/25, 10/27/25, 10/30/25, 12/26/25, 4/30/26 and 6/4/26 were provided by V1 Administrator on 6/8/26. There are no documented sign in sheets after 12/26/25 until 4/30/26. The 4/30/26 sign in sheet indicates December 2025-March 2026 were the months reviewed. The sign in sheets for 12/26/25, 10/30/25, 10/7/25, and 7/24/25 do not document V11 was in attendance for these meetings. On 06/08/2026 at 2:38 PM the facility's QAPI sign in sheets were reviewed and verified with V1. V1 confirmed the gap for meetings between 12/26/25 and 4/30/26. V1 confirmed V11 was not listed on the sign in sheets dated 12/26/25, 10/30/25, 10/7/25, and 7/24/25, which reviewed information for the months of June and August-November 2025. On 06/08/2026 at 3:36 PM V26 [NAME] President of Operations stated the facility has monthly QAPI meetings, but quarterly meetings are required. V26 stated there should have been a meeting in January 2026 but V26 was unable to find a sign in sheet for that meeting. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 6/7/26 documents the facility's census as 72 residents.

Based on observation, interview, and record review, the facility failed to assess for the ability to self-administer medications and failed to have physician orders to self-administer medications for three of three residents (R7, R21, R70) reviewed for self-administration of medications in the sample list of 40. Findings include: The facility's undated Self-Administration of Medications Procedure documents residents who wish to self-administer medications will be assessed to determine if the practice is safe based on the results of the Resident Assessment-Self Administration of Medications tool. This policy documents the assessment will be reviewed with the physician and orders will be obtained to self-administer medications. 1.) On 6/07/2026 at 8:53 AM there was a jar of Mentholatum nighttime rub and a bottle of Systane eye drops on R7's overbed table next to R7's bed. R7 stated R7's family provided these medications. R7 stated R7 applies the Mentholatum topically to her nostrils to help R7 breathe better and self-administers the eye drops. R7's electronic medical record does not contain orders for these medications or an assessment to determine R7's ability to self-administer these medications. On 6/7/26 at 12:30 PM V8 Registered Nurse entered R7's room and confirmed the jar of Mentholatum and Systane eye drops at R7's bedside. V8 stated there should be orders for these medications and for these medications to be kept at the bedside. On 6/08/2026 at 9:39 AM V20 Licensed Practical Nurse stated there should be a physician's order and an assessment for a resident to self-administer medications. V20 reviewed R7's orders and assessments and confirmed there were no orders for Mentholatum and Systane eye drops, and no assessment for the ability to self-administer medications. 2. On 6/7/26 at 9:20AM, R21 was lying in bed. 2 different bottles of Systane eye drops were on his bedside table. R21 reported the eye drops were from home and he uses them himself. There was miconazole powder on his bedside dresser. On 6/7/26 at 11:06AM, V2 (Registered Nurse) confirmed the eye drops and miconazole powder should not be in R21's room and R21 should not be self-administering the eye drops. V2 removed the eye drops from R21's room and explained R21 needs an assessment to self-administer his eye drops and that they could assess R21 when the doctor comes this week. On 6/8/26 at 11:09AM, V6 (Assistant Director of Nursing) confirmed R21's medication should not be left at the bedside or self-administered. On 6/9/26 at 9:14AM, V19 (Licensed Practical Nurse) confirmed R21 does not have an order to self-administer any medications or a self-administration assessment completed. R21's Minimum Data Set, dated [DATE], documents R21 is cognitively intact. R21's Clinical Assessments from 5/18/22 through 6/7/26 do not show an assessment completed for self-administration of medications. R21's Physician Order for Systane Ophthalmic Solution 0.4-0.3%, with a start date of 5/14/26, documents to instill 1 drop in both eyes every 4 hours as needed for dry eye. R21's Physician Order for Miconazole External Powder 2%, with a start date f 5/18/26, documents to apply to affected area topically at bedtime for rash. R21's Care Plan, with an initiation date of 5/15/26, does not document that R21 can self-administer any medications. 3. On 06/07/2026 at 08:47 AM, R70 was sitting in her room. On the bedside table was a small blue jar with a green lid containing a thick, greasy ointment with camphor, eucalyptus, and menthol (topical product). No expiration date was noted on the container. R70 stated she uses the ointment under her nose or smells the container when she feels congested or stuffy. Also on the bedside table was a 4 ounce container of Vitamin E cream. R70 reported she self administers the cream to her face and arms when her skin feels dry. R70 stated she has been keeping and using both products independently and does so based on how she feels day to day. R70 denied receiving instructions from staff regarding safe use or storage of these products. On 6/7/26 at 8:50AM V8 Registered Nurse (RN) verified that the products found on R70's side table were present and confirmed there was no physician order authorizing the resident to self administer these items. R70's electronic medical record did not contain an assessment authorizing her to self administer medications or topical agents.

Based on interview and record review, the facility failed to provide quarterly statements for trust fund accounts for three of three residents (R4, R6, R83) reviewed for personal funds in the sample list of 40. Findings include: The facility's Resident Funds policy dated 4/29/19 documents This facility manages the personal funds of residents when such request is made by the resident. The resident and/or resident representative is provided with a quarterly accounting report of his or her funds on deposit with the facility, and upon request. 1.) On 6/07/2026 at 10:55 AM V23 (Family Member) stated R6 has money in an account managed by the facility, V23 was unsure how much money was in the account as V23 has not received statements. R6's Minimum Data Set (MDS) dated [DATE] documents R6 has short and long-term memory impairment. R6's profile lists V23 as R6's Responsible Party and Guarantor. R6's Resident Statement Landscape dated 6/9/26 documents an accounting of R6's resident trust fund from March-June 2026, with a current balance of $1,598.14. R6's Financial Note dated 10/2/2025 at 7:32 AM documents a resident funds quarterly statement was mailed. There are no additional notes after this documenting quarterly trust fund statements were provided to V23. 2.) On 6/7/26 at 10:26 AM V24, R4's Family, stated R4 has money in an account managed by the facility, V24 was unsure the balance of the account as the facility has not provided quarterly statements. R4's MDS dated [DATE] documents R4 has short/long-term memory impairment. R4's profile lists V24 as R4's Responsible Party. R4's Resident Statement Landscape dated 6/9/26 documents an accounting of R4's resident trust fund from March-June 2026, with a current balance of $1,140.08. R4's Financial Note dated 10/2/25 at 7:30 AM documents a resident funds quarterly statement was mailed, There are no additional notes after this documenting quarterly trust fund statements were provided to V24. 3.) On 6/7/26 at 11:18 AM V25, R83's Family, stated R83 has a funds account managed by the facility and the facility has not provided quarterly statements. R83's MDS dated [DATE] documents R83 has short/long-term memory impairment. R83's profile lists V25 as R83's Responsible Party and Guarantor. R83's Resident Statement Landscape dated 6/9/26 documents an accounting of R83's resident trust fund from March-June 2026, with a current balance of $100. There are no documented financial notes in R83's electronic medical record to indicate resident trust fund quarterly statements were provided between October 2025 and June 2026. On 6/9/26 at 11:12 AM V21 Regional Business Office Manager (BOM) stated resident funds statements are provided quarterly, the last statement would have went out at the end of March and will be due again at the end of June. V21 stated this is typically documented in a note under the administrative section of the resident's electronic medical record. V21 reviewed R4's, R6's, and R83's administrative financial notes. V21 stated the last note for R6 was in October 2025 and the statement would have been mailed to V23. V21 stated the last note for R4 was in October 2025 and the statement would have been mailed to V24. V21 stated R83 has no documented notes indicating statements were provided, and statements should be given to V25. V21 stated the facility has been without a BOM since April 2026 and V21 has been filling in. V21 stated V21 will mail these statements today.

Based on observation, interview, and record review the facility failed to provide assistance with activities of daily living (ADLs) for four (R6, R7, R8, R30) of 18 residents reviewed for ADLs in the sample list of 40. Findings include: 1.) On 6/7/26 at 10:55 AM V23, R6's Family, stated V23 has concerns that staff don't always cut up R6's meat when they deliver R6's meal tray. R6's Minimum Data Set (MDS) dated [DATE] documents R6 has short/long-term memory impairment and requires supervision/touch assistance from staff for eating. R6's Care Plan with revised date 3/5/26 documents R6 has severely impaired vision and dementia, R6 requires feeding assistance due to vision loss, and R6 is at risk for aspiration (inhalation of food or fluids into the airway/lungs). On 6/7/26 at 12:56 PM V10 Certified Nursing Assistant (CNA) delivered R6's meal tray to R6's room. R6 did not unwrap R6's silverware or open R6's frozen nutritional supplement prior to leaving R6's room. R6 was in bed and R6's meal included pork loin, broccoli, mashed potatoes and pie. At 1:00 PM R6 was eating pie with R6's fingers and R6's silverware and frozen nutritional supplement were still unopen. At 1:05 PM V10 stated R6 only needs tray setup for meals and doesn't require assistance. V10 entered R6's room and confirmed R6's silverware and frozen nutritional supplement were unopen. R6 was still using R6's fingers to eat R6's pie. On 06/08/2026 at 3:16 PM V6 Assistant Director of Nursing stated R6 has a lot of behaviors but V23 has requested staff provide feeding assistance. V6 stated staff should set up R6's meal tray and confirmed this would include unwrapping silverware and opening containers. V6 stated R6's care planned aspiration risk is just a precaution related to dementia, R6 has not had any aspiration, and R6 does not require any staff to stay with R6 while R6 is eating. 2.) On 06/07/2026 at 8:37 AM R7 was lying in bed wearing Oxygen at 2.5 liters per minute per nasal cannula via an oxygen concentrator. There was no portable oxygen in R7's room. R7 stated R7 is able to walk by R7's self but can't go very far because R7 gets short of breath and requires Oxygen. R7 stated no staff assist with R7's Oxygen or offer to assist R7 out of R7's room. R7 stated R7 gets tired of being in R7's room all the time and would like to go out. R7 remained in R7's room at 12:00 PM and 12:30 PM. At 1:30 PM V9 CNA transported R7 in a wheelchair to the shower room at the end of the East hall. R7 did not have oxygen. On 6/8/26 at 8:58 AM, 10:34 AM and 12:25 PM R7 was in R7's room. There was no portable oxygen in R7's room, only an oxygen concentrator. R7's MDS dated [DATE] documents R7 as cognitively intact, R7 requires supervision/touch assistance from staff for transfers and setup/clean up assistance for walking 10 feet. This MDS documents R7 did not walk more than 10 feet during the review period. R7's Care Plan dated 4/21/26 documents R7 requires wheeled walker and supervision/touch assistance from staff for transfers, R7 has chronic respiratory failure and requires continuous oxygen. R7's May and June 2026 Medication Administration Record documents offer R7 to walk to activities or dining every day, document refusals, and notify R7's family with each refusal, scheduled for three times daily. There is no documentation that R7 has refused to walk or leave R7's room in May or June 2026. R7's Communication with Family Note dated 5/22/26 documents concern with increased depression, not coming out for activities, meals and restorative care. R7 needs assistance with ADLs, R7 has increased weakness with walking and is using a wheelchair. On 06/08/2026 at 11:52 AM V9 CNA stated V9 has been asking the nurses for a portable oxygen tank for R7 so that R7 is able to leave R7's room. V9 stated that is why R7 doesn't come out of R7's room, R7 needs assistance to walk to the dining room and needs continuous oxygen. V9 confirmed V9 did not assist or offer R7 to walk to meals or activities on 6/7/26 or 6/8/26. V9 stated recently V9 assisted R7 who enjoyed walking in the hallway to look out the window. On 06/08/2026 at 12:13 PM V13 Licensed Practical Nuse stated the facility has portable oxygen tanks available for use. V13 stated V13 can bring a portable oxygen tank to R7's room but that doesn't mean R7 will agree to walk or leave R7's room, R7 has dementia and refuses care at times. V13 stated V13 does not document if R7 refuses to walk or leave R7's room. 3.) On 6/7/26 at 10:00 AM R8's breakfast tray was untouched on the bedside table. R8's bed was in low position and the bedside table was out of reach of R8. On 6/7/26 at 1:15PM, R8's lunch tray was delivered by V10 Certified Nursing Assistant (CNA). R8's Apple pie was not unwrapped. R8 stated he could not open the pie so he could not eat it. R8's Care Plan, undated, documents R8 has a diagnosis of Rheumatoid Arthritis with limitations in bilateral hand control due to pain and disease, needs assistance with set up and clean up for meals, and is underweight due to malnutrition. R8's Minimum Data Sheet(MDS) dated [DATE] documents R8 is totally dependent on staff for bed mobility. 4.) On 6/7/26 at 1:13PM, R30's lunch tray was delivered by V10 Certified Nursing Assistant (CNA). The tray was placed on the bedside table over R30's bed. R30 was unable to reach the remote for bed control and was not positioned to reach the meal tray. R30 waited 10 minutes for assistance to eat the meal after the meal was placed in front of R30. R30's Care Plan, undated, documents R30 has diagnoses of Arthritis, Neuropathy, and Immobility and R8 is usually provided assistance with set up and clean up for all meals. R30's MDS dated [DATE] documents R30 requires set up and clean up assistance for eating and is substantially dependent on staff for bed mobility. The Facility Week at a Glance dated week 3 documents the lunch meal as Italian Marinated Pork Loin, Stuffing, Roasted Broccoli, Apple Pie, and beverage. The Facility Dining Options for Meal Service dated 2020 documents dining services and other staff will assist residents who need help. The Facility Dignity Policy dated 11/28/12 documents the facility shall promote resident independence and dignity while dining, such as avoiding staff interacting or conversing with each other rather than resident while assisting with meals.

Based on observation, interview, and record review, the facility failed to maintain safe hot water temperatures for 11 of 18 residents (R4, R6, R7, R18, R28, R35, R49, R51, R58, R63, R68) reviewed for accident hazards in the sample list of 40. Findings include: The facility's Domestic Water Temperature Policy dated 6/14/17 documents Temperatures are to remain between designated safe temperatures in all areas that are occupied by residents. Resident area hot water outlets should be between 100 degrees F (Fahrenheit) and 110 degrees F. On 6/07/2026 at 9:48 AM R6's bathroom faucet hot water felt very hot to touch. R6's bathroom adjoins and is shared with R58. At 9:50 AM R18's bathroom faucet hot water felt very hot to touch. At 9:52 AM R4's/R7's bathroom faucet hot water felt very hot to touch. This bathroom adjoins and is shared with R83. On 6/07/2026 at 2:00 PM V4 Maintenance Director calibrated a National Sanitation Foundation certified pen style thermometer with ice water. On 6/7/26 from 2:02 PM until 2:20 PM hot water temperatures in resident bathrooms and shower rooms were checked and verified with V4 using the calibrated thermometer as follows:R6/R68/R58 120 degrees F. R49/R18 120.2 degrees F.R51 114.2 degrees F.R28/R35 118.9 degrees F. R4/R7/R63 114 degrees F.The shower room located at the end of the middle hall near the front entrance 115.3 degrees F. On 6/7/26 at 2:20 PM V4 stated the maintenance department usually checks the temperatures of the resident rooms twice weekly and safe hot water temperatures for residents should be between 100 and 110 degrees F. V4 stated V4 will need to adjust the temperature of the hot water. On 6/7/26 at 3:20 PM V10 Certified Nursing Assistant (CNA) confirmed R51, R4, R7, R28, R63 and R35 all use their bathrooms. At 3:23 PM V9 CNA confirmed R6, R18, R68, and R58 all use their bathrooms. V9 stated R49 doesn't use R49's bathroom but takes showers in the shower room located at the end of the middle hall (near the front entrance).

Based on observation, interview, and record review, the facility failed to ensure an oxygen concentrator was unobstructed and easily accessible, provide oxygen as ordered, and appropriately store, label and change oxygen tubing/humidification, nebulizer tubing, and Continuous Positive Airway Pressure equipment for four of four residents (R7, R9, R24, R47) reviewed for respiratory care in the sample list of 40. Findings include: The facility's Oxygen and Respiratory Equipment- Changing/Cleaning documents handheld nebulizer equipment will be stored in a clean plastic bag, and oxygen nasal cannulas and humidification bottles will be changed weekly and as needed. This policy documents oxygen concentrators will be unobstructed by equipment, curtains, etcetera. 1.) On 06/07/26 at 8:37 AM R7 was in bed and using Oxygen at 2.5 liter per minute (l/min) per nasal cannula. The oxygen tubing and humidification bottle were not dated. R7's nebulizer mask and tubing were on top of R7's dresser, uncovered, and had remaining droplets of solution in the chamber. R7 stated staff don't change the oxygen tubing often enough and R7 has been asking for new tubing since the nasal part is sticky. R7 stated R7 is able to walk by R7's self but gets short of breath and requires oxygen. R7 stated no one assists with R7's oxygen for R7 to be able to leave R7's room. R7 stated R7 gets tired of being in R7's room all the time and would like to go out. R7 stated R7 last received a nebulizer treatment last night. At 12:00 PM R7's nebulizer mask and tubing were still uncovered on the dresser and R7's oxygen tubing and humidification bottle were not dated. On 6/7/26 at 1:30 PM V9 Certified Nursing Assistant (CNA) transported R7 in a wheelchair down the East Hallway to the Shower Room and R7 did not have any oxygen. R7's Minimum Data Set, dated [DATE] documents R7 as cognitively intact. R7's Care Plan dated 4/21/26 documents R7 has Chronic Respiratory Failure with hypoxia requiring continuous oxygen. R7's Physician Order dated 2/6/26 documents Oxygen at 3 l/min per nasal cannula every shift. R7's May and June 2026 Treatment Administration Records (TARs) document to change Oxygen tubing and humidification weekly on night shift on Sundays, which was not signed out as administered during these months. These TARs document R7 receives scheduled nebulizer treatments at 8:00AM, 2:00 PM and 8:00 PM. On 6/7/26 at 12:11 PM V8 Registered Nurse stated V8 administered R7's nebulizer treatment at approximately 9:00 AM and the tubing and chamber should be rinsed and dried then placed in a bag for storage. V8 stated R7 did not have a bag to store the nebulizer equipment. V8 confirmed R7's oxygen tubing and humidification were undated. On 06/08/26 at 11:52 AM V9 CNA stated V9 has been asking the nurses for a portable oxygen tank for R7 so R7 can leave R7's room. V9 stated R7 needs assistance with walking and requires continuous oxygen. V9 confirmed R7 did not have oxygen during R7's shower yesterday. On 06/08/26 at 12:13 PM V13 Licensed Practical Nurse stated the facility has portable oxygen tanks available for R7's use. On 06/08/2026 at 3:16 PM V6 Assistant Director of Nursing stated oxygen tubing is changed weekly and documented on the TAR, and the tubing should be dated. V6 stated nebulizer mask/chamber should be stored in a bag when not in use after rinsed and dried. 2.) On 6/7/26 02:03 PM, R9's oxygen nasal cannula was in use with no date indicating when it had last been changed. The oxygen humidifier bottle attached to the oxygen delivery system also did not have a date indicating when it was last replaced or cleaned. The oxygen concentrator in R9's room was pushed up against the bed, and the privacy curtain was draped over the oxygen delivery device, obstructing access and airflow to the equipment. R9's Physician orders dated 3/31/25 directed staff to change the oxygen humidifier bottle, tubing, and respiratory bag every seven days, and to date and initial the equipment at the time of change. The facility's Oxygen & Respiratory Equipment policy dated 1/17/19 documents nasal cannulas and oxygen humidifiers are to be changed weekly, as needed, and dated. This policy also states equipment should be stored clean and unobstructed. On 6/7/26 at 8:50AM, V8 Licensed Practical Nurse was unavailable to state when the equipment had last been changed. V8 confirmed that equipment should be dated according to policy and orders. 3.) On 6/8/2026 at 11:00 AM R24 was in bed receiving oxygen via nasal cannula at 1 liter per minute. The oxygen tubing did not have a date. R24's Physician's Orders dated 5/30/2026 document an order to date, time, and initial the oxygen tubing and humidifier bottle every seven days. R24's Treatment Administration Record (TAR) from June 2026 documents the order to date and time the oxygen tubing was signed as completed on 6/7/2026. On 6/8/2026 at 11:22 a.m., the Director of Nursing (V6) verified that R24's oxygen tubing was not dated or timed and stated that oxygen tubing should be dated and timed when changed. 4.) On 6/8/26 at 10:09AM, R47's Continuous Positive Airway Pressure (CPAP) mask was hanging in the bathroom from the shower handle and the tubing was hanging over the shower rod. On 6/8/26 at 10:12AM, V15 (Registered Nurse) confirmed that the CPAP mask and tubing should not be stored there and should be bagged. On 6/8/26 at 11:09AM V6 (Assistant Director of Nursing) stated that CPAP masks and tubing should be stored in a bag when not in use.

Based on interview and record review, the facility failed to administer insulin as ordered resulting in repeated significant medication errors for one of two residents (R63) reviewed for insulin in the sample list of 40. Findings include: The facility's undated Medication Administration General Guidelines documents medications are to be administered in accordance with the written physician's order and if medications are not given then document the rational, physician notification and response. This guide documents if the resident refuses three doses of medication there should be documentation that the provider was notified. On 06/07/2026 at 9:05 AM R63 stated R63 is supposed to get scheduled short acting insulin but some nurses don't administer the insulin and say R63 doesn't need the insulin. R63 stated R63 also receives long-acting insulin and has to tell the nurses to administer the insulin as ordered since the nurses try to hold the long-acting insulin too. R63's Nursing Note dated 5/7/2026 at 10:54 AM documents R63 admitted to the facility from the hospital and R63 is alert and oriented to person, place, time and situation. R63's Care Plan dated 5/12/26 documents R63 has Diabetes Mellitus and to administer insulin as ordered. R63's May and June 2026 Medication Administration Records (MARs) document to give Novolog insulin 100 units per milliliters, give 30 units three times daily with meals 5/10/26-5/20/26, and on 5/20/26 additional directions include to reduce to 15 units if blood glucose between 70 and 100 milligrams per deciliter (mg/dL). These MARs document 14 doses of scheduled Novolog were withheld and R63 refused eight doses when R63's corresponding blood glucose was above 70 mg/dL. There is no documentation in R63's medical record that a provider was notified of the withheld and refused doses of Novolog. On 06/08/2026 at 2:42 PM V6 Assistant Director of Nursing confirmed physician notification would be documented in a progress note. V6 reviewed R63's MARs and verified Novolog orders and insulin withheld when blood glucose was over 70 mg/dL as well as R63's documented refusals. V6 stated the nurses should notify the physician of resident refusals of medications if more than three occasions.

Based on observation, interview, and record review, the facility failed to ensure medications were administered and stored in accordance with professional standards of practice for 3 residents (R22, R44, and R59) reviewed from a sample of 40 residents and during medication storage observations. On [DATE] at approximately 11:09 AM, V13, Licensed Practical Nurse (LPN), administered medications to R59. V13 placed a cup containing R59's prepared medications on R59's bedside table and exited the room prior to observing R59 consume the medications. On [DATE] at approximately 8:37 AM, V19, Licensed Practical Nurse (LPN), placed a cup containing Miralax on R44's bedside table and exited the room prior to observing R44 consume the medication. At approximately 9:02 AM, V19 stated she should have remained with R44 and observed the resident consume the medication. On [DATE] at 9:15 AM, observation of the medication refrigerator located in the Middle Nurse's Station medication room identified an unlocked storage container containing liquid Ativan (lorazepam) 2 mg/mL prescribed for R22. The unlocked container was located within an unlocked medication refrigerator behind one locked door. On [DATE] at 9:20 AM, V6, Assistant Director of Nursing (ADON), stated lockable refrigerator boxes containing narcotic medications should remain locked when controlled substances are stored within them. On [DATE] between 11:00 AM and 11:23 AM, medication storage inspections were conducted on the facility's West, Middle, and East hallway medication carts. Inspection of the [NAME] hallway medication cart identified loose, unlabeled pills stored within the medication cart. In addition, an expired bottle of Melatonin 1 mg, with an expiration date of 5/2026, was observed in the medication cart. On [DATE] at 9:30 AM, an inspection of the medication storage room refrigerator revealed an open, half empty yogurt container with a small, fuzzy black round tuft consistent with mold growth. The container did not have an open date indicated on the label. Two unopened cartons of 2% milk were also present with an expiration date of [DATE], indicating the product was past its expiration date. A review of the undated facility policy titled Medication Administration General Guidelines documented residents are to be observed following medication administration to ensure the dose is completely ingested.

Based on observation, interview, and record review, the facility failed to ensure food was served at preferable temperature for four residents (R3, R6, R8, R30) reviewed for dining on a sample list of 40.On 6/7/26 at 11:50AM R3 stated the food is cold and does not taste good. The Facility Resident Council Minutes dated 3/30/26 document cold food was reviewed in old news and remained a current complaint with residents. The Facility posted meal times observed outside dining room entrance on 6/7/26 document breakfast at 7:00AM, Lunch at 12:00PM and dinner at 5:00PM. On 6/7/26 between the hours of 12:00PM and 1:30PM, room lunch trays were being delivered on an open rolling rack. Plates sat on a warming element and were covered. A dessert item was contained in a disposable bowl covered with clear wrap. On 6/7/26 between the hours of 12:00PM and 1:30PM, room delivered lunch tray items were tested using a NSF (National Sanitation Foundation) certified temperature measuring device. Observed plated food included shredded meat, broccoli, mashed potatoes with brown gravy, and slice of apple pie. On 6/7/26 at 1:00PM, R6's lunch tray was served. The temperature reading of the meat was 99.5 degrees Fahrenheit (F), the temperature reading of served vegetable was 98.8 degrees F; the temperature reading of plated carbohydrate was 97.6 degrees F. On 6/7/26 at 1:13PM, R30's lunch tray was served. The temperature reading of the meat was 99.7 degrees Fahrenheit (F), the temperature reading of the served vegetable was 97.9 degrees F; the temperature reading of the plated carbohydrate was 97.0 degrees F. On 6/7/26 at 1:15PM, R8's lunch tray was served. The temperature reading of the meat was 99.8 degrees Fahrenheit (F), the temperature reading of the served vegetable was 98.5 degrees F; the temperature reading of the plated carbohydrate was 98.0 degrees F. The Facility Week at a Glance dated week 3 documents the lunch meal as Italian Marinated Pork Loin, Stuffing, Roasted Broccoli, Apple Pie, and beverage. On 6/7/26 at 3:00PM V1 Administrator confirmed served temperatures were below appetizing temperatures and tray service was late. The Facility Dining Options for Meal Service dated 2020 documents meals will be served no more than 30 minutes after the scheduled meal times.

Based on observation, interview, and record review, the facility failed to complete hand hygiene during medication administration, wear gloves for medication injections and blood glucose monitoring, change soiled gloves during wound treatment and clean a glucometer after use for four residents (R25, R31, R32, and R59) of four residents reviewed for infection control from a sample of 40 residents. The Facility policy, undated, titled Medication Administration General Guidelines documents that individuals administering medications are responsible for adhering to good hand hygiene practices, including washing hands thoroughly before preparing medications, before and after resident contact, and after contact with potentially contaminated surfaces or equipment. The Facility policy, undated, titled Cleaning and Disinfecting Your (trade name) Blood Glucose Meter documents that blood glucose meters are to be cleaned and disinfected after each use. The Facility policy titled Pressure Injury and Skin Condition Assessment, effective 11/28/2012 and revised 1/7/2018, documents that gloves are required treatment supplies and that nursing staff are to conduct hand washing in accordance with facility standard and universal precautions when performing skin and wound assessments. 1. On 6/8/2026 at 11:02 AM, V13, Licensed Practical Nurse (LPN), administered medications to R59. Prior to entering R59's room, V13 did not perform hand hygiene. After placing the medications on R59's bedside table and exiting the room, V13 did not perform hand hygiene before proceeding to provide care and medication-related services to another resident. On 6/8/2026 at 11:13 AM, V13 performed a blood glucose test for R31 without wearing gloves. Upon completion of the blood glucose test, the glucometer was returned to the medication cart without being cleaned or disinfected. On 6/8/2026 at approximately 11:20 AM, V13 utilized the same glucometer to perform a blood glucose test for R32. Prior to use of the glucometer for R32, V13 did not clean or disinfect the glucometer and did not perform hand hygiene between resident contacts. On 6/8/2026 at 11:28 AM, V13 administered three units of Insulin Aspart via subcutaneous injection to R32's right upper arm. Prior to administration, V13 did not perform hand hygiene and did not wear gloves. On 6/9/26 at 10:45AM, V6 Assistant Director of Nursing (ADON) stated that nurses should be wearing gloves during blood glucose checks and should absolutely be completing hand hygiene prior to medication pass, after blood sticks, and prior to medication preparation for another resident. Glucometers should be cleaned between residents as indicated. 2. On 6/7/26 at 8:57AM, R25 reported his wound treatment to his sacrum is not always completed when it is supposed to be completed. On 6/8/26 at 2:43 PM, R25's wound care treatment for his sacrum was completed by V7 (Infection Preventionist/Wound Nurse) as ordered. During the treatment, after the soiled dressing was removed, V7 did not change her gloves prior to cleaning the wound. On 6/8/26 at 2:55 PM, V7 confirmed she should have changed gloves prior to cleaning the wound.

Based on observation, interview, and record review the facility failed to promote dignity during dining for two of 18 residents reviewed (R83, R15) for dignity in the sample list of 40.Findings include:On 6/7/26 at 1:01 PM V9 Certified Nursing Assistant was feeding R15 and R83 in the East dining room. There was a cellular telephone that was ringing on the dining room table, silenced by V9. V9 stated the telephone belonged to V9 and V9 usually keeps the telephone in V9's pocket while working. On 6/8/26 at 2:24 PM V6 Assistant Director of Nursing stated staff are not to have their cellular phones on them while working and during resident care, the phones should only be used when staff are out in their car when on break.R15's Minimum Data Set (MDS) dated [DATE] documents R15 is rarely/never understood and has short/long term memory impairment. This MDS documents R15 requires substantial/maximal assistance from staff with eating. R83's MDS dated [DATE] documents R83 has short/long term memory impairment, and R83 is dependent on staff assistance for eating. The facility's Dignity policy dated 4/23/18 documents The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and includes staff interacting with residents while assisting with meals.

Based on interview and record review the facility failed to report low blood glucose levels to the provider for one of five residents (R4) reviewed for unnecessary medications in the sample list of 40. Findings include: The facility's Physician-Family Notification-Change in Condition policy dated 10/1/15 documents the facility will notify the resident's physician/nurse practitioner with significant changes in condition and when there is a need to alter treatment significantly. On 6/07/2026 at 10:26 AM V24, R4's Family, stated R4 receives insulin, R4's appetite isn't always great, and R4's blood glucose has dropped to 30's milligrams per deciliter (mg/dl). V24 stated V24 questions whether R4 needs the insulin scheduled in the evening. R4's Physician Order dated 2/20/26 documents to notify the physician of blood glucose less than 70 mg/dl. R4's Nursing Notes documents the following: On 5/18/2026 at 6:16 PM R4 was sweating and slow to respond. R4's blood glucose was 38 mg/dl, Glucagon was given and blood sugar recheck was 64 mg/dl. V24 was notified. On 5/18/26 at 7:29 PM documents poor dinner intake with episode of hypoglycemia, blood sugar now 149 mg/dl. R4's Electronic Medical Record does not contain documentation that R4's low blood glucose on 5/18/26 was reported to R4's physician/practitioner. On 6/08/2026 at 2:42 PM V6 Assistant Director of Nursing confirmed blood glucose should be reported to the physician based on the ordered parameters and this would be documented in the nursing notes. V6 stated V6 would not have any additional documentation to provide for physician notification of R4's low blood glucose.

Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications by failing to ensure adequate indication for use of an antipsychotic and failing to attempt gradual dose reductions for two of five residents (R83, R52) reviewed for unnecessary medications in the sample list of 40. Findings include: The Facility's Psychotropic Medication Policy dated 11/28/12 documents it's purpose is to ensure residents are not given psychotropic drugs unless necessary to treat a specific or suspected condition as per current standards of practice. Residents on antipsychotic drug therapy will be monitored for side effects, and shall receive gradual dose reductions in an effort to discontinue or reduce the medication. 1. R52's Medication Administration Record (MAR) dated 5/1/26-5/31/26 documents R52 has been receiving Quetiapine Fumarate Oral Tablet 50 milligrams (MG) at bedtime for a diagnosis of Neurofibromatosis since 1/20/26. R52's Pharmacy Prescriber Recommendations dated 1/21/26 document a justification is needed for use of Quetiapine, an antipsychotic medication, without an appropriate diagnosis. The Recommendation also documents the provider's signature without any diagnosis chosen and marked that behavioral symptoms present a danger to the resident or others. R52's Behavior Tracking Records dated 5/10/26 to 6/7/26 document no behaviors.On 6/9/26 at 1:45PM V1, Administrator stated R52 has had no behaviors since admission to the facility on 1/20/26. R52's Care Plan, undated, documents R52 is on an antipsychotic medication related to a diagnosis of Neurofibromatosis. R52's Care Plan does not document any behaviors or psychiatric diagnosis. R52's Minimum Data Set (MDS) dated [DATE] documents no behaviors have been exhibited and no psychiatric diagnosis. 2. On 6/7/26 at 1:01 PM V9 Certified Nursing Assistant (CNA) was feeding R83. R83 had garbled speech/mumbling but no other behaviors noted. On 06/08/2026 during intermittent observations between 9:00 AM and 10:35 AM R83 was sitting in the common area near the East Hall nurse's station. At 10:37 AM V10 CNA transported R83 and returned R83 back to the common area at 10:52 AM. There were no staff interacting with R83 or provided activities for R83 and R83 did not have any behaviors during these observations. R83's Minimum Data Set, dated [DATE] documents R83 has short/long-term memory impairment and no recall ability. R83 did not have any behaviors during the review period. R83 receives antipsychotic medication with no gradual dose reduction attempted. R83's Care Plan dated 4/28/26 documents R83 receives antipsychotics for mood disorder, dementia and depression but does not identify R83's behaviors to warrant the use of these medications or specific nonpharmacological interventions used to address behaviors. This Care Plan documents R83's diagnoses include Anxiety Disorder, Psychotic Disturbance, Mood Disturbance, Depression, Dementia, Insomnia and Frontotemporal Neurocognitive Disorder. R83's May and June 2026 Medication/Treatment Administration Records (MARs/TARs) document antipsychotic behavior tracking, document the number of behavioral issues, anxiety and aggression, document in a progress note, and attempt non-pharmacological interventions of activities throughout the day, television shows, and sit with R83 to provide social interaction. These MARs/TARs document as of 8/14/25 R83 receives Risperidone (antipsychotic) 0.25 milligrams (mg) by mouth twice daily for Frontotemporal Dementia and Quetiapine Fumarate (antipsychotic) 300 mg by mouth at bedtime since 3/13/26 for Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. There are no documented behaviors in R83's nursing notes between January and June 2026. R83's 30 day behavior tracking report for May/June 2026 does not document any behaviors occurred other than one occurrence of grabbing others. The Prescriber Recommendations dated 1/21/26 document the pharmacy recommended a reduction in R83's Risperidone, which was declined by the provider due to agitation. R83's Psychotropic Medication Observation dated 2/6/26 documents R83 receives Quetiapine 400 mg daily at bedtime for Depression and Risperidone 0.25 mg twice daily for Frontotemporal Dementia and does not identify R83's targeted behaviors to warrant the use of these medications. R83's Psychiatry Progress Note dated 5/14/2026 documents assessment of frontotemporal dementia, R83 is nonverbal at baseline with grunting vocalizations. This note documents R83 as calm and behaviorally stable. This note documents gradual dose reduction contraindicated for Risperidone on 2/6/26 and 8/11/25 due to increased risk of agitation. On 06/08/26 at 11:52 AM V9 and V10 CNAs stated R83 doesn't really have any behaviors, R83 becomes stiff during cares as if R83 is scared. V9 and V10 stated R83 enjoys stuffed animals and a fidget apron. On 06/08/26 at 3:16 PM V6 Assistant Director of Nursing stated R83 receives antipsychotics for dementia and babbling behaviors. V6 confirmed R83 has no other behavioral issues. V6 stated the facility has implemented gradual dose reductions for Quetiapine but not Risperidone.

Based on observation, interview, and record review, the facility failed to provide the resident or resident representative with written notice of bed-hold rights upon transfer to the hospital for one (R14) out of two residents reviewed for hospitalization on a sample list of 40.Findings include:On 6/7/26 at 11:12AM, R14 reported he recently returned from the hospital last week. He recalled that it was explained to him why he was being sent to the hospital, but isn't sure if he was given a bed hold policy at that time.On 6/8/26 at 11:09AM, V6 (Assistant Director of Nursing) stated that nurses will send a bed hold with residents for trips to the emergency room and the Business Office Manager mails out the bed holds to the resident's Power of Attorney.On 6/9/26 at11:42AM, V6 stated that the nurses should document that the bed hold was sent with the resident when the resident goes to the emergency room and that it could be found in the nursing notes. V6 confirmed there is no documentation of R14 being given the bed hold policy on 5/27/26 when he went to the hospital.On 6/9/26 at 11:20AM, V21 (Regional Business Office Manager) stated that nurses should give the resident a bed hold at the time they (the resident) go to the hospital. The facility does not send out bed holds to resident representatives.R14's Health Status Note, dated 5/27/26 at 4:30AM, documents that R14 was sent to the hospital. It does not document that a bed hold policy was provided to or sent with R14.R14's Minimum Data Set, dated [DATE], documents R14 is cognitively impaired.

Based on interview and record review, the facility failed to submit a discharge due to death Minimum Data Set (MDS) for one (R55) resident of one resident reviewed for assessment on a sample list of 40.R55's Resident Census Sheet dated [DATE] documents R55 admitted to the facility on [DATE] and with a deceased date of [DATE]. R55's Minimum Data Set (MDS) admission Submission List dated [DATE] documents an MDS entry submission completed [DATE], and admission MDS completed [DATE] and a Medicare 5 day MDS completed on [DATE]. This list does not document an MDS submission completed for death in facility or discharge. On [DATE] at 1:58PM V26 [NAME] President of Operations confirmed an MDS should have been completed at the time of R55's death or discharge from the facility. The Facility Assessment of Resident Policy dated [DATE] documents assessments are to be completed within 14 days.

Based on observation, interview, and record review, the facility failed to assess for and offer adaptive communication devices or alternative communication methods for one of one resident reviewed (R3) for impaired communication and a weak voice in the sample size of 40.Findings include:On 6/7/2026 at 11:47 a.m., R3 stated he could not talk very well.On 6/7/2026 at 11:47 AM, 6/8/2026 at 9:45 AM and 12:00 PM, and 6/9/2026 at 8:45 AM R3 spoke very softly, requiring staff to be in close proximity to hear and understand him. R3's care plan dated 6/7/2026 identified impaired communication with expressive problems related to expressive aphasia and a weak or absent voice. Interventions included being conscious of R3's positioning during groups, activities, and dining to promote communication with others.On 6/8/2026 at 9:44 a.m., V18 (Social Services Director) stated R3 spoke very softly and could not write well, making the use of a whiteboard and marker ineffective. V18 stated R3 had not requested a communication device and acknowledged that alternative communication devices had not been offered or trialed with R3.On 6/8/2026 at 12:00 p.m., R3 stated he would be interested in trying a communication device, but staff had never offered one. R3 further stated he remained in his room and did not attend activities or dine in communal areas.On 6/8/2026 at 3:04 p.m., V16 (Certified Nursing Assistant) stated she frequently had to ask R3 to repeat himself and must get very close to hear what he was saying.On 6/8/2026 at 3:10 p.m., V17 (Certified Nursing Assistant) stated she must get very close to R3 to understand him because he spoke very slowly and quietly.On 6/9/2026 at 9:39 a.m., V1 (Administrator) stated the expectation was that staff, including Social Services, should offer alternative methods of communication when a resident experiences communication difficulties.

Failures at this level required more than one deficient practice statement. A. Based on observation, interview and record review, the facility failed to follow its bowel monitoring protocol and failed to assess, monitor, and report changes in condition to the physician for one resident (R49) reviewed for constipation in the sample list of 40. B. Based on observation, interview and record review, the facility failed to implement physician's orders for fluid restriction for one of 18 residents (R7) reviewed for physician's orders in the sample list of 40. Findings include: a.1.) On 06/07/2026 at 9:25 AM R49 was lying in bed, R49 was rubbing R49's stomach and had some facial grimacing. R49 stated R49 has abdominal pain and the nurses are aware. R49 described the pain as wrapping around and across R49's stomach. R49 stated R49 went two days without a bowel movement (BM) and was given medication yesterday for constipation which has helped some but R49 questioned whether R49 still had more inside that needs to come out. R49 stated R49 went to the emergency room recently, nothing was identified, and R49 went back to the facility the same day. At 11:40 AM R49 stated the pain is slowly improving, R49 questioned whether R49 is on bowel medications and thought that was something ordered by the hospital. R49 stated no staff has assessed R49's stomach or listened with a stethoscope. On 06/08/2026 at 9:48 AM R49 was in bed. R49 stated R49 is still having the same abdominal pain as yesterday, rated at an 8 or 9 on a 1-10 scale. R49 stated R49 last had a BM yesterday morning. R49 stated R49's stomach is quite hard if pressed. R49 demonstrated pushing on R49's stomach, which appeared firm. At this time V9 Certified Nursing Assistant (CNA) entered R49's room. V9 stated R49 goes two, three and sometimes four days without having a BM and then R49 will go a lot. V9 stated the CNAs record BMs in the resident's electronic medical record (EMR). V9 stated R49 had a large BM on 6/6/26 and a small yesterday. V9 stated R49 has been complaining of abdominal pain since Thursday when R49 had difficulty turning in bed due to the pain. V9 stated R49's appetite was good previously but has only been fair since the abdominal pain started. V9 stated V9 reported R49's abdominal pain to the nurses on Friday (6/5/26) and yesterday. V9 stated R49 went to the emergency room on 5/31/26. R49 stated 5/31/26 is when the pain started. R49's Minimum Data Set, dated [DATE] documents R49 as cognitively intact and R49 is dependent on staff assistance for toileting hygiene. R49's Care Plan dated 4/27/26 documents R49 receives diuretic medication and receives pain medication related to Multiple Sclerosis and Peripheral Neuropathy. This care plan includes monitoring, documenting, and reporting pain and side effects of medication including constipation. R49's May and June 2026 Medication Administration Records (MARs) document R49 receives Lyrica (pain medication) 100 milligrams (mg) by mouth three times daily since 5/16/26, Lasix (diuretic) 20 mg daily since 4/17/26, and Norco 5-325 mg every four hours as needed since 5/14/26. R49 has received six doses of Norco and R49 has no orders for bowel medications. R49's 30 day bowel monitoring documents R49 goes two to three days at times with no BM, including no BMS on 6/1/26-6/3/26 and three BMS as constipated/hard. R49's Nursing Note dated 6/4/2026 at 2:03 PM documents R49 had no BM since 5/31/26 and Miralax (laxative) was given. This medication is not listed on R49's MAR. R49's Hospital After Visit Summary dated 5/31/26 documents R49 was evaluated for abdominal and back pain, laboratory tests were completed but does not indicate any diagnostic scans were done.There are no documented assessments or monitoring of R49's abdominal pain, stomach, or bowel sounds after returning from the hospital on 5/31/26 and no physician notification documented in R49's EMR. On 06/08/2026 at 10:07 AM V13 Licensed Practical Nurse confirmed V13 documented R49's 6/4/26 nursing note. V13 stated the V6 Assistant Director of Nursing passed on that R49 had not had a BM since 5/31/26 so V13 administered Miralax which was obtained from standing orders. V13 provided the facility's Physician Standing Orders, which were unsigned and listed bowel medications, but did not include Miralax. This was confirmed with V13. V13 stated R49 was complaining of abdominal pain at that time and thought R49 had a BM the next day. V13 stated V13 would have documented physician notification in a nursing note. V13 stated abdominal assessments would be documented in a nursing note. V13 stated We (nurses) definitely need to listen to bowel sounds and assess (R49's) abdomen. V13 stated usually Miralax is ordered daily when a resident is on scheduled pain medication. On 06/08/2026 at 10:15 AM V6 stated R49 was complaining of abdominal pain and sent to the emergency room on 5/31/26. V6 stated abdominal pain would be considered new for R49 and the facility has a bowel protocol to follow. V6 stated Miralax, Milk of Magnesia, and other bowel medications can be given depending on what day the resident is without a BM, beginning on day 3. V6 stated the nurses should do an electronic interact form under the assessments section of the resident's EMR to document changes and physician notification, which would prompt for R49 to be added to the 24-hour report for ongoing monitoring/assessment. V6 verified there are no electronic interact forms in R49's medical record after 5/4/26. The facility's Bowel Elimination Protocol dated 5/31/19 documents the CNAs are responsible for recording BMs and residents with no BM for 48 hours will be observed for signs/symptoms of constipation which may include bowel sounds, abdominal distention, watery stool, nausea/vomiting, etcetera and review of the resident's record. This protocol documents prune juice, natural laxatives, and increased fluids can be offered if there are signs/symptoms of constipation. The facility's Assessment of Resident policy dated 4/18/22 documents to conduct a head-to-toe assessment when there are significant changes in the resident's condition including palpation and percussion of abdomen to identify masses or distention and assess for bowel sounds. This policy documents to document resident complaints and assessment findings in the nursing/progress notes and report findings to the physician. b.1.) On 6/8/26 at 8:58 AM and 10:34 AM R7 was in bed and there was a water pitcher at R7's bedside. R7's Care Plan dated 4/21/26 documents R7 has acute diastolic congestive heart failure and includes interventions to maintain fluid restriction as ordered and monitor and record fluid intake and output. R7's Physician Order dated 2/6/26 documents a daily fluid restriction of 1500 milliliters (ml). R7's fluid intake monitoring recorded by the CNAs does not identify this fluid restriction. R7's May and June 2026 Medication/Treatment Administration Records (MARs/TARs) do not identify a breakdown of specific fluid amounts allowed or given for each shift. R7's EMR does not document R7 is noncompliant with the ordered fluid restriction. On 06/08/2026 at 12:13 PM V13 Licensed Practical Nurse stated R7 is on a 1500 ml daily fluid restriction, activity staff pass the ice water so that staff would not know if R7 was on a fluid restriction. V13 stated V13 didn't think R7 should have a water pitcher in R7's room. V13 confirmed there is no breakdown of the amount of fluids to be given by nursing or dietary departments. On 6/8/26 at 11:52 AM V9 and V10 CNAs stated R7 is not on a fluid restriction and R7 drinks multiple cups of coffee each day. V9 and V10 stated if a resident is on a fluid restriction this would be noted on the fluid intake recorded in the resident's EMR by the CNAs. At 12:25 PM V9 and V10 CNAs were passing hall trays. R7's tray included an 8 ounce glass of water, 4 ounce nutritional supplement, and V9 added an 8 ounce cup of coffee. V9 stated fluid restriction would be indicated on the resident's meal ticket and confirmed R7's meal ticket did not identify a fluid restriction. V13 instructed the CNAs at this time to remove R7's water pitcher from R7's room and instructed V9 and V10 that R7 is on a fluid restriction. On 06/08/2026 at 12:30 PM V12 [NAME] stated nursing notifies the dietary department of fluid restriction orders. V12 stated dietary was not aware that R7 had fluid restriction orders and residents with fluid restrictions have designated fluid amounts that nursing and dietary are responsible for giving and this would be reflected on the resident's meal ticket. The facility's Fluid Restrictions policy dated 2022 documents fluid restrictions are typically ordered in total ml per day which is divided between nursing, dietary, and activity departments. This policy documents the amount allowed at meals is usually indicated on the resident's meal ticket and nursing is recommended to include the allocated amount with medication administration on the MAR or flow sheet.

Failures at this level required more than one deficient practice statement.A. Based on interview and record review the facility failed to implement diabetic care and follow physician's orders for two of three residents (R1, R3) reviewed for diabetic care in the sample list of four. This failure resulted in R3 being admitted to the intensive care unit for treatment of Diabetic Ketoacidosis. B. Based on observation, interview, and record review the facility failed to timely notify family and physician of a change in condition for one of three residents (R1) reviewed for falls in the sample list of four. This failure resulted in R1 experiencing a delay in treatment of compression fracture following a fall causing R1 increased pain and tearfulness. C. Based on observation, interview, and record review the facility failed to complete neurological assessments and assess blood glucose following falls for two of three residents (R1, R2) reviewed for falls in the sample list of 4. Findings include:The facility's Transcription of Physician's Orders policy dated 11/3/22 documents to review the hospital discharge summary, notify the physician to review and clarify orders, and enter each order in the Physician Order section of the resident's medical record. The facility's undated Hyperglycemia guideline documents to report all changes in a diabetic resident's condition immediately to the physician including loss of appetite and nausea/vomiting.The facility's Glucose Testing policy dated 11/28/12 documents to review the physician's order prior to checking blood glucose and document results on the electronic Medication Administration Record (MAR.) The facility's Physician-Family Notification-Change in Condition policy dated 10/1/25 documents to notify the family and physician timely of significant changes in a resident's physical, mental or psychosocial status, including clinical complications or a need to alter treatment significantly. A.1) On 3/9/26 at 9:33 AM V20 (R3's Family) stated R3 was hospitalized for dehydration and blood glucose prior to admitting to the facility. V20 stated R3 readmitted to the hospital on [DATE] after the facility was unable to get a blood glucose reading and R3's blood glucose was 1199 milligrams per deciliter upon arrival to the emergency room. V20 stated R3 has been a diabetic requiring insulin for 35 years and had a continuous glucose monitor to her left arm. V20 stated the monitor quit reading after R3 admitted to the facility, believed to be due to staff obtaining blood pressures on R3's left arm which damaged the sensor on the machine. V20 stated V20 did not think the facility was monitoring R3's blood glucose per R3's hospital discharge instructions. R3's Hospital Discharge Orders dated 1/22/26 documents an order for Novolog insulin subcutaneous per sliding scale three times daily, Insulin Glargine (long-acting insulin) 12 units subcutaneous every evening and to monitor R3's blood glucose often. R3's Progress Note dated 1/22/26, recorded by V18 Physician, documents R1 has history of hyperglycemia related to type 1 diabetes mellitus. This note documents R3's insulin glargine 12 units every evening, to monitor blood glucose regularly and adjust insulin dosage if necessary. R3's electronic medical record does not contain a baseline care plan to address R3's diabetes mellitus or that R3 uses a continuous glucose monitoring device.R3's physician orders dated 1/22/26-1/29/26 do not document orders for Novolog per sliding scale or to avoid obtaining blood pressure in left arm where R3's glucose monitoring device was located. R3's blood pressure log documents R3's blood pressure was obtained in left arm by V5, V21 Registered Nurses (RNs) and V23 Certified Nursing Assistant (CNA). There is no documentation as to whether the upper arm or wrist was used. R3's January 2026 MAR does not document the order for Novolog per sliding scale. This MAR does not document blood glucose was monitored three times daily prior to meals until 1/24/26. This MAR and R3's blood glucose log do not document R3's blood glucose levels on 1/24/26 at 11:30 AM and 4:30 PM. This MAR documents R3 refused scheduled bolus tube feedings on 1/23/26 at 8:00 AM and noon. R3's Nursing Note dated 1/22/26 at 5:51 PM R3 admitted to the facility after being hospitalized for dehydration and diarrhea. R3 receives bolus tube feedings and R3 vomited a moderate amount of undigested feeding upon arrival. R3's Nursing Note dated 1/22/2026 at 7:00 PM documents R3's blood glucose was 149 milligrams per deciliter and Insulin Glargine 12 units was not given due to R3's vomiting. There is no documentation a provider was notified that insulin was held. R3's Nursing Note dated 1/23/2026 at 8:41 AM documents attempted to administer bolus feedings and R3 refused. There is no documentation that R3's feeding refusals was reported to a provider. R3's Nursing Notes dated 1/23/26 at 3:27 PM and 3:31 PM document R3's blood glucose was over high/over 400 per continuous glucose monitor. Insulin Glargine 20 units and Novolog 8 units were administered per immediate orders. R3's Nursing Note dated 1/24/26 at 4:47 PM documents R3's continuous glucose monitor was not working and R3 refused to have finger poked for blood glucose check. There is no documentation a provider was notified of R3's continuous glucose meter not working and R3's refusal to have blood glucose checked. R3's Nursing Note dated 1/24/26 at 8:10 PM documents R3's blood glucose was high, physician notified, and to recheck blood glucose in one hour. R3's Nursing Note dated 1/24/26 at 11:38 PM R3's continuous blood glucose monitor was not reading, R3's blood glucose was checked and read high, physician was notified and gave orders to give Humalog 5 units. R3's blood glucose log documents R3's blood glucose on 1/25/26 was 365 at 2:26 AM and 375 at 5:45 AM. There is no documentation in R3's medical record that blood glucose was checked again until 12:00 PM. R3's Nursing Note dated 1/25/2026 at 12:00 PM documents R3's blood glucose was high, R3 was lethargic and had labored breathing. Physician notified and R3 was sent to the local emergency room.R3's Hospital emergency room Notes dated 1/25/26 document at 1:09 PM R3's bedside blood glucose was over 500 and at 2:07 PM laboratory glucose was 1194, critically high. R3 was admitted to the intensive care unit with diagnosis of Diabetic Ketoacidosis and placed on an insulin drip. On 3/9/26 at 12:44 PM V4 RN stated blood glucose checks are documented in the vitals section and MAR in the resident's electronic medical record. V4 stated V4 held R3's insulin glargine on evening of 1/22/26 due to vomiting and not having food until the next morning; V4 did not want R3's blood glucose to bottom out. V4 stated V4 doesn't give insulin if blood glucose is less than 100 and did not notify the provider to report holding R3's insulin. V4 stated the next day V4 notified V24 Nurse Practitioner of elevated blood glucose and administered additional doses of insulin. V4 stated R3 refused bolus feedings and did not report this to R3's providers. V4 and V14 RN reviewed R3's blood glucose documentation and orders and verified R3 did not have routine blood glucose checks prior to meals before 1/24/26 or orders for Novolog per sliding scale three times daily. V4 confirmed R3's hospital discharge orders included Novolog per sliding scale three times daily. On 3/9/26 at 2:59 PM V5 RN stated V5 was R3's nurse on 1/24/26 and R3 was more alert/coherent and talking. V5 stated V5 sent R3 to the hospital on 1/25/26 for lethargy, confusion, and inability to obtain blood glucose reading other than high. V5 stated R3's continuous glucose meter wasn't working on 1/24/26 and R3 refused blood glucose finger sticks. V5 stated V5 thought she reported this to R3's physician which would be documented in R3's nursing note. On 3/9/26 at 3:05 PM V6 RN stated R3 had elevated blood glucose reading high around midnight on 1/24/26, V6 notified the physician and gave an additional one-time dose of insulin. V6 stated V6 was concerned with R3's elevated blood glucose and passed on in shift report to follow up to see if R3 was getting enough insulin. V6 stated V6 checked R3's blood glucose with manual meter and was not aware that R3 had a continuous glucose monitor. On 3/11/26 between 9:39 AM and 11:17 AM the following staff were interviewed: V5 RN stated V5 did not recall which arm had R3's continuous glucose meter and this should be documented as a physician's order to avoid obtaining blood pressure in that arm. V21 RN stated V21 did not recall R3 and was unsure which arm had R3's continuous glucose monitor or which armed was used for blood pressures. V22 CNA stated V22 took care of R3 and did not recall if there were any restrictions for obtaining R3's blood pressures. V22 stated typically there is a sign above the bed stating to avoid obtaining blood pressures in a certain arm, but V22 did not think there was a sign for R3. V23 CNA stated V23 did not recall R3, if R3 used a continuous glucose meter, or if R3 had any restrictions for obtaining vital signs. On 3/11/26 at 10:19 AM V3 Minimum Data Set/Care Plan Coordinator stated baseline care plans are completed by the admitting nurse. V3 reviewed R3's medical record and confirmed R3 did not have a baseline care plan that addressed R3's diabetes mellitus. V3 stated typically if a blood pressure should be avoided for one arm it is documented as a physician order and in the care plan. V3 verified there was no documentation to avoid obtaining blood pressures in R3's left arm. V3 confirmed R3's blood pressure log documents left arm but does not identify if this was upper arm or wrist. On 3/11/26 at 1:37 PM V18 Physician stated V18 has no prior knowledge of resident history, V18 relies on the hospitals to have accurate medication lists, and V18 tells the nurses to continue the hospital orders. V18 stated staff should have reported R3's continuous glucose meter was not working and R3's refusals of blood glucose checks. V18 stated R3's hospital orders for Novolog per sliding scale three times daily should have continued as ordered and elevated blood glucose can lead to Diabetic Ketoacidosis. V18 confirmed this contributed to R3's rehospitalization. V18 stated it might have changed things if R3's blood glucose was monitored with Novolog sliding scale ordered three times daily.The continuous glucose monitoring device User Manual dated January 2025 documents pressure on the sensor can affect blood glucose readings. 2.) R1's January 2026 MAR documents to administer Insulin Glargine 6 units every evening with 12 doses not administered. This MAR documents blood glucose checks three times daily and insulin aspart 5 units given three times daily, hold for blood glucose less than 110. This MAR documents 28 doses of insulin aspart weren't given when blood glucose was greater than 110. There is no documentation in R1's medical record that V18 was notified that R1's insulin was held on these dates. R1's February 2026 MAR documents Insulin Glargine held three times and Insulin Aspart 5 units held 19 times with no documentation that V18 was notified. There is no active order after R1 readmitted to the facility on [DATE] to hold Insulin Aspart 5 units for blood glucose less than 110. R1's March 2026 MAR document Insulin Glargine held on 3/1/26 and Novolog 5 units scheduled three times daily, held for nine doses. There is no documentation that V18 was notified of R1's insulin being held on these dates. On 3/11/26 at 1:37 PM V18 stated this is the first V18 heard that staff are holding long-acting insulin. V18 stated V18 does not order parameters to hold long-acting insulin since it has a longer onset time. V18 stated V18 gives orders to hold short acting insulin if blood glucose below 110. V18 stated staff should report any time they hold insulin outside of the ordered parameters.On 3/11/26 at 10:04 AM V2 Director of Nursing confirmed there was no documentation to provider notification for R1's held insulin for the dates listed. At 10:50 AM V2 confirmed R1 does not have an active order to hold short acting insulin. V2 stated staff implemented R1's hospital discharge orders and V2 will need to clarify the prior hold order with V18. B.) On 3/9/26 at 8:45 AM R1 stated R1 stated R1 recently fell and broke her collar bone/neck and has to wear a brace when out of bed. R1 stated R1's pain was initially tolerable but then got worse and R1 was sent to the hospital a couple days after the fall. On 3/9/26 at 10:13 AM V9 Certified Nursing Assistant (CNA) applied a brace to R1's torso and stood pivot transferred R1 from the bed to the wheelchair. R1's Minimum Data Set, dated [DATE] documents R1 has severe cognitive impairment and requires substantial/maximal staff assistance for chair/bed/toilet transfers. This assessment documents R1 did not receive any scheduled or as needed (PRN) pain medications or have indicators of pain within the last five days. R1's Unwitnessed Fall Report dated 2/14/26 at 4:30 PM, recorded by V14 Registered Nurse (RN), documents R1 was found sitting on the floor of the bathroom on the Middle Hall. R1 was assessed with no injuries noted and R1 was transferred back into her wheelchair. This report includes an untimed note dated 2/16/26, recorded by V12 Licensed Practical Nurse (LPN), documenting R1 complained of lower back pain and was in tears crying after scheduled Tylenol was given. V24 Nurse Practitioner was notified and gave orders for lumbosacral x-ray and Ibuprofen 600 milligrams (mg) every 8 hours as needed for 7 days. There is no documentation R1's pain and new orders were reported to V17, R1's Family. This report includes an untimed note dated 2/17/26 by V12, which documents x-ray results received, and findings showed L1 compression deformity, V24 and V17 were notified, and R1 was transferred to the hospital. R1's February 2026 Medication Administration Record and Treatment Administration Record (MAR/TAR) document R1's twice daily pain rating as 0 on 1-10 scale 2/1/26-2/14/26. R1's pain was rated a 2 on night shift on 2/14/26 and 8 on day shit on 2/15/26. This MAR/TAR documents R1 did not receive any scheduled pain medication prior to readmitting from the hospital on 2/20/26 and only received PRN Tylenol 600 mg once on 2/15/26 at 8:56 AM for pain rated 8. This MAR does not document doses of Ibuprofen were given or follow up pain ratings after this medication was given. R1's Nursing Notes do not document R1's back pain and new orders for x-ray and Ibuprofen were reported to V17 prior to hospital transfer on 2/17/26. R1's Nursing Notes do not document R1's new onset of back pain following R1's fall was reported to a provider prior to 2/16/26. R1's lumbosacral x-ray dated as obtained 2/16/26 at 12:00 PM and resulted 2/17/26 at 7:52 AM, documents an L1 compression deformity. R1's Computed Tomography of Lumbar Spine dated 2/17/26 documents R1 has back pain following a fall and findings showed acute fractures of the right inferior and lateral L3 vertebral body, worsening compression deformity of L1, and chronic compression deformity at L5. R1's Hospital Neurosurgery Progress Note dated 2/19/26 documents medical and pain management per primary team and to wear thoracic-lumbar-sacral orthosis brace for comfort as needed. On 3/9/26 at 11:57 AM V14 RN stated V14 kept asking R1 about her pain the night of R1's fall and R1 later reported her lower back started to hurt, but R1 was still able to twist and turn without hurting. V14 stated V14 notified V18 Physician of R1's fall and initial pain and told V18 that V14 would follow up if an x-ray was needed. V14 stated V14 was going to wait and see how R1's pain was the next day, but the next day V14 was reassigned to a different hallway. On 3/9/26 at 2:53PM V7 LPN stated V7 is an agency nurse and R1's fall was passed on in report. V7 stated when the CNAs got R1 up on the morning of 2/15/26 R1 complained of back pain. R1 was resting her head while leaning forward, her body language signaled pain. V7 confirmed V7 documented R1's pain rated 8 and Tylenol administration that morning. V7 stated the CNAs reported R1 had been complaining of back pain frequently, but was unsure if that was R1's norm or following R1's fall. V7 confirmed V7 did not report R1's pain to R1's family or physician. On 3/11/26 at 12:39 PM V17 stated the facility notified her when R1 fell but then there was no follow up until staff told her that R1 was going to the hospital. V17 stated V17 was not aware R1 had pain or x-ray orders. On 3/11/26 at 1:28 PM V12 LPN stated R1 complained of back pain on 2/16/26 after R1 was gotten up. V12 stated R1 has occasional complaints of back pain prior, but this pain was different. V12 stated R1 was gotten up for lunch and was tearful and crying, complaining of back pain, V12 had staff transfer R1 back to bed, and V12 contacted V24 to obtain orders for x-ray and Ibuprofen PRN. V12 stated V12 gave Ibuprofen at 1:00 PM and all of this should be documented in the risk management report. V12 stated the next day R1 was also tearful the next day and V12 had to contact the x-ray company to obtain R1's results which were received at 8:00 AM and showed a compression fracture. V12 stated V12 had not given R1 any pain medication on 2/17/26 and night shift had passed on in report that R1 was fine during the night, pain was only noted with movement. \On 3/11/26 at 1:37 PM V18 Physician stated V18 was notified of R1's fall. V18 confirmed staff should have reported R1's new onset and increased pain when identified and since the onset of pain was within 24 hours of the fall the compression fracture is believed to be caused from the fall. V18 stated V18 would have ordered x-rays sooner, Lidocaine patch and Norco for pain relief if V18 was notified. V18 stated with compression fractures the focus is on pain relief and kyphoplasty helps with that but R1 was not a surgical candidate. V18 stated compression fractures need time to heal to improve pain management.On 3/12/26 at 9:03 AM V2 Director of Nursing reviewed R1's February MAR/TAR and confirmed Ibuprofen administration and post pain assessments were not documented. C.1) R1's Unwitnessed Fall Report dated 2/14/26 at 4:30 PM, recorded by V14 Registered Nurse (RN), documents R1 was found sitting on the floor of the bathroom on the Middle Hall. R1's February 2026 Medication Administration Record (MAR) documents R1 received Aspirin 81 milligrams daily 2/1/26-2/16/26. R1's post fall neurological assessments dated 2/14/26 at 4:30 PM, 4:45 PM, 5:00 PM, 5:15 PM, 5:45 PM, 6:15 PM, 6:45 PM, 7:15 PM, 11:15 PM and 2/15/26 at 3:15 AM all document the same set of vital signs and indicate these vitals were obtained on 2/14/26 at 4:30 PM. On 3/11/26 at 11:37 AM V14 stated neurological assessments are documented electronically in the resident's record and completed every 15 minutes x4, then every 30 minutes x4, then every 4 hours x8 with vital signs taken each time and documented on the assessment form. V14 reviewed R1's neurological assessments dated 2/14/26 and confirmed all have the same recorded vital signs dated as taken at 4:30 PM. V14 stated V14 did not document the vital signs anywhere else other than possibly on a scratch piece of paper which V14 no longer has. The facility's undated Neurological Assessment policy documents to observe, assess and document vital signs with neurological checks as ordered, with changes in condition, and after head injury every 15 minutes for one hour, every 30 minutes for two hours, then every four hours for 24 hours and then every shift for 48 hours. 2) R2's care plan dated 10/23/25 documents R2 has Diabetes Mellitus and includes an intervention to monitor/document/report any signs of hypoglycemia including staggering gait and lack of coordination. This care plan documents R2 is at risk for bleeding complications related to anticoagulant use and to monitor for signs of bleeding. R2's Hospital Discharge summary dated [DATE] documents R2 was treated for a Subdural hematoma and Subarachnoid hemorrhage (brain bleed) following a prior fall. R2's February 2026 MAR documents R2 received Eliquis (blood thinner) twice daily from 2/18/26 until 2/26/26. R2's March 2026 MAR documents R2 receives short acting insulin three times daily per sliding scale at 6:30 AM, 12:00 PM, and 5:00 PM. R2's blood glucose was 124 at 5:00 PM on 3/4/26. R2's Witnessed Fall Report dated 3/4/26 at 5:30 PM, recorded by V15 Licensed Practical Nurse, documents a certified nursing assistant (V8 CNA) heard R2 yell from across the hall and witnessed R2 attempt to self-transfer into bed and fall. There is no documentation that R2's blood glucose was evaluated at the time of the fall or that neurological assessments were initiated. On 3/9/26 at 3:19 PM V8 stated R2 had a recent fall where R2 slid out of bed. V8 was next door and heard a crash. V8 found R2 on the floor. On 3/11/26 at 11:20 AM V15 stated V15 did not check R2's blood glucose when R2 fell since R2 was alert and skin wasn't cool and clammy. V15 stated that is a good idea when asked if blood glucose is assessed as part of post fall assessments for diabetics. V15 stated post fall neurological assessments weren't implemented for R2's fall since V15 thought V8 witnessed R2's fall. On 3/11/26 at 2:54 PM V2 Director of Nursing stated neurological assessments should be initiated for any unwitnessed falls.

A partial extended survey was conducted. Failures at this level require two separate deficient practice statements. A. Based on observation, interview and record review the facility failed to reposition a resident timely, prevent cross contamination during wound care, provide the correct wound treatment, complete skin assessments timely, update a resident's care plan with pressure sore interventions, provide wound supplements, obtain ordered laboratory tests timely, and implement care plan interventions for pressure sore care and prevention for one (R4) resident of five residents reviewed for pressure sores. These failures resulted in R4 obtaining 18 separate facility acquired Pressure Sores from January 2025 through September 2025. R4 currently has five facility acquired Stage 4 Pressure Sores and two facility acquired Stage 2 Pressure Sores. The immediate jeopardy began on 8/19/25. V1, Administrator was notified of the Immediate Jeopardy on 9/26/25 at 3:23PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 9/26/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. B. Based on observation, interview and record review the facility failed to provide a timely initial assessment of R2's Left Ischium Stage 4 Pressure Ulcer, failed to identify R2's Coccyx Stage 2 Pressure Ulcer, failed to transcribe and provide physician ordered wound supplements and dressing changes and failed to prevent cross contamination during pressure ulcer care. The facility failed to update resident care plans with wound interventions and failed to prevent infections for R2 and R4. R2 obtained a Left Ischium Stage 4 Pressure Ulcer and a Coccyx Stage 2 Pressure ulcer at the facility. R2's Left Ischium Stage 4 facility acquired infected Pressure Ulcer and R13's Right Great Toe Stage 4 facility acquired Pressure Ulcer requires Antibiotic treatment and Contact Isolation. These failures affect two of five residents reviewed for Pressure Ulcers in a sample list of 14 residents. Findings include:A. R4's Electronic Medical Record (EMR) documents R4's medical diagnoses as fusion of the spine-lumbar region, spondylolisthesis, Parkinson's disease without dyskinesia, hypokalemia, anemia, vascular dementia, Escherichia coli, methicillin-susceptible Staphylococcus aureus infection, disorders of muscle, dysphagia- oropharyngeal phase, difficulty in walking, abnormal posture, reduced mobility, and pressure ulcers of the right buttock, left hip, sacrum, and left ankle.R4's Minimum Data Set (MDS), dated [DATE], documents R4 as severely cognitively impaired. This same MDS notes R4 as being completely dependent on staff for assistance with eating, oral hygiene, toileting, dressing, personal hygiene, and bed mobility.R4's Care Plan intervention, dated 11/23/2024, instructs staff to complete weekly treatment documentation including measurements of each area of skin breakdown's width, length, depth, type of tissue, exudate, and any other notable changes or observations. This same Care Plan, initiated 11/19/2024, does not include a focus area, goal, nor interventions due to R4 being placed on contact isolation for his wound infection. It also does not include R4's Stage 4 sacral pressure ulcer; Stage 4 left lateral ankle pressure ulcer; Stage 4 right upper shin pressure ulcer; Stage 4 left lower medial knee pressure ulcer; or Stage 2 left inner buttock and right hip pressure ulcers. R4's Care Plan intervention dated 2/27/25 instructs staff to follow facility policies and protocols for the prevention and treatment of skin breakdown.R4's Pressure Ulcer Risk Assessment, dated 8/28/25, documents R4 as being at high risk for developing a pressure ulcer.R4's tasks do not include a turning schedule.R4's Pressure Report, dated 7/25/25, documents a facility-acquired left inner buttock Stage 2 pressure ulcer measuring 1.5 centimeters (cm) long by 0.8 cm wide with non-measurable depth.R4's Skin Condition Report, dated 8/19/25, documents a newly acquired coccyx pressure ulcer. This same report does not document the size, drainage, redness, signs of infection, and/or odor of R4's coccyx pressure ulcer.R4's Skin Condition Report, dated 8/27/25, documents a Stage 2 left inner buttock pressure ulcer. This same report does not document the size, drainage, redness, signs of infection, and/or odor of R4's left inner buttock pressure ulcer.R4's Physician Order Sheet (POS), dated September 2025, documents physician orders as follows:7/25/25: For R4's left inner buttock Stage 2 facility-acquired pressure ulcer-cleanse the wound, apply skin protectant, and cover with hydrocolloid dressing daily and as needed.9/12/25: Reposition R4 frequently while in bed.9/12/25: Meropenem intravenous solution reconstituted 1 GM every eight hours for twelve days, related to an unstageable sacral pressure ulcer. The same POS also documents an order to administer sulfamethoxazole-trimethoprim oral tablet 800-160 mg twice daily, related to Escherichia coli as the cause of methicillin-susceptible Staphylococcus aureus (MSSA) infection, for 11 days.9/13/25: Right hip Stage 2 pressure ulcer-cleanse with wound cleanser and apply skin prep covering in silicone border dressing daily and as needed.9/18/25: Contact precautions for methicillin-resistant Staphylococcus aureus (MRSA).9/20/25: Right hip Stage 2 pressure ulcer-cleanse with wound cleanser and gauze, apply skin protectant to periwound area, cover wound with oil emulsion sheet cut to size, cover with silicone bordered foam, three times per week and as needed.9/20/25: Sacral Stage 4 pressure ulcer-cleanse with wound cleanser and gauze, pack wound with gauze soaked in quarter-strength Dakin's solution, cover with absorbent pad, and secure with retention tape twice daily and as needed.9/20/25: Left medial lower knee/leg-cleanse with wound cleanser and gauze, apply oil emulsion dressing to wound bed, then cover with gauze soaked with quarter-strength Dakin's solution. Cover with absorbent pad and secure with retention tape twice daily and as needed.9/20/25: Right upper shin Stage 4 pressure ulcer-cleanse with wound cleanser and gauze, apply oil emulsion then gauze soaked with quarter-strength Dakin's solution to wound bed, cover with absorbent pad, wrap with roll gauze, and secure with tape twice daily and as needed.9/20/25: Left lateral ankle Stage 4 pressure ulcer-cleanse with wound cleanser and gauze, apply oil emulsion then gauze soaked with quarter-strength Dakin's solution to wound bed, cover with absorbent pad, wrap with roll gauze, and secure with tape twice daily and as needed.9/20/25: Right ischium Stage 4 pressure ulcer-cleanse with wound cleanser and gauze, pack wound with iodoform packing strip, cover with absorbent pad, and secure with tape twice daily and as needed.9/20/25: Start Vitamin C 500 milligrams (mg) twice daily.9/21/25: Start Zinc 220 milligrams (mg) daily.9/22/25: Obtain a prealbumin level.R4's Hospital Record, dated 9/2/25-9/12/25, documents R4's chief complaint as an infected sacral decubitus wound and infected left lateral malleolus ankle wound. This same record documents that R4 underwent excisional debridement of his infected sacral decubitus and left ankle wounds. The record also documents that R4 was treated for sepsis due to an infected decubitus ulcer.R4's Laboratory Results for wound culture, reported on 9/5/25, document R4 has >100,000 colony-forming units (CFU)/milliliter (ml) of Proteus mirabilis.R4's Nurse Progress Note dated 9/2/25 at 3:10 PM documents: (R4) is warm to touch, temperature 100.1 degrees Fahrenheit after ibuprofen and acetaminophen administered. Blood pressure (B/P) 92/58, pulse 99, oxygen saturation 98% on room air. Void test negative; strong odor coming from wound as well as increased drainage. (V21) Nurse Practitioner advised (V13) Wound Physician will be rounding this afternoon and will assess.R4's Nurse Progress Note dated 9/2/25 at 5:44 PM documents V13 Wound Physician debrided and obtained a culture of R4's sacral pressure ulcer. This same note documents: Infection confirmed, orders received to send (R4) out for possible sepsis due to wound infection.R4's Wound Management and Summary Evaluation progress notes dated 9/17/25 document a physician order for Zinc 220 mg daily, Vitamin C 500 mg twice daily, and to obtain a prealbumin level.R4's Laboratory Report dated 9/22/25 documents an albumin level of 3.0 grams (g)/deciliter (dl) with a normal range of 3.3-5.0 g/dl. This same laboratory report does not document a prealbumin level.On 9/20/25, from 10:05 AM to 2:45 PM, R4 was in his bed in his room. R4 was not repositioned or provided incontinence care during this timeframe.On 9/20/25 at 2:45 PM, R4's room door had a sign posted that read Contact Isolation. Personal protective equipment (PPE) supplies were hanging from R4's door, including masks, gowns, and gloves.On 9/20/25 at 2:50 PM, V9 Licensed Practical Nurse (LPN) and V10 Registered Nurse (RN) completed pressure ulcer care for R4's sacrum, right ischium, right buttock, left inner buttock, and right hip. V9 LPN did not cleanse nor apply a new dressing to R4's right hip nor left inner buttock. V9 LPN removed R4's sacral dressing that was saturated with yellow drainage. V9 LPN was standing in front of the room air conditioner that was blowing air, which caused V9's PPE gown to make contact twice with R4's sacrum Stage 4 pressure ulcer. V9 LPN used her left gloved hand to push her gown off of R4's sacral pressure ulcer and then continued to complete R4's wound dressing change without washing her hands or changing gloves. V10 RN assisted in holding R4 onto his left side during wound care. V10 RN released her hold on R4, which caused R4's sacral Stage 4 pressure ulcer to touch his contaminated incontinence brief. V9 LPN applied R4's sacral dressing without cleansing R4's sacral Stage 4 pressure ulcer after the wound made contact with the incontinence brief and prior to applying a new dressing.On 9/20/25 at 3:45 PM, V9 LPN stated she knew that her gown had made contact with R4's sacral Stage 4 pressure ulcer. V9 LPN stated she should have changed her gown and re-cleansed R4's sacral wound prior to applying a clean dressing. V9 LPN stated she had reviewed all of the orders prior to completing the wound dressing changes but said, there are so many, it is confusing. V9 LPN stated cross-contaminating R4's open pressure ulcers could cause an infection or worsen his current wound infection.On 9/21/25 at 10:30 AM, V2 Director of Nurses (DON) stated R4 has multiple facility-acquired pressure ulcers. V2 DON stated R4 has had an overall decline in his mobility over the last several months. V2 DON stated the facility should have provided complete wound care, which would involve full assessments, obtaining and following physician orders for wound care, and ensuring pressure ulcer interventions are being followed. V2 DON stated R4 is considered a long-term resident who is unable to care for himself and relies wholly on staff for all care. V2 DON stated V13 Wound Physician sees R4 weekly. V2 DON stated the facility does not always send a nurse to round with V13 Wound Physician. V2 DON stated the facility floor nurses are expected to review V13's wound progress notes for their assigned residents prior to providing wound care. V2 DON stated V13's wound progress notes are located in the miscellaneous tab and are not added to the Physician Order Sheet (POS) until V14 RN completes her review of all resident wounds on Wednesdays.On 9/21/25 at 12:00 PM, R4 was not served double portions of protein as ordered by the physician.On 9/22/25 at 11:50 AM, V14 Registered Nurse (RN)/Float Nurse stated the role of the float nurse is to take an assigned group of residents for the first half of the shift, provide all treatments for all residents, and assist R4 in eating for two meals of the day. V14 RN stated she is not the wound nurse and is not in charge of the wound program but frequently completes wound care for all residents. V14 RN stated R4's sacrum Stage 4 pressure ulcer has declined significantly. V14 stated when she first assessed R4's sacral pressure ulcer, it was smaller than my fingertip with no drainage or infection. V14 RN stated V13 Wound Physician couldn't make it on 9/16 but did round on 9/17/25. V14 RN stated she was not able to round with V13 Wound Physician that day and is not aware of any new orders. V14 RN stated the floor nurses do not look in the miscellaneous tab and search through pages of wound progress notes. V14 RN stated the floor nurses should follow what the POS has listed for wound care for any given resident. V14 RN stated she is not sure why R4's left inner buttock has not been assessed from 7/25/25 to 9/12/25. V14 RN stated she assessed R4 when he returned from the hospital on 9/12/25 and observed R4's sacral Stage 4 pressure ulcer, right ischium Stage 4 pressure ulcer, right hip Stage 2 pressure ulcer, left inner buttock Stage 2 pressure ulcer, and two separate Stage 2 pressure ulcers on R4's right buttock, in addition to other wounds on R4's right and left lower legs and left foot. V14 RN stated she documented all of these wounds on R4's readmission assessment from his return from the hospital but did not complete full assessments of each wound.On 9/24/25 at 12:15 PM, V20 (R4's Power of Attorney [POA]) stated R4 was admitted to the facility in November 2024 and was still walking in January 2025. V20 stated the facility let R4 walk all day and never changed (provided incontinence care) for R4, which caused his first pressure ulcer on R4's right ischium in January 2025. V20 stated R4 has had multiple facility-acquired pressure ulcers since January 2025, all caused by facility staff not turning and positioning R4 timely. V20 stated R4's condition declined due to his Parkinson's disease, but the facility should have been paying closer attention to R4. V20 stated R4 requires good skin care that he is not receiving. V20 stated she visits R4 daily and sees every day that the staff wait three to four hours before coming into R4's room to reposition him or to check if he is incontinent. V20 stated V13 Wound Physician had to cut all the dead skin off R4's sacral wound on 9/2/25, and the hospital then took R4 into surgery to remove the rest. V20 stated R4's sacral wound smelled horrible from outside the room.On 9/24/25 at 2:00 PM, V14 Float Nurse stated R4's wound round report dated 9/17/25 documents R4's left buttock pressure ulcer as being present on admission. V14 stated R4's left buttock pressure ulcer should have been labeled left inner buttock and facility-acquired. V14 LPN stated this was a documentation error on her part and should be corrected.On 9/30/25 at 2:45 PM, V13 Wound Physician stated the facility is expected to follow V13's orders for wound care the day the order is received. V13 stated he sees residents at this facility without any staff assistance and then writes the progress notes, which get uploaded early the next day. V13 Wound Physician stated he was under the impression that V2 Director of Nurses (DON) was reviewing and entering his wound orders into the Electronic Medical Record (EMR) the same day as they are uploaded. V13 stated it is not acceptable for the facility to wait two, three, or four days for changes in wound orders to be entered. V13 Wound Physician stated R4 is very compromised by all of his pressure ulcers. He stated R4 has had a total of 18 facility-acquired pressure ulcers since the beginning of the year. V13 stated R4 has had several pressure ulcers resolve, which shows R4 has the potential to heal his wounds. V13 stated the facility lags behind in getting the interventions and orders in place, and then when the facility finally catches up, the resident's wounds begin to heal. V13 stated this lag shows that the facility is not doing their job and that it takes a negative toll on the residents affected.The Immediate Jeopardy that began on 8/19/25 was removed on 9/26/2025 when the facility took the following actions to remove the immediacy:The facility reviewed all resident wound progress notes and Physician Order Sheets (POS) and updated them as needed prior to the resident's next scheduled treatment change. V2 Director of Nurses (DON) and V22 Regional Clinical Nurse Consultant oversee this. On 10/1/25 at 9:00 AM, V2 DON stated that V2 reviewed all resident wound progress notes and POSs to ensure they matched on 9/26/25. V22 Regional Clinical Nurse Consultant stated she will monitor V2 DON's reviews to ensure all residents with wounds have accurate records.All licensed nurses were educated on the facility Physician Ordering process, including entering and processing policy. On 10/1/25 at 9:00 AM, V2 DON stated that V2 educated all nurses and had them sign an in-service sheet on 9/26/25.All licensed nurses were educated on the facility documentation policy using an Electronic Medical Record (EMR), including timeliness, accuracy, relevance, and completeness of entries. On 10/1/25 at 9:00 AM, V2 DON stated that V2 educated all licensed nurses on documentation on 9/26/25.The facility developed and implemented a plan to ensure staff who identify residents acquiring new pressure sores document the sore assessment, make the appropriate notifications, reassess the newly acquired wound within 24 hours, and obtain consent for the resident to see V13 Wound Physician. On 10/1/25 at 9:00 AM, V2 DON stated that V2 educated all licensed nurses and Certified Nurse Aides (CNA) on this plan on 9/26/25.The facility will ensure the direct care nurse reviews the Treatment Administration Record (TAR) prior to conducting wound care. On 10/1/25 at 9:00 AM, V2 DON stated that V2 educated all licensed nurses on reviewing the TAR on 9/26/25.The facility developed a process to ensure physician orders for laboratory tests are entered in the resident EMR timely. On 10/1/25 at 9:00 AM, V2 DON stated that V2 educated all licensed nurses to enter laboratory orders timely on 9/26/25.The facility has a process to ensure staff develop and provide interventions to prevent pressure ulcers from forming and/or worsening. On 10/1/25 at 9:00 AM, V2 DON stated that V2 educated all licensed nurses and CNAs on repositioning, correct dietary supplements, following physician orders, monitoring wound treatments, and referencing the Kardex in the EMR. Education was also provided on the Pressure Injury and Skin Assessment and conducting weekly skin assessments. V2 stated dietary staff were also educated on ensuring wound supplements are served correctly and according to physician orders. V2 DON stated these educations were completed on 9/26/25.All licensed nurses were provided education on the facility Pressure Injury and Skin Condition Assessment policy. On 10/1/25 at 9:00 AM, V2 DON stated that V2 educated all licensed nurses on this policy on 9/26/25.All licensed nurses and CNAs were educated on the facility Pressure Ulcer Prevention Policy. V2 DON stated that V2 educated all CNAs and licensed nurses on this policy on 9/26/25.All CNAs were provided education on how to access wound care prevention interventions. On 10/1/25 at 9:00 AM, V2 DON stated that V2 and V1 Administrator jointly provided education to staff on 9/26/25.All licensed nurses and CNAs were educated on the facility Physician-Family Notification Policy. V2 DON stated that V2 educated all CNAs and licensed nurses on this policy on 9/26/25.All licensed nurses and CNAs were educated on the facility Basic Care Plan Policy. V2 DON stated that V2 educated all CNAs and licensed nurses on this policy on 9/26/25.All licensed nurses and CNAs were educated on the facility Resident Round guidelines. V2 DON stated that V2 educated all CNAs and licensed nurses on this policy on 9/26/25.The facility Dietary Manager was educated on following physician diet orders, including ensuring residents with wound supplements were served the correct diet. V1 Administrator stated that V1 in-serviced V30 Certified Dietary Manager (CDM) on 9/26/25.All licensed nurses, CNAs, and dietary staff were educated on the facility Diet Orders guidelines. V2 DON stated that V2 educated all CNAs and licensed nurses, and V1 Administrator assisted in educating the dietary staff on this policy on 9/26/25.All licensed nurses were educated on the facility admission of Resident guidelines. V2 DON stated that V2 educated all licensed nurses on this policy on 9/26/25.All licensed nurses and CNAs were educated on the facility Resident Round guidelines. V2 DON stated that V2 educated all CNAs and licensed nurses on this policy on 9/26/25.The facility Care Plan Coordinator was educated on the facility Comprehensive Care Plan review. V2 DON stated that V2 educated V29 Care Plan Coordinator on this policy on 9/26/25.The facility Interdisciplinary Team (IDT) members were educated on the facility Comprehensive Care Plan policy. V22 Regional Clinical Nurse Consultant stated that V22 provided education to the IDT members on 9/26/25.The facility held a Quality Assurance Performance Improvement (QAPI) meeting on 9/26/25. V1 Administrator stated that V1 Administrator, V2 DON, V29 Care Plan Coordinator, V19 Medical Director, V30 CDM, and V8 Minimum Data Set (MDS) nurse were all present on 9/26/25 for this meeting.The facility conducted a facility-wide audit of all resident wound care plans. V2 DON stated that V2 DON, V29 Care Plan Coordinator, and V8 MDS nurse completed this on 9/26/25.The facility initiated audits on 9/26/25, seven days per week, to ensure residents with pressure ulcers have correct physician orders in the EMR, completed assessments, revised care plans, reviewed wound physician progress notes, and reviewed and updated the resident Physician Order Set (POS). The facility created a Quality Assurance Tool to verify these practices are occurring. V2 DON stated that V2 initiated this tool on 9/26/25 and will complete it daily for six weeks.The facility presented an abatement plan to remove the immediacy on 9/27/25. The survey team reviewed and accepted the first version of the abatement plan on 9/29/25.B. 1. R2's undated Face Sheet documents that R2 was admitted to the facility on [DATE]. R2's undated Medical Diagnosis list documents R2's medical diagnoses as Parkinson's Disease without dyskinesia, moderate protein-calorie malnutrition, anemia, dementia, Stage 4 pressure ulcer of the left buttock, and lack of coordination.R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents that R2 is dependent on staff for total assistance with oral hygiene, toileting, dressing, personal hygiene, and requires maximum assistance from staff for bathing and transfers.R2's Care Plan intervention dated 7/01/25 instructs staff to provide supplemental protein, amino acids, vitamins, and minerals as ordered to promote wound healing. R2's Care Plan does not include a focus area, goal, or interventions for R2's left ischium Stage 4 pressure ulcer or R2's coccyx Stage 2 pressure ulcer.R2's Electronic Medical Record (EMR) repositioning task documentation dated 8/22/25 through 9/21/25 documents that R2 was repositioned in bed two times on 9/20/25. There are no other entries recorded for R2 being repositioned.R2's EMR documents that V15 CNA recorded redness on R2's left lower buttock on 8/29/25 at 10:58 PM. R2's Nurse Progress Notes dated 9/1/2025 at 4:22 PM document that staff notified R10, a Registered Nurse (RN), that R2 had an open area on her buttocks. The same note documents an open area measuring 2.0 cm long by 2.0 cm wide on R2's left gluteal fold and a treatment order received for skin prep, calcium alginate, and a foam dressing to be applied daily.R2's Physician Order Sheet (POS) dated September 2025 documents the following physician orders:Starting 9/3/25 and ending 9/20/25 for R2's left gluteal fold (later labeled as left ischium): Cleanse with wound cleanser and gauze, apply skin prep to periwound, then apply calcium alginate and bordered foam dressing daily on Tuesday, Thursday, Saturday, and as needed.9/20/25 for Vitamin C 500 mg twice daily for wound care, with no end date.9/20/25, with no end date, for R2's left ischium Stage 4 pressure ulcer: Cleanse with wound cleanser and gauze, pack wound with woven gauze soaked with 1/4 strength Dakin's solution, cover with absorbent pad and secure with retention tape twice daily and as needed.9/21/25 for Zinc 220 mg daily for wound care through 10/5/25.9/21/25 for Contact Isolation Precautions for wound infection.9/21/25 to administer Levofloxacin oral tablet 500 mg daily for a wound infection through 10/5/25.9/30/25-10/14/25: administer Linezolid (antibiotic) 600 mg twice daily for R13's Stage 4 pressure ulcer.R2's Laboratory Results Report, as reported to the facility on 9/19/25, documents that R2's wound culture resulted in >100,000 colony-forming units (CFU)/ml of Escherichia coli (E. coli), Extended Spectrum Beta-Lactamase (ESBL), and Enterococcus faecalis.R2's Wound Evaluation and Management Summary dated 9/2/25 documents an initial visit to assess an unstageable pressure injury/deep tissue injury (DTI) of the left ischium. The same summary documents moderate serous drainage with purple/maroon discoloration, no signs of infection, and wound measurements of 2.0 cm long by 1.5 cm wide with undetermined depth.The Wound Summary dated 9/17/25 documents the left ischium pressure ulcer as a Stage 4 ulcer (post-surgical debridement), with moderate serous drainage, 100% thick adherent devitalized necrotic tissue, measuring 3.0 cm x 3.0 cm, with unmeasurable depth due to nonviable tissue and necrosis. A wound culture was obtained. Physician orders documented in the same summary include:Cleanse the wound, pack with gauze soaked in 1/4 strength Dakin's solution, and cover with absorbent dressing twice daily and as needed.Vitamin C 500 mg twice daily, Zinc 220 mg daily for 14 days, and obtain a pre-albumin level starting 9/17/25.On 9/20/25, from 10:30 AM to 1:50 PM, R2 was sitting upright in a reclining wheelchair in the resident common area. R2 was not repositioned or provided incontinence care during this time. At 1:55 PM, CNAs V7 and V11 assisted R2 to bed. CNA V7 stated that R2 had not been repositioned or provided incontinence care since being assisted out of bed before lunch at 10:15 AM.At 2:00 PM, RN V8 and LPN V9 provided wound care for R2's Stage 4 pressure ulcer on the left ischium. The wound had a golf ball-sized opening with moderate serous drainage and white and grey soft adherent tissue. The open wound emitted a foul odor that became more pungent as the dressing was removed. V8 RN's right forefinger fit into the wound while cleansing it. V8 RN applied calcium alginate and a dry dressing, but did not use gauze soaked in 1/4 strength Dakin's solution.R2 also had a 1 cm open, red area on her coccyx. V8 RN identified it as a Stage 2 pressure ulcer and said this was the first time they were aware of the coccyx wound. RN V8 and LPN V9 completed wound care without measuring or dressing the coccyx Stage 2 ulcer. LPN V9 described the ischium wound as smelling terrible in the morning and even worse during the dressing change.On 9/22/25 at 2:30 PM, CNA V15 stated she found a new reddened area on R2's left lower buttock on 8/29/25. She said it was closed, dark red with even darker red spots in the center. V15 CNA reported it to RN V10, who applied a brown foam patch that night. V15 stated the patch remained for a couple of days and then the area was not covered at all for several days.On 9/22/25 at 11:45 AM, Float RN V14 stated she had seen R2's ischium wound when it was still closed and again on 9/17/25. She noted significant deterioration. V14 RN emphasized that R2 is severely cognitively impaired and fully dependent on staff for turning, bed mobility, and toileting.On 9/23/25 at 2:15 PM, DON V2 stated that any time a resident develops a new pressure ulcer, a risk management assessment should be initiated. The wound should be fully assessed, including measurements, odor, drainage, and signs of infection. V2 DON stated that R2's coccyx Stage 2 ulcer should have been identified during incontinence care, skin checks, or showers. She confirmed that the Stage 4 ischium ulcer was acquired in-house and became infected during R2's stay. V2 DON acknowledged that the facility caused both the ulcer and the resulting infection.2. R13's undated Face Sheet documents that R13 was admitted to the facility on [DATE]. R13's Electronic Medical Record (EMR) lists diagnoses including chronic systolic heart failure, atrial fibrillation, anemia in chronic kidney disease, acute respiratory failure with hypoxia, dysphagia, unsteadiness on feet, reduced mobility, and disorders of the lung.R13's Minimum Data Set (MDS) dated [DATE] documents R13 as moderately cognitively impaired. The same MDS shows R13 requires maximum assistance from staff for toileting, upper and lower body dressing, putting on and taking off footwear, personal hygiene, and bed mobility. R13 is completely dependent on staff for transfers and bathing.R13's Physician Order Sheet (POS) dated September 2025 documents a physician order dated 9/20/25 for wound care for a Stage 4 pressure wound of the right, distal, medial foot:Cleanse with wound cleanser and gauze.Apply gauze soaked in 1/4 strength Dakin's solution.Fill wound cavity with collagen powder.Cover with absorbent pad (cut to size) and wrap with roll gauze twice daily and as needed.The same POS includes a physician order starting 9/26/25 through 10/4/25 to administer Linezolid (antibiotic) 600 mg twice daily for R13's Stage 4 pressure ulcer.R13's Wound Evaluation and Management Summary - Initial Evaluation dated 4/1/25 documents the Stage 4 pressure ulcer on the right, distal, medial foot as having 30% thick adherent devitalized tissue, moderate serous drainage, and measuring 1.3 cm long by 1.0 cm wide by 0.2 cm deep.A subsequent Wound Evaluation and Management Summary dated 9/17/25 documents the same ulcer as exacerbated due to infection and measuring 0.7 cm long by 1.0 cm wide by 0.5 cm deep, with signs of infection.Another Wound Evaluation and Management Summary, dated 9/24/25, documents that a wound culture was obtained via deep swab on 9/17/25 and the results revealed Methicillin-Resistant Staphylococcus Aureus (MRSA).On 9/30/25 at 3:00 PM, V13 (Wound Physician) and V23 (Registered Nurse) completed wound care for R13's right medial great toe Stage 4 pressure ulcer. RN V23 did not change gloves or perform hand hygiene after removing R13's dressing and prior to applying a clean dressing.The old dressing was adhered to the wound, requiring V23 to soak it off with normal saline. The ulcer appeared dime-sized with a thick, dry, yellow slough covering it before V13 debrided the wound, revealing a red wound bed.At 3:20 PM on the same day, RN V23 admitted she forgot to change gloves or perform hand hygiene between removing and reapplying the dressing.At 2:55 PM on 9/30/25, Wound Physician V13 stated that R13's right medial great toe Stage 4 pressure ulcer was caused by the inside of R13's shoe, which had overlapping material that rubbed against the toe. V13 stated that they had cut a hole in the side of R13's shoe to relieve pressure months ago.On 10/1/25 at 2:00 PM, DON V2 stated that facility nurses are expected to change gloves and perform hand hygiene after removing a soiled dressing and prior to applying a new one. V2 DON stated she was not in her role at the time R13 developed the pressure ulcer and therefore could not speak to how it was acquired. She also confirmed that a risk management assessment was not completed for R13's ulcer.V2 DON stated that cross-contaminating an open pressure ulcer can allow bacteria to enter the wound and cause an infection. She confirmed that R13's infected Stage 4 pressure ulcer on the right great toe was facility-acquired and could have been prevented.On 9/26/25 at 11:00 AM, Nurse Practitioner (NP) V21 stated that both R2 and R4 are completely dependent on staff for all care and are severely cognitively impaired. V21 NP stated that the facility should, at minimum:Turn, reposition, and provide incontinence care at least every two hours.Provide proper nutrition.Complete thorough admission assessments.Conduct weekly skin assessments, as required by facility protocol.V21 NP stated that the facility did cau

Based on observation, interview and record review the facility failed to implement fall interventions resulting in a falls for three (R2, R12, R13) residents and failed to complete a resident fall assessment timely for two (R12, R13) residents out of three residents reviewed for falls in a sample list of thirteen residents. R2 fell at the facility resulting in R2 being sent to the emergency room and diagnosed with a Right Temporal lobe laceration requiring five staples and a Right Femoral fracture as a result of the fall which occurred in the facility. R2 experienced pain, discomfort and additional medical procedures due to R2's fall. Findings include: 1. R2's undated Face Sheet documents medical diagnoses as Chronic Ischemic Heart Disease, History of Falling, Diabetes Mellitus Type II, Glaucoma Left Eye Severe Stage, Hypertensive Retinopathy Right Eye, Primary Open Angle Glaucoma Sever Stage Bilateral, Delirium, Anxiety and Chronic Obstructive Pulmonary Disease (COPD). R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 requires set up/supervision assistance with eating, bed mobility, dependent on staff for toileting, dressing and maximum assistance for bathing. R2's Careplan intervention dated 4/27/25 documents requires assist by one staff for locomotion using wheelchair/walker. This same careplan includes fall interventions for the staff to ensure proper functioning and placement of an electronic bed alarm dated 4/21/25, fall mat next to R2's bed dated 4/21/25 and instructs staff to ensure R2's call light is within reach dated 6/7/24. R2's Fall Risk assessment dated [DATE] documents R2 as a risk for falls. R2's Final Incident Report to the State Agency dated 5/12/25 documents R2 had an unwitnessed fall in the facility on 5/11/25 at 6:10 AM resulting in an acute angulated impacted fracture of the Right Subcapital Femoral neck. This same report documents (R2)) is up with one assist. (R2) stated he was trying to go to the bathroom. (R2) requires supervision for transfers and ambulation. Call light was not activated at the time of the fall. (R2) is impulsive and does not always activate call light for staff assistance, (R2) diagnosed with acute angulated impacted fracture of the Right Subcapital Femoral Neck. R2's Fall Investigation dated 5/11/25 documents staff head a thud and R2 yelled out for help. This same report documents R2 was noted to be laying on the floor with his head over the bathroom floor with his pants around his lower legs. This same investigation documents R2 obtained a 2.5 centimeter (cm) laceration on the Right Side of his head with active bleeding, Right Upper Forearm measuring 2.8 cm long by 1.2 cm wide, Left Upper Forearm skin tear measuring 2.5 cm long by 3.0 cm wide. This same report documents R2 complained of Right Hip Pain. This same report documents R2 was assessed, then assisted to bed and then staff provided first aid for injuries sustained in fall. This same report documents R2's clothing was a predisposing factor in R2's fall. R2's Transfer Form dated 5/11/25 documents R2 complained of 10 out of 10 pain from unwitnessed fall. R2's Hospital Record dated 5/11/25 documents R2 presented to the emergency room due to a ground level fall at the facility resulting in hip pain at the facility. This same record documents R2 sustained abrasions to his forearms, a 3.0 centimeter (cm) laceration to the Right Frontotemporal region which required five staples and a Right acute impacted Subcapital Femoral Neck Fracture. R2's X-Ray of his Right Hip two-three views with Pelvis dated 5/11/25 document Findings: Acute angulated impacted fracture of the Right Subcapital Femoral Neck. On 5/27/25 at 10:35 AM R2's call light was laying on the floor next to his bed. R2's call light was out of reach. R2 did not have a fall mat visible in his room. R2 was not laying on a personal alarm. R2 had five staples in his Right Temporal lobe. R2 stated My hip hurts so bad (as R2 was rubbing his Right Hip). On 5/27/25 at 1:40 PM R2 was laying on his back in his bed with his call light laying on the floor next to his bed. R2's call light was out of reach. R2 was not laying on a personal alarm. R2 did not have a fall mat visible in his room. On 5/28/25 at 10:20 AM R2 was laying in his bed with his call light laying on the floor. R2's call light was out of his reach. On 5/28/25 at 10:25 AM V6 Licensed Practical Nurse (LPN) stated R2 cannot reach his call light when it is laying on the floor. V6 LPN entered R2's room and positioned R2's call light. On 5/28/25 at 11:25 AM V21 Registered Nurse (RN) stated she was R2's nurse on 5/11/25 the morning R2 fell . V21 RN stated R2 had an unwitnessed fall in his room while trying to use the bathroom. V21 RN stated she found R2 laying on the floor with his head on the bathroom floor and the rest of his body laying in the room. V21 RN stated R2 was wearing cacky casual pants around his ankles. V21 RN stated it looked like R2 was laying in bed and had tried to get up and walk over to use the bathroom but tripped because his pants were around his ankles. V21 RN stated R2 did not have siderails in the up position and did not have a fall mat on the floor. V21 RN she heard a loud thud noise and immediately following, heard R2 yelling out 'Help!'. V21 RN stated R2 was sent to the hospital because of his injuries from his fall and the amount of pain R2 was having. V21 RN stated R2 rated his pain a 10 out of 10. V21 RN stated R2 showed signs of pain by grimacing and yelling out in pain. On 5/28/25 at 12:00 PM V5 Certified Nurse Aide (CNA) stated R1 would not have been able to put his own pants on prior to his fall on 5/11/25. V5 CNA stated R1 would have been able to 'fidget' with his clothing but not able to get up out of bed, walk over to his closet, pick out a pair of pants, put his own pants on and then get back into bed just to get up again and fall. V5 CNA stated she had received report from the night shift staff and was told that they (staff) had put on R2's pants to help the day shift staff assist residents up quicker. V5 CNA stated it is common practice for the night shift to get some residents up or get some resident half dressed to make it easier on the day shift staff to get everyone up and to breakfast on time. V5 CNA stated when V5 arrived at work the morning of 5/11/25, R1 had already fallen and V5 saw that R1 had cacky colored casual pants on around his ankles. On 5/28/25 at 12:50 PM V14 Assistant Director of Nursing (ADON) stated the staff should know the fall interventions for the residents or at least know how to locate the careplan. V14 ADON stated the fall interventions should be in place to help prevent a fall. On 5/28/25 at 1:10 PM V26 Certified Nurse Aide (CNA) stated she worked the night of 5/10/25 into the morning of 5/11/25. V26 CNA stated she was not R2's assigned CNA but did help with R2's fall. V26 CNA stated R2 was laying on the floor in his room complaining of his Right Hip hurting. V26 CNA stated R2's head was bleeding enough the nurse (V21) had to apply pressure with a bandage. V26 CNA stated R2 had on 'regular' pants that were around his ankles. On 5/28/25 at 1:45 PM V27 Medical Director stated if a resident falls, there should be a fall intervention put into place to help prevent further falls. V27 stated the staff should be following the resident's careplan and make sure that the fall interventions are in place. V27 stated R2's fall was preventable due to the fall interventions not being in place at the time of R2's fall on 5/11/25. V27 stated R2 was sent to the emergency room after his fall on 5/11/25 and diagnosed with a Right Femoral fracture and Right Temporal lobe laceration. V27 stated R2's family decided to not pursue a surgical option so R2 was sent back to the facility. V27 stated R2 will most likely be bedbound until he passes away. V27 stated R2 has had a general decline since his fall. V27 Medical Director stated the basic fall precautions typically instituted were not followed resulting in certain facility protocols not being followed which resulted in R2's fall with; major injuries. The facility policy titled Fall Prevention Program dated 11/21/17 documents the facility fall 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. 34058 2. R12's Census Detail and Medical Diagnoses List, both dated 5/28/25, document R12 was admitted to the facility 6/4/24 with medical diagnoses including Parkinson's Disease, History of Falling, Difficulty Walking, Lack of Coordination, and Dementia. R12's Fall Risk Assessments List dated 5/28/25 documents no Fall Risk Assessment completed from 9/22/24 through 3/1/25. R12's Fall Risk Assessment dates corresponded directly with the falls experienced by R12 documented in R12's Nurses Progress Notes and Initial Fall Occurence Notes dated 6/14/24, 6/26/24, 7/5/24, 8/13/24, 9/22/24, 3/1/25, 4/4/25, and 5/20/25. The facility's Fall Prevention Program policy dated 11/21/17, provided by V2, Director of Nursing, documents fall risk assessments will be completed on admission, at least quarterly, after each fall incident, and with any significant change in status. On 5/28/25 at 11:18 AM, V20, Director of Operations, stated she had checked with the Regional Nurse and the facility policy, and confirmed the fall risk assessments should be completed on admission, quarterly, after each fall, and with any significant change. R12's Nurses Notes dated 5/20/25 document R12's wheelchair alarm was not sounding at the time of her fall on this date. R12's comprehensive Electronic Medical Record did not include any administration instructions, interventions, nor orders to check R12's alarm routinely. 3. R13's Census Detail and Medical Diagnoses List, both dated 5/28/25, document R13 was admitted to the facility 10/5/23 with medical diagnoses including Depression, Bipolar Disorder, Vascular Dementia with agitation, and Delusional Disorder. R13's Initial Fall Occurence Notes and Nursing Progress Notes, dated 5/15/25 document R13 exprienced a fall in her room on this date. R13's Fall Risk Assessments List dated 5/28/25 documents no fall risk assessment completed from 10/8/24 through 2/21/25. The facility's Fall Prevention Program policy dated 11/21/17, provided by V2, Director of Nursing, documents fall risk assessments will be completed on admission, at least quarterly, after each fall incident, and with any significant change in status. On 5/28/25 at 11:18 AM, V20, Director of Operations, stated she had checked with the Regional Nurse and the facility policy and the fall risk assessments should be completed on admission, quarterly, after each fall, and with any significant change. R13's Care Plan for fall prevention documents for R13 to wear non-skid type socks whether she is wearing tennis shoes or not, initiated 2/9/24. This same Care Plan documents R13 is to be assessed for fall risk per the facility policy. This Care Plan documents, in three separate focus areas, that R13 is a high risk for falls initiated 10/5/23, a moderate risk for fall initiated 2/20/24, and at risk for falls initiated 9/26/24. On 5/28/25 at 12:30 PM, R13 was laying in bed wearing thick fuzzy regular socks which were not of the non-skid type. V24, Registered Nurse, stated and confirmed R13 should be wearing non-skid socks, as should all residents in the facility. V24 instructed V25, Certified Nursing Assistant to place the non-skid socks on R13. V25 confirmed R13 should be wearing non-skid socks.

Based on observation, interview and record review the facility failed to administer a medication according to manufacturer's directions and failed to utilize PRN (as needed) doses for one resident (R1) of three residents reviewed for medications in a sample list of four residents. This failure caused R1 to receive insufficient dose of medication which lead to increasing signs and symptoms of Parkinson's Disease which caused R1 to be fearful and suffer psychosocial harm. Findings Include: R1's Care Plan updated 4/17/25 includes the following diagnoses: Parkinson's Disease without Dyskinesia, Functional Quadraplegia, Chronic Obstructive Pulmonary Disease, Type II Diabetes Dysphagia, and Dysphasia with a gastrostomy tube. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact and is dependent on staff to complete Activities of Daily Living (ADLs). R1's current physician's orders include an order for Apomorphine HCl (Apokyn)Solution Cartridge 30 MG/3ML Inject 0.6 ml subcutaneously every two hours as needed for freezing or slowness/inability to speak related to Parkinson's Disease. Can be given up to two times two hours apart. Maximum of five times daily and Inject 0.6 ml subcutaneously before meals for freezing episodes related to Parkinson's Disease. Give one hour prior to meals. The manufacturer's directions for administering Apokyn state IMPORTANT - Prior to each injection, it is important that the Apokyn Pen be properly primed. For a new Apokyn Cartridge (1 that has not been used before), repeat the priming procedure described on the next page (Steps 8-9) 3 or 4 times to make sure all the air has been removed from the needle and cartridge. For an Apokyn Cartridge you have used before (1 that has been previously primed), repeat the priming procedure described on the next page (Steps 8-9) 1 time to make sure all the air has been removed from the needle and cartridge. Step 8. You must prepare (prime) the Apokyn Pen for use before injecting the medicine. To prime the Apokyn Pen, set the dose by turning the dose knob to 0.1 ml. This is important so you can get rid of any air bubbles in the cartridge. Step 9. Remove the inner needle shield. Remember, do not let the needle touch anything. With the needle pointing up, firmly push the injection button in as far as it will go and hold for at least 5 seconds. A small stream of medicine must come out of the end of the needle. If it does not, reset the dose by repeating Step 8. Repeat these steps (Steps 8-9) until a small stream of medicine comes out the end of the needle. When medicine comes out of the end of the needle, the Apokyn Pen is primed for injection and ready to use. On 5/8/25 at 11:30AM V7, RN (Registered Nurse) administered R1's Apokyn. V7 did not prime the needle. When asked if the needle needed primed V7 stated As far as I know we have never primed the needle. V7 verified she regularly works the day shift on the hall where R1 resides. On 5/8/25 at 11:35AM (R1) was seated in a high-backed reclining chair in her room. (R1) was able to speak softly and slowly at this time. (R1) stated when I freeze up like that I am scared to death. I can't talk, but I know what is going on. All I can really do is roll my eyes up to the ceiling to let them know I am in here. I don't think all the staff know this is my only communication. If I get the shot I am able to move and talk a lot sooner. On 5/8/25 at 1:00PM V5, R1's family member stated (R1) gets the Apokyn to help her avoid or shorten the time of episodes where her muscles freeze and (R1) is unable to move, swallow, or speak. This is very frightening to (R1). I have cameras in R1's room so I can see that (R1) is taken care of. (R1) is to get her shot an hour prior to meals and that doesn't happen always. (R1) is also able to get up to two additional doses for freezing episodes and that is often not given. This is causing more frequent and longer episodes. V5 stated according to her camera on 5/5/25 (R1) had an episode from 12:00PM until 3:48PM and again from 5:42PM until 12:00AM. R1's Medication Administration Record (MAR) does not document any PRN doses of Apokyn were given on 5/5/25. On 5/12/25 at 9:54AM V13 Registered Pharmacist for the facility's contracted provider stated the manufacturer's direction should definitely be followed when administering any medication. If the needle isn't primed the resident is definitely not receiving the correct dose of the medication especially when the dose is a small amount. Not receiving the correct dose as ordered could potentially affect the efficacy of the medication. The facility's policy Subcutaneous Injection revised 2/2/18 fails to address the necessity of priming the needle when utilizing multidose cartridge pens.

3.) During intermittent observations on 3/31/25 and 4/1/25 between 9:30 AM and 4:00 PM there was no Enhanced Barrier Precautions (EBP) sign posted on R38's room door and there was no cart containing personal protection near R38's room door. On 4/01/25 at 1:11 PM V48 Certified Nursing Assistant entered R38's room and removed R38's socks in order to observe R38's heel wound dressings. V48 was not wearing a gown. On 4/01/25 at 3:38 PM V8 Assistant Director of Nursing transferred R38 into bed and administered R38's sacral and heel pressure ulcer treatments without wearing a gown. V8 confirmed R38 is not on EBP. V8 stated V8 thought EBP was only needed for open wounds and indwelling devices. V8 confirmed stage two pressure ulcers are considered open wounds. R38's Wound Management Summary dated 3/18/25 documents R38's stage two sacral pressure ulcer measures 3 centimeters (cm) x 2 cm x 0.01 cm, the right heel stage two pressure ulcer measures 1 x 1.2 x 0.01 cm, and the left heel stage two pressure ulcer measures 0.8 x 0.5 x 0.01 cm. R38's sacral wound duration was greater than 63 days. R38's Wound Management Summary dated 3/26/25 documents the sacral pressure ulcer measures 2.8 x 2 x 0.01 cm, the right heel stage two pressure ulcer measures 1 x 1.5 x 0.01 cm and the left heel stage two pressure ulcer measures 1 x 0.8 x 0.01 cm. There is no physician's order that R38 is on EBP 4.) On 4/02/25 at 11:22 AM V14 Registered Nurse applied gloves and obtained R34's blood sugar with a blood glucose meter. V14 removed gloves and placed the blood glucose meter into the top drawer of the medication cart. V14 did not perform hand hygiene before or after checking R34's blood sugar and did not disinfect the blood glucose meter after use. On 4/02/25 at 11:28 AM V14 stated there are two blood glucose meters in the medication cart and they are shared between residents on the [NAME] Hall. V14 confirmed V14 did not disinfect the blood glucose meter after use and did not perform hand hygiene before and after checking R34's blood sugar, and confirmed this should have been done. V14 stated bleach disinfect wipes should be used to disinfect the blood glucose meter. There were no bleach wipes in the medication cart, confirmed with V14. The facility's Cleaning and Sanitizing Wheelchairs and Other Medical Equipment dated 1/25/18 documents medical devices will be cleaned and sanitized between each use if shared between residents. The facility's Hand Hygiene/Handwashing policy dated 7/30/24 documents hand hygiene should be performed upon entering and leaving the resident's room, before performing aseptic tasks, after handling medical equipment, after removing gloves, and after contact with blood, body fluids, mucous membranes, non-intact skin or wound dressings. The facility's EBP policy dated 5/7/24 documents EBP is an infection control intervention used to reduce the transmission of multidrug resistant organisms by using gown and gloves during high contact resident care activities and is indicated for residents with chronic wounds. Chronic wounds includes pressure ulcers. Failures at this level require more that one deficient practice statement. A. Based on observation, interview and record review, the facility failed to follow their Norovirus policy by failing to restrict symptomatic staff from work and handling food, and by failing to implement and follow isolation and contact precautions during a Norovirus outbreak. These failures resulted in R45 contracting Norovirus and subsequently expiring. R45's documented cause of death is listed as Acute Renal Failure related to Viral Gastroenteritis. These failures have the potential to affect all 79 residents who reside in the facility. The Immediate Jeopardy began on 3/19/25 when the facility failed to restrict V20 Dietary Aide from working with gastrointestinal virus symptoms. V1 Administrator was notified of the Immediate Jeopardy on 4/4/25 at 8:15 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 4/4/25, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: a. The facility's Norovirus Outbreak Measures dated 2/15/18 documents Norovirus is very resilient therefore preventative measures should be continued for at least 3 days after outbreak appears to be over. Control measures include isolation, grouping ill residents together, discontinue admissions for 7 days after onset of last known case, discontinue group activities, and post signage explaining risks of infection for residents and visitors. The Policy documents to interview each employee at the start of each shift for any symptoms of vomiting and diarrhea, exclude ill staff until asymptomatic for at least 48 hours, food staff cannot work with symptoms and are to be immediately excluded until 72 hours after last symptom. PPE (Personal Protective Equipment) of gowns and gloves should be worn by all staff, including housekeeping, and masks should be worn when providing cares for residents who are actively vomiting. The facility resident and employee infection logs document 33 residents and nine staff members with norovirus symptoms of nausea, vomiting and/or diarrhea. Logs identify V20 Dietary Aide was the first to present with symptoms on 3/19/25. The resident log includes R45 with symptom start date of 3/22/25 and R51 with symptom starting on 3/27/25. Review of employee call off forms for the dates of 3/20/25 thru 4/2/25 document a total of 10 employees who called off within that time frame. Of those 10, seven were Certified Nursing Assistants (CNAs), two were nurses and one was a dietary aide. All 10 employees reported symptoms of nausea, vomiting, fever, and/or diarrhea. On 3/31/25 at 9:10 am V3, dietary manager stated the facility is currently in Norovirus Outbreak. During intermittent observations from 3/31/25 at 8:40 am thru 4/4/25 at 10:00 am there was no signage posted at any of the facility entrances to alert staff and visitors that the facility was experiencing an outbreak of norovirus. On 3/31/25 at 11:25am R46 was seated at a main dining room table with other residents. The Progress Notes dated 3/31/25 at 5:06 am document R46 having diarrhea. The Progress Notes dated 4/4/25 document R46 is currently on contact isolation precautions related to active symptoms of nausea, vomiting, and diarrhea. On 3/31/25 at 12:34 PM V18, Activity Aide, was assisting with meal tray delivery to resident rooms. V18 entered R51's contact isolation room without putting on a gown or gloves. A contact isolation sign was posted at the room entrance. V18 stated I'm just an activity aide I'm not sure what resident's need what, you'll have to ask a CNA. On 04/01/25 from 10:20am thru 11:00am, V15, CNA, was giving direct resident care, changing soiled linens, collecting garbage, and disposing of soiled items for R50 inside the resident room. During this time V15 was not wearing a gown and gloves for contact isolation precautions. A contact isolation sign was posted at the room entrance with available PPE directly underneath. Upon completion of care, V15 exited the room without performing hand hygiene, and drug both the garbage and dirty linen bag on the floor to the dirty linen closet wearing only a mask. V15 did not perform hand hygiene after disposal of dirty linen and garbage bags. On 04/01/25 at 12:15 pm hall trays and drinks were distributed on the east hall. V16, CNA, entered a contact isolation room to serve a resident tray wearing only a mask stating they said I could serve trays without wearing a gown and gloves. V16 did not perform hand hygiene upon exiting the contact isolation rooms and prior to handling the next meal tray. On 4/1/25 at 12:16 AM, V6 Business Office Manager (BOM) delivered a tray into R51's room where a contact precautions sign was posted on the door. V6 did not have on a gown or gloves. V6 left the tray in the room, removed some drinking glasses off the bedside table with V6's bare hands and brought them to a cart with soiled dishware on it. V6 stated she was unaware that contact precautions were in place for R51. On 04/01/25 at 11:49 am, V20, Dietary Aide stated he had symptoms of vomiting and headache on Wednesday 3/19/25 while he was working in the kitchen and he called off for his shift the next day. At that time, he was told he could return to work in 48 hours and that there was nothing mentioned about having to be symptom free. V20 returned to working in the kitchen at 6:00 am Sunday (3/23/25), stating his last episode of vomiting occurred approximately at 10:00 am Saturday (3/22/25). On 4/3/25 at 1:57 PM, V20 stated that when he felt ill while working on the 19th, he wore gloves but nothing else. V20 also stated that when he returned to work that Sunday, he was told the facility was not in outbreak, therefore he only needed to wear gloves. V20's timecard dated 3/16/25-3/30/25 documents on 3/19/25 V20 worked 6:00 am-10:39 am and did not return until 6:00 am on 3/23/25. The Employee Call Off Form dated 3/21/25 documents V20 called off for the 3/21/25 shift with complaints of vomiting and diarrhea starting Thursday evening. On 4/3/25 at 9:14 AM, V31, CNA, stated her symptoms of loose stools started on Saturday 3/22/25 while working at the facility. V31 stated when she received report that morning, she was told several residents started having loose stools, nausea and vomiting the night prior (3/21/25) after eating the fish dinner served by the facility. V31 stated by Sunday everybody was sick having at least 3-4 loose stools daily. V31 stated no contact precautions were put into place that weekend but that she chose to wear a mask and gloves for resident care. V31 stated she was assigned to residents on the middle hall where at least three residents were sick with vomiting and diarrhea Saturday morning. V31 stated about four or five days later management started posting white signs indicating contact isolation outside of the rooms with residents who had been sick and during this time she was floated between all the halls to give resident care. V32 stated the facility has not provide education to staff during the outbreak. V31 stated when she called off with gastrointestinal (GI) symptoms, she was told by V2, DON, that she had to be off for 48 hours before returning to work, however she wasn't clear so she followed up with V41, Human Resources Director (HR) who told her she could return to work 24 hours after becoming asymptomatic. V31 returned to work 3/26/25 at 6:00 am, but states she started feeling really sick, having stomach pain and vomiting again yesterday (4/2/25) while at work, and was ultimately sent home and told she could return to work on Saturday (4/5/25). V31's Employee Call Off Form documents the reason for call off on 3/22/25 was GI/diarrhea. V31's Employee Call Off Form documents the reason for call off on 4/2/25 was V31 reported vomiting. On 4/3/25 at 1:15 PM, V37, CNA, stated that she had GI symptoms that started about one to one and a half weeks ago. V37 stated her stomach started to hurt, she had diarrhea and started to feel dizzy while she was at work. V37 stated that she wore gloves and a mask but no gowns while she was experiencing symptoms. They told me I just had to be off for 48 hours prior to returning to work and did not mention that V37 had to be symptom free for 48 hours before returning to work. V37's employee call off form documents the reason for call off on 3/29/25 was nausea and vomiting. On 4/3/25 at 10:40am, V21, RN, stated on 3/21/25 everyone was sick, and the facility continued to receive new admissions. V21 stated she received an admission on [DATE] (R56) and another on 3/25/25 (R14) and both residents were having GI symptoms within 12-24 hours of admission. V21 also stated management insisted on floating CNAs between halls of sick and well residents. V21 stated that just this morning (4/3/25) they attempted to tell the mid-hall CNA to float between there and east-hall. East-hall has the most recent symptomatic residents and mid-hall residents have already resolved GI symptoms. On 04/01/25 at 9:15 am V8, Assistant Director of Nursing/ Infection Preventionist (ADON/IP), stated the facility tracks and trends all infections for residents and employees on a log. V8 stated when a resident is on contact isolation anyone entering the room must put on a gown and gloves even if they aren't providing cares. It is also recommended that the residents stay in their room until symptom free for 48 hours. V8 stated she notified the County Health Department on March 24, 2025, of the Gastrointestinal Virus Infection outbreak. At 12:55 pm on 4/1/25, V8, Assistant Director of Nursing/ Infection Preventionist (ADON/IP), stated historically the housekeeping supervisor had been responsible for educating staff about isolation precautions and appropriate personal protective equipment. V8 stated the facility is aware that they are having issues regarding staff not wearing appropriate PPE and following isolation precautions this week. On 4/3/25 at 10:00am, V8 stated the dates recorded on the employee illness log for the start of symptoms are the dates the employee called off from their scheduled shift, and that she had not personally spoken to any of the employees to identify what symptoms they were having and the date of onset. V8 confirmed staff did not report to her at the beginning of the outbreak, which lead to delay in isolation precautions being implemented for four days. On 4/3/25 at 11:45 am, V8 stated she was not aware the norovirus policy stated employees must be interviewed about symptoms before each shift during active outbreak and was unclear who would be responsible for doing that. On 4/3/25 at 3:15 pm, V22 [NAME] President of Operations stated employees should be asymptomatic for at least 48 hours prior to returning to work, and all dietary staff at least 72 hours prior. V22 confirmed the facility's Norovirus policy was not being followed. R45's progress notes document date of discharge from the facility as 3/26/25 with R45 being discharged to a funeral home. R45's Death Certificate dated 3/28/25 signed by V30, Facility Medical Director, documents R45's cause of death as Acute Renal Failure related to Viral Gastroenteritis. R45's Nurse Practitioner visit notes dated 8/14/24 document a past history of chronic kidney disease resolved in October of 2021 by Urologist with urology sign off and there have been no kidney issues since. On 3/24/25 at 5:54 AM, V33, Licensed Practical Nurse (LPN), documented in R45's Medication Administration Record Progress Notes that she held R45's scheduled 6:00 AM dose of acetaminophen related to R45 vomiting. The Progress Notes dated 3/24/25 at 12:10 PM by V27, Registered Nurse (RN) document that R45 was assessed for GI symptoms and vital signs due to GI illness going around the facility. Resident's temperature 101.5 degrees Fahrenheit (F) and V30, Medical Director, and R45's POA were notified. New orders received for anti-nausea medications and to start an intravenous (IV) line and give 2 liters of Lactated Ringers (LR) intravenous (IV) solution. The Progress Notes dated 3/24/25 at 6:36 PM by V27 state R45 has IV fluids infusing, more lethargic with current temperature of 102.5 F, V30 updated, and order received to send R45 to the emergency department. The Visit Note dated 3/24/25 at 10:01pm by V30 documents R45 has symptoms of nausea, multiple episodes of vomiting after meals, diarrhea and tested positive for Norovirus. R45's Progress Note dated 3/25/25 at 12:23 PM documents R45 returned to the facility with oxygen 2 liters (L) nasal cannula (NC) with a new order for antibiotic related to a possible urinary tract infection and that V30 was notified of R45's return. R45's Progress Note dated 3/26/25 at 3:00 AM documents R45 was found unresponsive in room at 1:55 AM and pronounced deceased . On 4/3/25 at 10:20 am, V27 Registered Nurse (RN), stated on 3/24/25 V27 received report that several residents in the facility were having GI symptoms and that R45 had started vomiting throughout the night. Upon assessment of R45, V27 stated R45 had a temperature of 101.5 degrees Fahrenheit and appeared more fatigued than his baseline. V27 indicated R45 was mostly non-verbal at baseline and moderate to maximum assistance for all care but was not a sickly person, never had any urinary issues and no recent illnesses. V27 stated V30 was notified of the fever and gave orders for anti-nausea medications and to start an intravenous (IV) line and give 2 liters of Lactated Ringers (LR) IV solution. V27 stated that after about 250 milliliters of LR had infused, R45's temperature increased to over 102 and his level of consciousness (LOC) decreased. V27 stated she notified V30 and R45 was sent to the local emergency department but was quickly returned with an order for antibiotic and diagnosis of urinary tract infection but no documentation of any labs or cultures performed. On 4/3/25 at 9:52 am V30, Medical Director (MD) stated he was first informed of the facility's norovirus outbreak on Monday 3/24/25 and was told that 6-7 residents had GI symptoms including headache, fever, nausea, vomiting, and diarrhea within the last 24 hours. At that time, V30 stated he was working with the floor nurses to provide residents with acetaminophen for symptoms of headache and fever, anti-nausea medications for nausea and vomiting and IV hydration to counter dehydration. V30 stated he also ordered laboratory testing for influenza, COVID-19 and norovirus. V30 stated later that same day V27, RN, called with concerns about R45 not responding to any of the treatments and R45's fever had increased from 101.5 degrees Fahrenheit to now over 102 degrees Fahrenheit (F) and that R45's level of consciousness had declined. V30 ordered to send R45 to the emergency department for evaluation and treatment. V30 stated it is unclear as to why R45 was sent back to the facility so quickly and unfortunately R45 passed away not long after. V30 confirmed that on 3/28/25 he personally filled out and signed R45's death certificate documenting R45's cause of death as Acute Renal Failure due to Viral Gastroenteritis. V30 stated R45 had a history of hypertensive renal failure but that was resolved in October 2021 by the urologist and R45 had not had any further issues. V30 confirmed R45's last laboratory values completed on 3/3/25 indicated R45 had normal renal function. V30 stated R45 would have lived much longer without contracting Norovirus. The facilities Long-Term Care Facility Application for Medicare and Medicaid dated 03/31/25 indicates that there are 79 residents that reside in the facility. The facility presented an abatement plan to remove the immediacy on 4/4/25 at 10:35 AM and presented revision of the abatement plan on 4/4/25 at 11:00 AM, 11:15 AM, 11:45 AM, and 12:51 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions on 4/4/25 at 10:50 AM, 11:04 AM, 11:43 AM, 12:20 PM, and 12:57 PM. The facility presented a revised abatement plan on 4/4/25 at 1:08 PM and the survey team accepted the abatement plan on 4/4/25 at 1:19 PM. The Immediate Jeopardy that began on 3/19/25 was removed on 4/4/25 when the facility took the following actions to remove the immediacy: 1.) Infection Preventionist, Director of Nursing and Administrator were educated by the Regional Nurse Consultant on 4/3/25 on the facility's Norovirus - Outbreak Measures Policy including but not limited to Isolate all ill residents from others by encouraging residents to remain in their room until symptom free for 48 hours after last symptom of vomiting or diarrhea, post signs explaining the risk of infection of ill patients and ill visitors, interview each employee at the start of their shift regarding vomiting and diarrhea, exclude ill staff until asymptomatic for at least 72 hours after cessation of symptoms, and staff should wash hands when entering and leaving every resident room with soap and water, and wash hands thoroughly and often during the outbreak - DO NOT use alcohol based hand sanitizers. 2.) All staff were educated on the facility's Norovirus - Outbreak Measures Policy including but not limited to Isolate all Ill residents from others by encouraging residents to remain In their room until symptom free for 48 hours after last symptom of vomiting or diarrhea, post signs explaining the risk of Infection of Ill patients and ill visitors, interview each employee at the start of their shift regarding vomiting and diarrhea, exclude Ill staff until asymptomatic for at least 72 hours after cessation of symptoms, and staff should wash hands when entering and leaving every resident room with soap and water, and wash hands thoroughly and often during the outbreak - DO NOT use alcohol based hand sanitizers by the Infection Preventionist, Director of Nursing and Administrator on 04/03/2025. Staff members who are on FMLA (Family Medical Leave of Absence) or vacation and all agency staff will be in-service prior to returning to the facility by the Infection Preventionist/Director of Nursing/ Designee or Administrator. 3.) The Infection Preventionist, Director of Nursing and Administrator were educated on the facility's Infection Precaution Guidelines including but not limited to standard precautions and transmission-based precautions including precautions needed, duration of precautions, and type of PPE that is required for each contact precautions, droplet precautions and airborne precautions. Hand hygiene, gather all equipment and supplies needed before going into the room and only take needed supplies into the room. All personal protective equipment (PPE) should be used once and discarded in either the trash or used linen receptacle before leaving the room, and precaution signs will be utilized to alert staff and visitors to see the nurse for instructions prior to entering the room by the Regional Nurse Consultant on 4/3/25. 4.) All staff were educated on the facility's Infection Precaution Guidelines including but not limited to standard precautions and transmission-based precautions including precautions needed, duration of precautions, and type of PPE that is required for each contact precautions, droplet precautions and airborne precautions. Hand hygiene, gather all equipment and supplies needed before going into the room and only take needed supplies into the room. All personal protective equipment (PPE) should be used once and discarded in either the trash or used linen receptacle before leaving the room, and precaution signs will be utilized to alert staff and visitors to see the nurse for instructions prior to entering the room by the Infection Preventionist, Director of Nursing and Administrator on 04/03/2025. Staff members who are on FMLA or vacation and all agency staff will be ln-serviced prior to returning to the facility by the Infection Preventionist, Director of Nursing/Designee, or Administrator. 5.) All staff were educated on the facility's Hand Hygiene Policy including but not limited to when to wash hands with soap and water-when hands are visibly dirty and after known or suspected exposure to Clostridium difficile, or after known or suspected exposure to patients with infectious diarrhea during norovirus outbreaks and the procedure for using alcohol-based hand sanitizer and washing hands with soap and water by the Infection Preventionist, Director of Nursing and Administrator on 04/03/2025. Staff members who are on FMLA or vacation and all agency staff will be in-serviced prior to returning to the facility by the Director of Nursing/Designee or Administrator. 6.) All staff were educated on the facility's Infection Control - Determining PPE Needs Policy including but not limited to type of personal protective equipment (PPE) used in different situations and each situation may be evaluated on an individual basis to determine the level of risk associated and may be determined to require more or less protective equipment by the Infection Preventionist, Director of Nursing and Administrator on 04/03/2025. Staff members who are on FMLA or vacation and all agency staff will be in-serviced prior to returning to the facility by the Director of Nursing/Designee or Administrator. 7.) Notification of Norovirus outbreak has been posted at all facility entrances on 4/4/25 by Administrator. 8.) A communication log will be utilized and updated at least every 24 hours to communicate the new infectious symptoms to staff to ensure awareness of all communicable diseases. Communication logs will be placed at each nurse's station and dietary department. Infectious Symptoms for Communication log will be updated by the Infection Preventionist or Director of Nursing. Staff were educated on the Communication log to communicate new infectious symptoms for current residents on communicable diseases by Infection Preventionist /Director Nursing and Administrator on 4/4/2025. 9.) All management staff were educated on reporting timely all employee illnesses to Infection Preventionist or Director of Nursing by RNC on 4/3/25. 10.) IDPH Infection Control Coordinator was contacted by [NAME] President of Operations on 4/4/25 for Infection Control and Outbreak Consulting with tentative visit on 4/22/2025. 11.) An impromptu QAPI (Quality Assurance Performance Improvement) meeting was held with the medical director and staff IDT (Interdisciplinary Team) team on 4/4/25 to discuss deficiency and facility action plan. 12.) The facility has started (4/4/25) and will continue to conduct audits (7 days per week for 6 weeks) to ensure staff are conducting hand hygiene, donning/doffing PPE, staff are interviewed prior to shift regarding vomiting/diarrhea, and staff with symptoms do not return to work until 72 hours have passed since last symptom. A QA tool will be completed to verify this practice has occurred. The QA tool will be completed by infection Preventionist/DON or designee, daily for 6 weeks. There will be oversight of the QA tool by RNC. B. Based on observation, interview, and record review the facility failed to ensure that the mixing valve on the hot water heater had temperatures that are 120 degrees Fahrenheit or above and failed to properly monitor and document water temperatures and flush water lines to reduce the risk of Legionella per the facility policy. These failures have the potential to affect all 79 residents in the facility. The facility also failed to follow contact precautions, implement enhanced barrier precautions, perform hand hygiene during blood glucose testing, and disinfect a blood glucose meter after use for three of (R13, R38, R34) 24 residents reviewed for infection control in the sample list of 51. Findings include: b. 1.) The facility's Water Management Program for the Prevention of Legionella Growth with a recent revision date of 5/17/2024 documents that the thermostats will indicate the temperature of the water entering the circulating system at the mixing valve is 120 degrees Fahrenheit or above. The policy also documents that that mixing valve temperatures will be verified and documented at least once weekly. On 4/2/25 between 2:20 PM and 2:41 PM, V5 Maintenance Supervisor went to each mechanical room to show where the thermostats are on the mixing valves. The temperatures at that time ranged between 105 degrees to 112 degrees Fahrenheit. V5 confirmed that the temperatures where not at the right temperatures that were included in their policy. V5 also confirmed that he wasn't checking/flushing lines of empty resident rooms weekly per policy. On 4/2/25 at 1:35 PM, V5 stated that he checks the mixing valve temperatures once every month. V5 stated he doesn't have any documentation showing that he has checked the thermostats that indicate the temperatures at the mixing valve. On 4/2/25 at 2:25 PM, V5 stated that water temperatures fluctuate depending on where water is being used in the building and the temperatures should be between 130 degrees and 140 degrees. The facilities Long-Term Care Facility Application for Medicare and Medicaid dated 03/31/25 indicates that there are 79 residents that reside in the facility. 2.) On 3/31/25 at 10:11 AM, a contact isolation sign for ESBL (extended-spectrum beta-lactamase) of urine was on R13's door. No PPE (Personal Protective Equipment) station was at the door to R13's room. V40 CNA stated, they just put that sign up and she was unsure which resident the sign is for. V36 housekeeper was in the room with no PPE on other than gloves. V36 picked up the resident's garbage can and leaned it against her shirt while changing the trash bag. V36 took trash bags out of her scrub pocket and then put the roll of bags back in her pocket without changing gloves. V36 set the full trash bag on R13's roommates' bed and proceeded with gathering the roommate's trash without changing gloves. V36 mopped the isolation side of R13's room and then mopped the roommate's side of the room using the same mop head. V36 placed the trash from R13's room in the regular trash on the housekeeping cart in the hall. The trash was disposed of in a clear garbage bag instead of the colored isolation trash bag. On 03/31/25 at 10:15 AM, V38 (Housekeeper) entered R13's room with no PPE, dragging his broom through the isolation room floor. V38 did not wash his hands after exiting the room. V39 (Maintenance) entered R13's room with no PPE on to check the water temperature in the bathroom. The Contact Precautions sign states that upon entry hand hygiene, gloves, and gown are required. When leaving the room the sign states- Remove PPE and wash hands with soap and water. On 4/1/25 at 9:15 AM, V2 stated that when a resident is on contact isolation, all staff entering that room must follow the PPE directions posted on the door. V2 stated for R13 staff should put on gloves and gown when entering the room and perform hand hygiene when entering and exiting the resident's room.

Based on observation, interview and record review the facility failed to implement nutritional interventions, timely implement dietitian recommendations, care plan for weight loss, and timely notify the dietitian, physician, and resident representative of significant weight loss for three of four (R38, R72, R36) residents reviewed for nutrition in the sample list of 51. These failures resulted in ongoing and significant weight loss for R38 and R36. Findings include: The facility's undated Weight Assessment and Intervention policy documents the following: Weights will be monitored at least monthly and as recommended by the interdisciplinary team (IDT). Residents on fluid management programs will be weighed frequently to monitor changes in fluid status and if weight loss is desirable or related to fluid loss, this will be documented. Weights are documented in the resident's medical record. Weight changes of 5% or more will have a re-weigh to verify accuracy. Once the weight change is verified, nursing staff will notify the physician, Registered Dietitian (RD), Dining Services Manager, or other members of the IDT and this notification must be confirmed in writing. The weight log will be reviewed monthly by the RD to evaluate negative trends and determine significant changes and will discuss interventions with the resident's representative. A one month loss of 5% is significant and greater than 5% is severe. A three month loss of 7.5% is significant and greater than 7.5%. A six month loss of 10% is significant and greater than 10% is severe. The physician with the IDT will identify conditions or medications that may be contributing to weight loss. Undesirable weight loss will be care planned to include the problem, goals, and interventions. Interventions will be based on resident choice, nutritional needs, contributing factors, medication effects, use of supplements, and end of life decisions. 1.) On 3/31/25 at 12:16 PM R38 stated R38 is unaware if R38 has lost any weight or if anything has been done to address R38's weight loss. On 3/31/25 at 1:31 PM R38 had finished eating lunch in R38's room. R38 ate half of the chicken patty, all of the baked potato, no broccoli, 75% of fruit, and drank all of the nutritional shake. On 4/01/25 at 12:47 PM R38 was finished eating lunch in R38's room. R38 ate almost all of the meatballs, and a few bites of vegetable blend, mashed potatoes, and pineapple. R38 drank all of the nutritional shake. R38 stated R38 did not want to eat anymore of the meal. R38's Minimum Data Set (MDS) dated [DATE] documents R38 has moderate cognitive impairment, had a significant weight loss within the last month or last six months, is not on a prescribed weight loss regimen, and has one stage one and two facility acquired stage two pressure ulcers. R38's active care plan does not address R38's significant weight loss. R38's ongoing weight log documents: admission weight 104 pounds (lbs) on 11/26/24 104 lbs on 11/28/24 92 lbs on 12/11/24 (11.54% loss in less than one month) 96.4 lbs on 12/30/24 90.4 lbs on 1/27/25 (6.22% loss in one month) 92 lbs on 3/2/25 93 lbs on 4/1/25 R38's Nursing Note dated 12/24/24 documents R38 tested positive for COVID-19 and was placed on isolation. R38's meal intake report dated 12/1/24-2/28/25 document R38 ate 50% or less for 44 meals in December, 69 meals in January, and 57 meals in February. R38's meal intake report dated 3/6/25-4/4/25 document R38 ate 50% of less for 73 meals. There is no documentation in R38's medical record that R38's significant weight loss noted on 12/11/24 was reported to V43 RD or evaluated by V43 until 12/23/24. R38's Request for Diet Change dated 12/23/24 documents V43 RD recommended adding nutritional shake three times daily. This form was not signed by the physician until 12/30/24 and there is no documentation that this was implemented until 1/6/25. There is no documentation in R38's medical record that a physician was notified of R38's weight loss other than this diet change request. R38's January 2025 Medication Administration Record (MAR) documents nutritional shakes three times daily was implemented on 1/6/25. R38's Nutrition/RD Note dated 1/20/2025 documents R38 is receiving treatment for a stage two pressure ulcer. R38's Nutrition/RD Note dated 2/25/25, recorded by V43, documents R38's weight is down 6.5% in one month and 13.4% in three months, R38 has stage two pressure ulcers to left buttock and sacrum, and R38's meal intakes are poor to fair. V43 recommended adding nutritional supplement 90 milliliters (ml) three times daily for extra calories and protein. R38's March MAR documents nutritional supplement 90 milliliters three times daily was implemented on 3/4/25. There is no documentation in R38's medical record that V44, R38's Family, was notified of R38's significant weight loss prior to 2/25/25. R38's Care Conference dated 2/25/25 documents V44 was notified of R38's weight loss and weight loss was expected due to age and appetite level. R38 was refusing to eat and upset with family due to nursing home admission. R38 was noted to eat desserts prior to meal so may try incorporating yogurt and applesauce. On 4/2/25 at 1:32 PM V43 RD stated V43 is at the facility one day per month and also works remotely. V43 stated V43 has to do a lot of research herself because the facility does not have a great system for referring residents to V43. V43 stated V43 has to run a report during her visit to determine new admissions and a weight report from the beginning of the month to the beginning of the next month to determine significant weight loss. V43 stated it would be great if the facility would notify V43 at the time the significant weight loss occurs since V32 goes by the weights recorded at the beginning of each month. V43 stated V43 does not have time to run a weight report each week and relies on the facility to do that. V43 stated V43's biggest concern is if the resident is eating less than 50% of each meal. V43 stated V43's recommendations should be implemented within a week and V43 provides recommendations to the facility within 24 hours of V43's visit. V43 stated there may be a delay due to the facility having to wait for the physician or nurse practitioner to approve V43's recommendations. V43 stated V43 first evaluated R38 on 12/23/24, R38's advanced age and COVID-19 could have contributed to R38's weight loss, as well as R38's decreased appetite. V43 confirmed the facility should also report significant weight loss to the physician for review. V43 stated R38's additional weight loss could have possibly been prevented if the facility had reported R38's weight loss in December prior to V43's visit. V43 stated the facility should be monitoring weights closely to catch weight loss sooner. On 4/2/25 at 2:14 PM V2 Director of Nursing (DON) stated V3 Dietary Manager (DM) is responsible for notifying V43 of weight loss and V43's recommendations are given to nursing to follow up to obtain physician approval. V2 stated we have a new medical director , V30, that started in January who is here two or three times, and initially V30 did not want to sign off on V43's recommendations until V30 got to know the residents. V2 stated there have also been changes in the facility's nurse practitioners and the facility used to have nurse practitioners that were in the facility daily. V8 Assistant DON stated nursing staff are responsible for reporting weight loss to V3 who notifies V43. Both V2 and V8 stated physician notification would be in a nursing note or physician progress note. Neither V2 or V8 were aware of who has been notifying resident representatives of significant weight loss. V8 stated that is something nursing should probably be doing and this should be documented in a nursing note. V8 confirmed care plans should address weight loss and was unsure if V3 or V9 Care Plan Coordinator was responsible for updating this on the care plan. V2 stated weight loss is reviewed as part of the facility's monthly Quality Assurance Performance Improvement (QAPI) meetings. V2 stated nutritional supplements are recorded on the MAR and physician orders. On 4/3/25 at 11:14 AM V2 stated R38 was initially upset with R38's family for admitting to the facility, R38 was on strike, and refusing to eat. R38's family started coming during meal times and we discovered R38 likes sweets. V2 stated R38's family was notified of R38's weight loss during the care plan meeting on 2/25/25. V2 confirmed R38's diet change request was signed by the physician on 12/30/24 and confirmed there was no other documented notification to R38's family or physician. V2 stated V2 thought R38's weight loss was related to diuretic use. V2 and V34 Regional Nurse Consultant confirmed R38 had no increased or additional doses of diuretics given. V34 confirmed R38's care plan was not updated to address R38's weight loss prior to 4/1/25. V34 stated V3 DM needs to be updating the nutrition/weight loss on the care plan and will need additional training on this. V2 stated the former DON left in November 2024, V2 started as DON on 12/6/24 and is new to this role, and V9 Care Plan Coordinator was trying to catch up on V43's recommendations. On 4/2/25 at 2:35 PM V3 DM stated V3 is responsible for reporting significant weight loss to V43 RD via electronic mail or phone calls. V3 also runs a weight report weekly that is forwarded to V43 each week but V3 does not document this notification in the resident medical record. V3 stated V43 sends recommendations to V3 and nursing is responsible for implementation. V3 stated weight loss is reviewed during the monthly QAPI meetings and not during the daily IDT meetings. V3 stated V3 only updates the care plans with new supplements/interventions and V9 is responsible for updating the care plan with weight loss. On 4/3/25 at 1:35 PM V3 stated V3 had no electronic mail communication with V43 reporting R36's, R38's or R72's significant weight loss. On 4/2/25 at 3:30 PM V1 Administrator stated significant weight changes is reviewed as part of the morning IDT meetings, but no weight reports are reviewed at that time. V1 stated that is something we are going to start doing and implementing weekly weight meetings. 2.) On 3/31/25 at 10:01 AM R36 stated R36 has lost about 50 lbs since admitting to the facility and was unsure why. On 3/31/25 at 12:39 PM R36 was served lunch in R36's room which consisted of baked potato, broccoli, hamburger, bread with butter, and fruit parfait. R36's meal tray did not include a nutritional shake. R36's meal ticket does not include a nutritional shake as part of the noon meal, but lists instructions that nutritional shakes are not part of R36's fluid restriction. On 3/31/25 at 1:14 PM V31 Certified Nursing Assistant (CNA) stated R36 ate half of the hamburger, all of the dessert, and only bites of the other food. V31 stated R36 used to get nutritional shakes with meals when R36 resided on another hallway, but V31 did not think R36 gets the shakes anymore due to being on a fluid restriction. V46 CNA looked at R36's meal ticket and stated the nutritional shake is not included as part of the fluid restriction. V31 and V46 confirmed the nutritional shakes are served by dietary on the meal trays and R36 did not have a nutritional shake as part of his meal. On 4/01/25 at 12:55 PM R36 was lying in bed and finished eating lunch. R36 ate one meatball, all of his mashed potatoes, half of his pineapple, half of a slice of bread with butter and a few bites of vegetable blend. R36's meal did not include a nutritional shake and the nutritional shake was not listed on R36's meal ticket, only the instructions that the shake is not part of his fluid restriction. R36 stated R36 just doesn't have much of an appetite and R36 is depressed. R36 stated R36 had not told staff that he was feeling more depressed. At 1:15 PM R36's concerns of depression was reported to V45 Registered Nurse (RN) and V45 stated she would follow up on this. R36's MDS dated [DATE] documents R36 has moderate cognitive impairment and had a significant weight loss within one or six months without a prescribed weight loss regimen. R36's active care plan does not address R36's weight loss. R36's active Care Plan does not address R36's weight loss. R36's active physician's orders includes orders for a daily 1600 ml fluid restriction related to Congestive Heart Failure (CHF) as of 11/23/24, nutritional shake daily since 11/24/24, and nutritional supplement 90 ml three times daily as of 4/2/25. R36's March MAR documents nutritional shake daily at noon since 11/24/24 and nutritional supplement 60 ml three times daily since 1/6/25. R36's December 2024-March 2025 MARs do not document any changes in R36's diuretic medications and there is no documentation in R36's medical record that R36 had edema during this time frame. R36's Nursing Note dated 12/20/24 documents R36 tested positive for COVID-19. R36's active weight log includes the following: 165.8 lbs on 12/2/24 163.7 on 12/7/24 170.3 lbs on 12/9/24 171 lbs on 12/14/24 156.2 lbs on 12/21/24 (5.79% loss since 12/2/24) 153.5 lbs on 1/1/25 (7.42% loss in one month) 153.8 on 1/4/25 149.6 lbs on 2/2/24 146.4 lbs on 2/10/24 147 lbs on 3/3/25 144.6 lbs on 4/2/25 141.1 on 4/3/25 (8.26% loss in three months) R36's meal intake reports dated 12/1/24-2/28/25 document R36 ate 50% or less for 14 meals in December, 11 meals in January, and 23 meals in February. R36's meal intake report dated 3/5/25-4/3/25 documents R36 ate 50% or less for 27 meals. R36's Nutrition/RD Note dated 12/23/2024 at 12:34 PM documents R36's meal intakes vary and a recommendation for nutritional supplement three times daily for extra calories and protein. This recommendation was not implemented until 1/6/25. R36's Nutrition/RD Note dated 2/25/25 at 1:31 PM documents R36's weight down 12.8% in three months, intakes are fair to good for most meals, and R36 receives nutritional shake daily and nutritional supplement 60 ml three times daily. R36's Nutrition/RD Note dated 3/24/25 at 2:05 PM documents R36's weight is down 11% in three months, intakes are fair to good for most meals, and a recommendation to increase the nutritional supplement to 90 ml three times daily. There is no documentation that this was implemented prior to 4/2/25. There is no documentation in R36's medical record that R36's weight loss was reported to R36's physician after 11/20/24 until 3/28/25. As of 4/2/25 there is no documentation in R36's medical record that R36's physician was notified of R36 feeling depressed after this was reported to V45 RN on 4/1/25. On 4/2/25 at 1:32 PM V43 RD stated R36's appetite is overall fair but varies, and within the last week or so R36's appetite has been poor with meal intakes less than 50%. V43 stated on 3/24/25 V43's assessment noted weight loss and V43 recommended increasing the nutritional supplement to 90 ml three times daily. V43 confirmed R36 has had additional weight loss since then and confirmed that if the nutritional supplement was increased as recommended, it could have helped stabilize R36's weight. V43 stated V43 does not round at the facility until later in the month and the facility should be reporting any weight loss prior to V43's visits. V43 stated no one had reported R36's depressed feelings. V43 would have recommended for R36 to see a therapist or social worker and a pharmacy medication review. On 4/2/25 at 2:35 PM V3 DM stated R36's weight loss is related to CHF, fluid restriction and water weight fluctuation. On 4/3/25 at 11:14 AM V34 Regional Nurse Consultant stated on 2/6/25 R36's Zoloft (antidepressant) was decreased from 100 milligrams daily to 75 milligrams. V34 stated the facility will need to follow up with R36's physician today to report R36's depression symptoms and that the gradual dose reduction failed. On 4/2/25 at 2:14 PM V2 DON confirmed R36's nutritional supplement 60 ml was not started until 1/6/25. On 4/03/25 at 1:35 PM V2 stated V2 found s progress noted dated 11/20/24 that documented physician notification of R36's weight loss. V2 provided this documentation and confirmed this was the only physician notification V2 could locate. 3.) On 3/31/25 at 11:11 AM R72 stated R72 used to weigh around 170 lbs and is now around 150 lbs and was unsure what the facility was doing to address this weight loss. On 3/31/25 at 12:34 PM R72's noon meal was delivered to R72's room and contained a baked potato, chicken patty, broccoli, fruit parfait, and high protein ice cream. At 1:14 PM R72's meal tray was on the hall cart. R72 only ate half of the fruit parfait. R72 did not eat the high protein ice cream. V46 CNA stated R36 does not like sweets so R36 does not eat the ice cream, R36's family brings in food and nutritional supplements. On 4/01/25 at 1:02 PM R72 was in bed with lunch tray at bedside which included vegetable blend, mashed potatoes, and meatballs. R72 ate all of the high protein ice cream and only bites of mashed potatoes and meatballs. R72 stated R72 does not like broccoli and has reported this to staff. R72's meal ticket does not document R72 dislikes broccoli. R72 stated R72 ate a granola bar and drank a nutritional supplement instead of eating yesterday's lunch. R72's active weight log documents the following: 11/14/24 admission weight of 156.2 lbs 165.4 lbs on 12/3/24 172.3 lbs on 12/12/24 157.5 lbs on 1/10/25 (8.59% loss in one month) 154.8 lbs on 1/16/25 143.5 lbs on 2/5/25 (16.72% loss since 12/12/24) 148.8 lbs on 3/4/25 149 lbs on 3/12/25 152.6 lbs on 3/21/25 151.2 lbs on 3/26/25 148.8 lbs on 4/2/25 and 4/3/25 R72's Hospital Discharge summary dated [DATE] documents R72 weighed 178.3 lbs. R72's meal intake reports dated 1/1/25-2/28/25 document R72 ate 50% or less for 12 meals in January and 17 meals in February. R72's admission MDS dated [DATE] document R72 admitted with a stage four pressure ulcer. R72's MDS dated [DATE] documents R72 is cognitively intact and has a stage four pressure ulcer. R72's Care Plan dated 11/15/24 documents R72 has a nutritional problem or potential for nutritional problem related to depression and new admission. Interventions include encouraging and monitoring intake of meals and snacks, monitoring and reporting signs of malnutrition including significant weight loss to the physician, and for dietitian evaluation and recommendations. This care plan documents R72 receives a frozen nutritional supplement as of 12/31/24. This care plan has not been updated to include R72's significant weight loss since admission or any new interventions besides the frozen nutritional supplement. There is no documentation in R72's medical record that R72's significant weight loss was reported to R72's physician. R72's Initial Nutritional assessment dated [DATE] documents a recommendation for Prostat 30 ml twice daily to aid with wound healing. This same recommendation is listed in R72's Nutrition/RD Note dated 12/23/24 . R72's December 2024 MAR documents Prostat 30 ml daily was not implemented until 12/31/24. R72's January 2025 MAR documents Prostat was increased to twice daily on 1/6/25. R72's Nutrition/RD Note dated 1/20/2025 documents R72's weight of 172 was higher than usual and current weight of 154.8 lbs is more consistent with R72's prior weights. R72's nutritional interventions include high protein ice cream, nutritional supplement 120 ml, and Prostat 30 ml twice daily. R72's Nutrition/RD Note dated 2/25/2025 documents R72's weight is down 8.9% in one month and 8.1% in three months, and V43 recommended increasing the nutritional supplement to twice daily for extra calories and protein. R72's March 2025 MAR documents nutritional supplement was increased to twice daily on 3/4/25. R72's Nutrition/RD Note dated 3/24/2025 documents R72's weight is down 10% in three months and does not document any new recommendations. On 4/2/25 at 1:32 PM V43 RD stated R72 admitted with a pressure ulcer and initially had weight gain. V43's initial assessment of R72 was completed on 11/25/24 and V43 recommended Prostat 30 ml twice daily for wound healing. V43 confirmed this was also recommended on 12/23/24 as it had not yet been implemented. V43 questioned the accuracy of R72's weight of 172 and was unsure if R72's weight loss was a true weight loss. V43 stated the facility should have reweigh R72 when R72 returned from the hospital at the end of December 2024. V43 stated R72's weight has since stabilized within a 10 lb fluctuation. V43 stated on 1/20/24 R72 was already on protein ice cream and a daily nutritional supplement. V43 stated V43 was not notified of R72's significant weight loss until V43's visits on 1/20/25 and 2/25/25, and V43 would have given recommendations if V43 was notified sooner. On 4/3/25 at 1:35 PM V2 DON confirmed V2 was unable to locate documentation that R72's significant weight loss was reported to the physician.

Based on interview and record review, the facility failed to provide pain medication and antifungal medication to one resident (R1) of three residents reviewed for significant medication errors in the sample list of eight. These failures resulted in R1 experiencing pain and continued symptoms of infection. Findings include: R1's undated diagnoses sheet, documents R1's diagnoses as: aftercare following Joint Replacement surgery, presence of Left Artificial Hip Joint, Candidiasis, unspecified, and unilateral Primary Osteoarthritis, left hip. R1's Physician Order Sheet (POS) dated January 2025, documents Hydrocodone/Acetaminophen Oral Tablet 5-325 milligrams (mg), give 5 mg by mouth one time only for pain related to following Joint Replacement surgery, for 1 day, give 2 tablets Hydrocodone/Acetaminophen 5/325 mg one time only dose; start date 1/30/2025, discontinue date 1/31/2025. R1's January 2025, Medication Administration Record (MAR) has no documentation that Hydrocodone/Acetaminophen Oral Tablet 5-325 milligrams (mg), medication was given on 1/30/25. R1's MAR dated January 2025, documents an order for Clotrimazole Vaginal Cream 2%, insert one applicator vaginally at bedtime for yeast infection, start date 1/30/2025. R1's Treatment Administration Record (TAR) dated January 30, 2025, has no documentation of Clotrimazole Vaginal Cream 2% being administered on 1/30/25 at bedtime. R1's TAR dated February 2025, has no documentation of Clotrimazole Vaginal Cream 2% being administered on 2/4/25, 2/7/25, 2/8/25, and 2/13/25. R1's Orthopedic Discharge Summary dated 1/22/25-1/30/25, documents an order for Lidocaine 4% one patch transdermal on 12 hours, off 12 hours. R1's MAR dated January 2025, documents Lidocaine External Patch 4% apply to left hip topically every morning and at bedtime for pain apply in AM, remove at night, start date 1/30/2025. R1's TAR dated February 2025, has no documentation of a Lidocaine patch being put on R1's left hip on 2/1/25. On 2/14/25 at 10:26 AM, R1 stated when she first got here, they did not have her medications so she did not get her pain medications and she was in a lot of pain. R1 stated they have forgotten her lidocaine patch too. R1 stated she is not getting her vaginal cream at night and still has symptoms of an infection On 2/14/25 at 12:54 PM, V2 (Director of Nursing) DON stated when R1 was admitted the pharmacy did not get R1's orders in time so they did not have the medications. V2 stated the script that was sent to the facility first was for Oxycodone and the facility does not have that in the convenience box and had to get another order for something else that the facility does have which took a while so R1 did not get the pain medication until the middle of the night. V2 stated if a medication is not checked off as being given then it was not administered. V2 verified R1's Clortrimazole has not be given to R1 on several days according to the TAR. V2 verified R1 did not get the one time dose of Hydrocodone on 1/30/25 and that R1 did not get the Lidocaine patch on 2/1/25. On 2/20/25 at 11:35 AM, V6 Medical Doctor (MD) stated R1's hospital discharge orders should have been followed and R1 should have gotten pain medications that were ordered. V6 stated by not getting pain medications when ordered, it can lead to an increase in pain after a hip replacement and R1 should have received the Lidocaine patch as ordered. V6 also stated R1's orders for medication for a yeast infection should have been followed and given as ordered. V6 stated with a delay in treatment, the infection can continue to get worse. The facility's Medication Administration General Guidelines Policy, undated, documents medications are administered in accordance with written orders of the prescriber.

Based on interview and record review, the facility failed to complete pressure sore treatments for one resident (R2) of one resident reviewed for infection's in the sample list of six. This failure resulted in R2 developing an infection in R2's pressure wound. Findings include: R2's undated diagnosis list includes pressure ulcer left hip stage 4. R2's Wound Culture Left Hip final results dated 12/11/24, document Staphylococcus Aureus and many Gram positive cocci in pairs, chains, and clusters. R2's Medication Administration Record (MAR) dated 12/1/24 - 12/31/24, documents Probiotic Oral Capsule (Saccharomyces boulardii), give 1 capsule by mouth in the morning for wound infection for 14 Days, start date 12/14/2024 8:00 AM. This same MAR documents G (Sulfamethoxazole-Trimethoprim), give 1 tablet by mouth every morning and at bedtime for left hip wound infection for 10 days, start date 12/14/2024, 8:00 AM. R2's Physician Order Sheet (POS) dated 1/16/25, documents R2's treatment order as: wound care: left hip, cleanse with wound cleanser and gauze, apply collagen powder to wound cavity, pack wound with 3.4 inch bandage roll soaked with betadine solution, cover with (abdominal) pad, secure with retention tape three times a day (TID) and as needed (PRN). R2's Treatment Administration Record (TAR) dated November 2024, documents Treatment Administration Record (TAR) wound care left hip: twice (BID) a day and PRN, every day and evening shift for wound care, start date 11/14/24 7:00 AM, discontinue 12/4/24 10:00 AM. This same TAR documents treatments not being completed on: day shift - 11/15, 11/16, 11/17, 11/21, and 11/26/24; evening shift - 1120/24. R2's TAR dated December 2024, documents a wound treatment for R2's left hip as TID and PRN every shift for Wound Care, start Date 12/11/2024 11:00 PM, discontinue date 01/16/2025 12:04 PM. This same TAR documents treatments not being completed on: day shift - 12/14, 12/15, 12/21, 12/24 - 12/29, and 12/31/24; evening shift - 12/18, 12/27, 12/30/24; night shift - 12/13, 12/14, 12/15, 12/17, 12/23, 12/27, 12/29/24. On 1/15/25 at 11:00 AM, R2 stated he had Covid back in December (2024) and staff wore Personal Protective Equipment (PPE) in his room, stated no problems with staffing on night shift, got needs met then, stated R2 never had any symptoms either. R2 stated R2 has a pressure ulcer on his left hip and treatments do not get done. R2 stated it was almost healed and then got infected, and this has been going on since October (2024). R2 stated the dressing change is not done for 24 hours sometimes and it should be done at the beginning of the shift. On 1/16/25 at 12:13 PM, V13 Nurse Practitioner (NP) stated R2's wound has been an issue since September (2024) going back and forth with it. V13 stated V13 sees treatments are not being done and the wound gets worse. V13 stated V13 has told the staff about it but the wound still remains and has gotten infected. The facility's Licensed Practical Nurse and Registered Nurse Job Descriptions dated 5/2/2017, both document the nurse is responsible for administering professional services such as applying and changing dressings and be knowledgeable of nursing practices and procedures.

Based on interview and record review the facility failed to provide timely emergency airway management and suctioning for a resident in respiratory distress during a medical emergency. This failure affected one of three residents (R1) reviewed for emergency airway management and has the potential to affect all 77 residents residing in the facility. This failure resulted in R1's subsequent death. The Immediate Jeopardy began on [DATE] when R1 aspirated and could not maintain adequate oxygenation. Staff could not locate the suctioning equipment, made multiple trips in and out of R1's room getting missing equipment, and could not get the suctioning equipment functioning therefore delaying emergency airway management and respiratory treatment for R1. V4 Licensed Practical Nurse (LPN) did not notify Emergency Medical Services or V18 Advanced Practice Registered Nurse regarding R1's medical emergency. V2 Human Resources Director was notified of the Immediate Jeopardy on [DATE] at 9:32 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: R1's Progress Note dated [DATE] documents R1 was diagnosed with Esophageal Cancer, Dysphagia, Choking in Adult, and History of Esophageal Stricture. R1's Minimum Data Set, dated dated dated [DATE] documents R1 is severely cognitively impaired, requires partial/moderate assistance with eating, holds food in his mouth, and coughs or chokes during meals. R1's Physician Order Sheet dated [DATE] documents R1 is prescribed a regular diet, pureed texture, and thin liquids. R1's Care Plan dated [DATE] documents R1 is at risk for aspiration due to difficulty eating and coughing noted with meals. Staff are to monitor for choking or coughing with meals or liquids. The same Care Plan documents on [DATE] R1 was placed on a Regular diet, Pureed texture, Thin Liquid consistency. Resident placed on a puree diet temporarily related to mucus, choking, and Barrettes Esophagus. The same Care Plan documents R1 had a Do Not Resuscitate (DNR) order in place. Staff are to follow advance directives on R1's chart, honor R1's choices, and notify the physician of changes in R1's condition. R1's Practitioner Order for Life Sustaining Treatment (POLST) form dated [DATE] documents R1 wished to have no Cardiopulmonary Resuscitation performed however did wish to have Selective Treatment including but not limited to non-invasive forms of positive airway pressure, intravenous fluids, antibiotics, vasopressors, or antiarrhythmics. R1 wished to be transferred to the hospital if indicated. R1's Progress Note dated [DATE] documents R1 was observed in the dining room during the noon meal, unable to cough up phlegm or verbalize words. R1's Progress Note dated [DATE] documents R1 expired with family at the bedside in the facility. Time of death was 5:55 PM. R1's Progress Note: Skilled Nursing Facility Acute Note dated [DATE] documents at 12:30 PM that day, R1 was found coughing and choking on secretions. V7 Family Caregiver was with R1 at the start of the incident. V18 Advanced Practice Registered Nurse went into R1's room to find staff attempting oral suction for R1. R1 was in his wheelchair and hypoxic with oxygen at 50%, heart rate at 120, respiratory rate at 40. R1 was pale and diaphoretic with grossly congested lungs. V18 APRN took over suctioning, switched to nasotracheal suctioning and retrieved copious amounts of dark tan secretions. R1 however did not improve. R1 was placed on oxygen support at 10 liters via non-rebreather mask. R1's Death Certificate dated [DATE] documents R1's expired on [DATE]. R1's cause of death listed: Acute Hypoxic Respiratory Failure, Acute Aspiration of Stomach Content, Esophageal Dysphagia/History of Esophageal Cancer. At [DATE] at 8:09 AM V7 Family Caretaker stated she arrived at the facility around 11:50 AM on [DATE]. R1 was propelling himself down the hall in his wheelchair. V7 stated she came up to R1 and could audibly hear phlegm rattling in the back of his throat. V7 stated she took R1 to the dining room and he was served his lunch tray. V7 stated R1 took one bite of his mashed potatoes. V7 stated he was having trouble with all the extra phlegm in his throat and V7 then took him to V5 Licensed Practical Nurse (LPN) for some cough medicine. V5 gave R1 cough medicine and V7 took him back to the dining room. V7 stated R1 sat at the table for a few minutes not eating or drinking when she saw him start to struggle to breath. V7 stated she took off with R1 in his wheelchair to the nurses station and found V5 LPN. She told V5 R1 was choking on his phlegm and needed suctioning. V5 told V7 to take R1 back to his room. V7 stated R1 was struggling to breath, was visibly scared, was gasping for air, had audible gurgling sounds, and was anxiously flailing his arms around. V5 LPN could not find the suctioning equipment. V7 stated V5 asked other staff to assist and help find the suctioning equipment. V13 Certified Nurses Assistant (CNA) brought in the suctioning machine. V7 stated more staff came into R1's room and multiple staff were attempting to get the suctioning equipment put together and working. V7 stated after about 15 minutes R1 stopped moving around and went limp in his wheelchair however he was still gasping for air. V7 stated one staff member (V22 Registered Nurse) went in and out of the room multiple times to get items the suction machine was missing. V7 stated eventually V3 Registered Nurse was called from another unit to come and help get the suctioning machine working. V3 RN came and got the machine working and began to suction R1 orally however nothing much came out. A couple minutes later V18 Advanced Practice Registered Nurse (APRN) came into the room and assessed R1 and requested a different suctioning catheter. Staff ran out of the room again to retrieve what she had requested. V18 APRN was then able to suction R1 and got quite a lot of phlegm out however R1 did not seem to improve at all. V7 stated R1 was left in his wheelchair the entire time and was only placed in his bed after V18 had suctioned him. V7 stated forty minutes passed between the time she realized R1 had aspirated in the dining room until V18 Advanced Practice Registered Nurse began to suction R1. V7 stated R1's status never improved and he passed away later that same evening. V7 stated R1 was very scared of choking and it was horrible to witness someone so scared of choking end up aspirating and then no one was able to provide him the help he needed for such an extended period of time. V7 stated she had asked V24 Director of Nurses at the time if anyone had called for an ambulance and V24 stated R1 was not supposed to be transferred to the hospital. V7 stated that was not true. On [DATE] at 3:50 PM V4 Licensed Practical Nurse (LPN) stated V7 (R1's Caregiver) came up to her with R1 in the wheelchair and told her R1 had aspirated and was having trouble breathing. V7 took R1 back to his room and V4 called for help. V4 stated she did not know where the suctioning machine was located and V13 Certified Nurses Assistant located the suctioning machine for her and brought it to R1's room. V22 and V23 MDS Nurses came into R1's room and attempted to help get the suctioning working. V24 (DON at the time) also came into the room. V22 had to run in and out multiple times to get supplies needed for the suctioning equipment. V4 stated even when they had all the equipment needed they could not get the machine to work. V4 stated she called V3 Registered Nurse from another unit to come and help. V3 came over and was able to get the suctioning working and suctioned R1 orally. V18 APRN came in the room and asked for a different suctioning catheter. V18 then began to suction R1 and asked for a non-rebreather mask and oxygen. V4 stated she went to retrieve the oxygen supplies. V4 stated during the entire incident R1 was was struggling to breath, he was diaphoretic, and anxious. V4 denied calling for emergency services or alerting V18 APRN. On [DATE] at 2:35 PM V3 Registered Nurse stated on [DATE] she was working on another unit when she got a phone call from V4 LPN stated R1 is in respiratory distress and they needed help with the suction machine. V3 stated she ran to R1's room and the staff (V24 DON at the time, V22 and V23 MDS coordinators, and V4 LPN) were having issues with the tubing and how to place it onto the suction equipment correctly. V3 RN stated she hooked up the suctioning tubing correctly and it worked. V3 stated she did the initial oral suctioning but couldn't get much out, then V18 APRN came in and did a deep nasotracheal suctioning then asked for a non-rebreather mask and high flow oxygen and V3 left the room to get it. V3 RN stated staff should know how to use the suctioning equipment. On [DATE] at 3:32 PM V23 Minimum Data Set Nurse confirmed on [DATE] she attempted to assist in providing emergency care to R1 when he was in respiratory distress. V23 stated R1 was in his wheelchair and was diaphoretic, had labored breathing, audible gurgling, and was in severe distress. R1 oxygen saturation was very low and he was not getting enough air in and out. I was attempting to assist in getting the suctioning equipment working but the kit was missing pieces and we could not get it to work. V22 MDS Nurse was making trips in and out of R1's room to get what we were missing and we still could not get it working. V3 RN was called over and she was able to finally get the suctioning working and she began to suction R1. V23 stated she was never trained on the suctioning unit that was being used and did not know how to use it. V23 stated V18 APRN came in the room and performed nasotracheal suctioning however R1 was not responding to her efforts and had no eye contact, was not verbal or talking and continued with labored breathing post suctioning and oxygen administration. V23 stated as far as she knows 911 was never called. On [DATE] at 2:00 PM V22 Minimum Data Set Nurse confirmed on [DATE] he attempted to assist in providing emergency care to R1 when he was in respiratory distress. V22 stated entered R1's room and he could not breath- it appeared as though he had aspirated. R1 was gasping for air and trying to clear stuff from his throat but was unsuccessful. V22 stated the suctioning equipment was brought to the room however it was not complete and he had to run in and out of the room ,d+[DATE] times to retrieve the necessary pieces for the suctioning. V22 confirmed that they still could not get the machine to work until V3 RN came over from another unit and was able to get it working. V3 then started suctioning R1. V18 APRN also came into the room and started suctioning R1. After V18 APRN suctioned R1, I moved him to his bed. R1 did not recover and passed away later that evening. On [DATE] at 9:18 AM V24 Registered Nurse (Previous Director of Nurses DON) confirmed on [DATE] she was called into R1's room to assist in caring for him. V24 stated R1 had aspirated and was struggling to breath. V24 stated when she arrived in R1's room V22 and V23 Minimum Data Set Nurses were attempting to put together the machine and get it working however pieces were missing and V22 had to leave the room a few times to get different things. Even after V22 retrieved the missing pieces they could not get the machine working and ended up calling for V3 Registered Nurse who was working on another unit to come and assist. V3 RN arrived and was able to get the suctioning machine to start working and began to suction R1. V24 stated soon after that V18 APRN came into the room and requested a different suctioning catheter, which had to be retrieved, and V18 then suctioned R1 herself. V24 confirmed many errors occurred during the incident and R1 was not able to get the suctioning/care he needed timely because of the missing suctioning pieces and that they could not get the machine working right away. V24 stated R1's primary nurse V4 Licensed Practical Nurse should have called 911, R1's Power of Attorney, and V18 APRN. On [DATE] at 10:11 AM V18 Advance Practice Registered Nurse (APRN) stated on [DATE] R1 had a massive aspiration episode. V18 stated she was in the building and was notified V24 DON at the time would be late or the meeting because she was assisting in an emergency with R1. V18 stated she jumped up and ran to R1's room to see what was going on. V18 stated when she entered R1's room, V3 RN was performing oral suctioning but it was not doing any good. R1 was hypoxic and in severe distress. V18 stated she asked for a different suctioning catheter and performed nasotracheal suctioning on R1 retrieving copious amounts of thick secretions. V18 stated despite her efforts R1's status was not improving and the suctioning was not going to relieve his distress. V18 stated she spoke with R1's POA (V6) who requested at that point they keep R1 comfortable. V18 stated R1 was provided with comfort measures and medications to keep him comfortable until he expired later that evening. V18 stated the facility nursing staff knew she was in the building and should have notified her immediately when it was first noticed that R1 was in respiratory distress. V18 stated she was not aware that initially the nursing staff had issues finding the suctioning equipment or issues with getting it working. V18 confirmed nursing staff should know where to locate suctioning equipment and how to use it. On [DATE] at 2:16 PM V6 (R1's) Health Care Power of Attorney/Niece stated even through R1 had a DNR order in place she would have wanted the facility to call EMS when R1 began having trouble breathing. V6 stated she feels the facility was negligent. V6 stated she was only called concerning the situation by V7 (R1's Personal Care Taker) a little before 1:00 PM. V6 stated she could hear all the commotion in the background and V7 told R1 V6 was coming. V6 stated she got there about ten minutes later. V6 stated when she arrived in R1's room, R1 was still struggling to breath but he was no longer able to speak, he was not making eye contact, or acknowledging her presence. V6 stated she knew he was not going to make it at that point. V6 stated she made a comment in the past (when he seemed to be declining naturally) that if R1 was comfortable and calm, they did not need to send him to the hospital but V6 stated- that does not mean that if there was an emergency situation, and R1 was gasping for air and needed emergent care that they should not get him the help he needed. V6 stated R1 deserved better than this and the facility should have done better. The undated Oropharyngeal Suctioning policy documents the purpose is to maintain an unobstructed airway and prevent aspiration of mucus secretions. Staff are to place a resident in semi-Fowlers or side lying position and proceed with suctioning procedure. The Facility Assessment, last reviewed on February 2024 documents the facility will ensure staff are educated and have competencies in the areas that are necessary to provide the level and type of support and care needed for their resident population. This includes specialized care such as oxygen administration and suctioning. The same assessment documents the facility on average within an typical month has eight residents requiring oxygen respiratory services and one resident requiring suctioning. (This is a typical month, not taking into an account emergency medical situations.) The facility resident roster dated [DATE] documents 77 residents reside in the facility. The facility presented an abatement plan to remove the immediacy on [DATE] at 11:34 AM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on [DATE] at 2:32 PM, and the survey team accepted the abatement plan on [DATE] at 3:22 PM. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1. On [DATE] V1 [NAME] President of Operations initiated education of all licensed nursing staff regarding Physician-Family Notification - Change of Condition Policy and policy on when to transfer or discharge the resident from the facility. 2. On [DATE] all facility nursing staff were in-serviced by V1 [NAME] President of Operations and V3/V24 Nurse Managers regarding the suctioning manufacturer's guidelines for suction machine maintenance including but not limited to machine inspection before each use to ensure there are not cracks, breaks, etc. before using the machine. 3. On [DATE] all facility nursing staff were in-serviced by V1 [NAME] President of Operations and V3/V24 Nurse Managers regarding where emergency medical equipment is stored, checking all items for medical emergency are in place weekly per checklist and a nurse is responsible to complete the audit and sign off on the checklist weekly. 4. On [DATE] all facility nursing staff were in-serviced by V1 [NAME] President of Operations and V3/V24 Nurse Managers regarding the facility's guidelines for Oropharyngeal Suctioning including but not limited to resident positioning, suctioning process, canister exchange, and documentation. 5. On [DATE] all facility nursing staff and Direct Care Staff were in-serviced by the V1 [NAME] President of Operations and V3/V24 Nurse Managers regarding the facility's Code Blue Procedure Policy, including but not limited to CPR for choking event. 6. On [DATE] all facility nursing staff and Direct Care Staff were in-serviced by the V1 [NAME] President of Operations and V3/V24 Nurse Managers regarding the facility's Equipment Replacement - Disposable - Nursing Policy including but not limited to suctioning equipment replacement including canister, connection tubing, oral suctioning tool, and sterile suction catheters. 7. On [DATE] an impromptu Quality Assurance Performance Improvement meeting was held with V12 Medical Director and staff Interdisciplinary Team to discuss facility deficiencies and an action plan. 8. The facility began it's audits (5 days per week for 6 weeks) to ensure staff is knowledgeable of the location of emergency medical equipment, how to use the equipment and how to ensure the required supplies. A Quality Assurance (QA) tool will be completed to verify this practice has occurred. The QA tool will be completed by the Directed of Nurses or designee, daily for 6 weeks. There will be oversight of the QA tool by the Regional Nurse Consultants (V27, V28). \

Based on observation, interview, and record review the facility failed to protect the resident's right (R1) to be free from sexual abuse by another resident (R2) by failing to supervise R2, a resident with a known history of behaviors of inappropriate touching towards other residents (R3, R4, R5, R6, R7, R8, R10, R14). R1-R8, R10, and R14 are nine of 14 residents reviewed for abuse in the sample list of 16. These failures resulted in R2 sexually abusing R1 when R2 was left unsupervised. The Immediate Jeopardy began on 5/24/24 when R1 was sexually abused by R2. V1 Administrator was notified of the Immediate Jeopardy on 6/11/24 at 11:21 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/13/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The facility was previously cited F600D on Facility Reported Incident of April 7, 2024/IL171905, survey exit 4/23/24 for resident to resident sexual abuse by R2. The facility's Abuse Prevention and Reporting-Illinois policy dated 10/24/22 documents residents have the right to be free from abuse and the facility prohibits abuse. This policy documents the facility will identify occurrences and patterns of potential mistreatment, investigate abuse allegations and make changes to prevent future occurrences. This policy documents sexual abuse is non-consensual contact with a resident and includes unwanted intimate touching of any kind, including breasts and perineal area. The facility's investigation for R2's/R3's incident on 4/7/24 at 2:58 PM documents V1 was notified that R3 reported that R2 touched R3's breast. This investigation documents V11 Activity Aide was interviewed and V11 stated R3 was brought to activities by V20 Visitor who reported R3 said R3 was afraid of R2, because R2 follows R3 around and won't leave R3 alone. This interview documents V20 told V11 that V20 witnessed R2 grab R3's hand and R3 told V11 that R3 was afraid of R2 because He's (R2) following me around and rubbing my chest on top of my clothes. V11's statement dated 4/8/24 documents after lunch on the same day as R2's/R3's incident, R2 was sitting next to R5 with R2's hand on R5's upper left thigh, R5 pushed R2's wheelchair away, and V11 separated R2 and R5. V41 Certified Nursing Assistant (CNA) interview dated 4/8/24 documents R2 and R14 were sitting at the nurse's desk and R2 rubbed R14's stomach. The facility's investigation for R1's/R2's incident of 5/24/24 at 3:18 PM, documents the following: A Registered Nurse (RN V3) reported R2's hand was underneath of R1's shirt. Prior to the incident, V5 CNA brought R2 to the East lounge. Approximately five to ten minutes later, V4 Registered Nurse (RN) looked up to see R2 had wheeled his wheelchair in front of R1, and R2's right hand was underneath the left front side of R1's shirt. V4 asked V3 RN (who had her back to R1/R2) to separate R1 and R2. R1 had no reaction to R2, and neither R1 or R2 remembered the incident. R2 was placed on one to one monitoring during waking hours and has a bed alarm at night. R2 has a history of wandering into other resident rooms looking for R2's spouse, who previously resided in the facility. This investigation documents that during staff and resident interviews, R6 reported R2 wandered into R6's room and asked to hold R6's hand and staff promptly removed R2 from R6's room. V21's (CNA) statement dated 5/24/24 documents prior to today V21 had not witnessed R2 touch other residents, but at supper R2 was sitting with R2's eyes closed and his hand was underneath of the table on R10's leg. This statement documents V21 asked R2 if R2 knew that R2's hand was on a man's leg, and R2 immediately removed R2's hand. V10's (CNA) statement dated 5/28/24 documents two or three weeks ago V10 came from the main dining room, R5 was sitting in a wheelchair in the middle hall and R2 came from the west area and reached towards R5's chest. This statement documents R2 barely touched R5 as V10 separated R2 from R5 and took R2 back to the East wing (where R2 resides). R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment. R1's Care Plan revised 5/29/24 documents R1 is at risk for abuse/neglect related to dementia, depression, and behaviors, and there was an incident with another resident on 5/24/24 where R1 was touched inappropriately. R2's MDS dated [DATE] documents R2 has severe cognitive impairment. R2's Care Plan dated 4/8/24 documents R2 has behaviors of physical inappropriate touching towards female residents due to R2's dementia and poor impulse control. The Care Plan includes interventions to analyze the time of day, places, circumstances, triggers, and what de-escalates the behavior (5/24/24), encourage acceptable behaviors (4/8/24), involve physicians and counseling services to detour inappropriate behaviors (4/8/24), maintain communication with R2's family and potentially suggest memory care placement (4/8/24), monitor/document/report inappropriate behaviors (5/24/24), staff should monitor R2 when around female residents and remove R2 if R2 moves too close to female residents or displays inappropriate behaviors (4/8/24), and R2 will be offered one to one monitoring (5/24/24). There is no documentation in R2's medical record of one to one monitoring implementation, besides nursing notes that do not document consistent one to one monitoring daily for each shift. The Daily Nurse Assignment Sheets dated 5/25/25-6/10/24 documents a sitter is assigned for one to one monitoring on days and evening shifts, but does not document one to one monitoring was assigned on evening shift on 6/7/24 and 6/8/24 or any night shifts. On 6/10/24 at 8:45 AM and 1:56 PM, and on 6/11/24 at 8:50 AM R2 was lying in bed with bed alarm in place, and no staff were in or directly outside of R2's room. On 6/10/24 at 8:45 AM R2 was confused and did not recall incidents involving female residents. On 6/10/24 at 9:16 AM R2 self propelled R2's wheelchair up the East hall towards the nurses' station. There was no staff directly with R2. V1 Administrator came up behind R2 and mentioned R2 was done with therapy, and then V13 Housekeeper pushed R2 to the dining room and sat with R2. On 6/10/24 at 3:27 PM R2 was sitting in the dining room at the end of a table participating in a large group BINGO activity. R7 and R13 (female residents) were on each side of and within R2's reach. There was no staff directly with R2 besides V14 Activity Director who was standing near R2 and leading the activity, occasionally turning V14's back to R2 as V14 called out BINGO numbers. On 6/10/24 at 8:48 AM R1 was lying in bed. R1 was confused and not interviewable. On 6/10/24 at 9:38 AM R3 stated there was only one time that a male resident (identified as R2) touched her inappropriately. R3 stated (R2) put his hand on R3's thigh and went up underneath of R3's shirt, which made R3 feel uneasy. R3 stated when R3 sees (R2) now R3 thinks danger and stays aware from R2. On 6/10/24 at 10:00 AM R6 stated several weeks ago a male resident (identified as R2) came into R6's room while R6 was in bed, and attempted to hold R6's hand. R6 stated R6 pulled her hand away and called for staff who immediately removed R2 from R6's room. At this time R5 (R6's roommate) was confused and not interviewable. On 6/10/24 at 8:55 AM V9 CNA stated V9 heard that R2 has inappropriately touched R1, R3, R5 and R7. On 6/10/24 at 9:00 AM V3 RN stated (in reference to R1's/R2's 5/24/24 incident) at 3:20 PM V3 was talking to an unidentified resident in the East lounge and V4 RN asked V3 to get R2. V3 stated V3 turned around to see R1 and R2 sitting near the patio doors and R2's hand was up underneath of R1's sweatshirt near R1's breast. V3 stated R1 had no expression or response to R2 touching R1. V3 stated R2 was moved to an area away from R1. V3 described R1 as having limited cognition and V3 confirmed R2 had prior similar incidents involving other unidentified female residents. V3 stated staff had been trying to keep R2 in a visual observed area and there was no one specifically assigned to monitor the East lounge at the time of R1's/R2's incident. On 6/10/24 at 9:22 AM V12 Housekeeping Supervisor stated V12 heard that R2 tried to touch R3 again and R4 a couple of weeks ago, and R2 had tried to touch R10. V12 stated R2 gets touchy feely with staff as well and a couple weeks ago R2 rubbed V12's arm and tried to move up V12's arm. On 6/10/24 at 10:17 AM V8 CNA stated a couple months ago R8 was yelling get out of here and V18 receptionist found R2 in R8's room. V8 stated V8 heard R8 yell out he (R2) was rubbing my (R8's) leg, but V8 did not witness R2 touch R8. V8 stated a couple months ago R2 was found on the floor of R7's room after R2 tried to get into bed with R7. V8 stated V8 was not sure what was done at that time to address R2's behaviors other than staff would redirect R2 when R2 wandered to the middle hall. V8 stated R2 has a sitter now, but if there isn't an assigned sitter then R2 sits in an area where staff can watch R2. V8 stated after R2 is gotten up V8 takes R2 to activities where staff are present, since the CNAs are busy giving showers. V8 stated today someone is assigned to be with R2 from 9:00 AM until 3:00 PM, but there isn't always someone assigned for R2's one to one monitoring. On 6/10/24 at 10:30 AM V4 RN stated (in reference to R1's/R2's incident) V4 had just started V4's shift and was working the East hall. V4 stated R2 had tried to get out of bed and V4 told V5 to bring R2 to the East Lounge where a lot of residents were seated due to a severe thunderstorm. V4 stated V4 was not aware at that time that R2 was not to be by other residents and supervised. V4 stated R2 was sitting between R10 and an unidentified female resident. V4 stated V4 was counting narcotic medications with the oncoming shift nurse and about five to ten minutes after R2 was brought to the lounge, V4 looked up to see R2 in front of R1 with R2's hand underneath of R1's shirt near R1's breast. V4 stated V4 told V3 RN, who had her back to the lounge, to separate R2 from R1. V4 stated R2 was not aware of what was going on, R2 is confused and tries to find R2's wife, which V4 believes to be the root cause of R2's behavior. V4 stated R1 had no response to R2, R1 is confused and does not have the cognitive ability to consent to being touched like that. V4 stated there was no staff directly supervising the lounge at the time of the incident, and if R2 had a sitter or direct supervision it likely would have prevented the incident. V4 stated The hard thing is, he moves very fast. You can be watching him one minute and then the next thing you know he's on the other side of the building. He is very fast when he gets his feet moving. It's very hard to do your stuff (work) and keep an eye on him. V4 stated since the incident R2 has been on one to one monitoring during the day until 8:00 PM, but not at night since R2 has a bed alarm. On 6/10/24 at 11:16 AM V10 CNA stated V10 has only heard of incidents approximately one month ago including R2 touching R8 while R8 was in bed, R2 touching R5's thigh, and R2 falling in R7's room while attempting to get into bed with R7. V10 stated within the last couple weeks, V10 caught R2 just in time as V10 came from the dining room and witnessed R2 reach out towards R7's breast while sitting near the middle hallway. V10 stated R2's fingertip barely brushed across R7's breast as V10 separated R2 from R7. V10 stated R2 now has someone assigned to be with R2, and if we don't due to short staffing then we just keep our eyes on R2. On 6/10/24 at 3:22 PM V5 CNA confirmed V5 was the CNA who brought R2 to the lounge on 5/24/24. V5 stated prior to that day, V5 was not aware that R2 had behaviors of inappropriately touching other residents. On 6/10/24 at 3:46 PM V22 CNA stated V22 worked evening shift on the East wing on 6/7/24 and 6/8/24. V22 confirmed R2 requires one to one monitoring and there was no staff assigned for R2's one to one monitoring on evening shift on 6/8/24. On 6/10/24 at 1:18 PM V1 Administrator confirmed R2's history of inappropriate touching and attempts to touch other residents. V1 stated we implemented closer monitoring, which was not one to one supervision, for 72 hours after R2's first incident with R3 on 4/7/24, and after the 72 hours staff were just aware to keep an eye out for R2's location and keep R2 away from female residents. V1 stated that same day (4/7/24), R2 had R2's hand on R5's leg. V1 stated R2 returned from the hospital on 5/24/24 and R2's wife had visited at the hospital, which we believe may have been a trigger for R2's behavior causing R2 to think R1 was R2's wife who previously resided in the facility. V1 stated after R2's incident on 5/24/24, we implemented one to one monitoring of R2 while awake since R2 has a bed alarm. V1 stated therapy staff do not always notify the staff when R2 is finished with therapy. V1 stated with staffing we try to assign someone to be with R2 or the department heads/office staff take turns sitting with R2, and the Daily Staffing Sheets document the assigned one to one sitter. V1 stated R2 likes to wander about the facility and talk to residents, R2 is confused and not aware of what R2 is doing. V1 stated V1 did not think R1 has the ability to consent to sexual contact, and V1 interviewed R1 who had no recollection of the incident with R2. On 6/10/24 at 2:24 PM the Daily Staffing Sheets were reviewed and verified with V1, confirming no documented assigned staff to provide R2's one to one monitoring on evening shift on 6/7/24 and 6/8/24. V1 stated the East CNAs would have shared the monitoring on 6/8/24 and V1 did R2's monitoring from 5:00 PM until 7-7:30 PM on 6/7/24. On 6/11/24 at 8:55 AM V1 confirmed there is no documentation of one to one monitoring in R2's medical record, besides the nursing notes. On 6/10/24 at 2:18 PM V6 (R1's Family) stated the facility notified V6 that a male resident put his hand up underneath of R1's shirt. V6 was asked how R1 would have felt or responded if R1 did not have cognitive impairment. V6 stated R1 would have been shocked and would have yelled/screamed. The Immediate Jeopardy that began on 5/24/24 was removed on 6/13/24 when the facility took the following actions to remove the immediacy. 1. V1 Administrator, V37 Minimum Data Set (MDS)/Registered Nurse (RN) and V40 MDS/RN all stated on 6/13/24 that staff in-services on the Abuse Policy were started on 6/11/24 and completed on 6/12/24. V1 Abuse Coordinator stated V1 was inserviced by V47 Regional Clinical Nurse on 6/11/24. V37 and V40 MDS/RN's both stated they had received their abuse policy inservices on 6/11/24 by V1 Administrator. On 6/13/24 V1 Administrator stated the facility's plan to in-service those staff such as PRN (As-Needed) and/or Agency staff is to notify the staff member by email with a link to complete abuse training. V1 Administrator stated the facility has not received the staff member's submitted Abuse Training in-service then the staff schedules will be monitored by V36 Scheduler. V36 will notify V1 Administrator if there are any agency staff scheduled. V1 Administrator stated V1 or the nurse on-call will meet the staff member at the facility and ensure the Abuse Policy training is completed prior to the staff member working. 2. V44 Human Resources Director stated on 6/13/24 that there have not been any new staff member hired since 6/6/24. V44 stated all new hire employees receive the Abuse Policy training through an electronic system which the new employee must complete prior to working in the facility. V44 HR stated the new hire employee also has a face to face meeting in which the Abuse Policy is also discussed verbally. V44 HR stated the employee is encouraged to ask questions. V44 HR stated the Abuse Policy is reviewed in its entirety. 3. V32 Social Service Director (SSD) stated on 6/13/24 that R1's Abuse Assessment was completed on 6/11/24 but did not reflect R1's recent history of being abused. V32 SSD stated R1's assessment completed on 6/11/24 was not accurate. V32 SSD completed R1's Abuse Risk Assessment on 6/13/24 that did reflect R1's recent history of being sexually abused. 4. A facility wide audit was started on 6/10/24 for all residents who have been identified via the careplan to show potential behaviors that may impede other resident's safety. This audit was completed daily from 6/10/24-6/13/24 for 'the week ending 6/15/24.' V1 stated the facility wide audit was completed by V1. V1 Administrator stated there were no new residents identified by the audit. V1 stated this audit will continue daily for six weeks in conjunction with the later audit in the abatement plan. 5. V43 [NAME] President of Operations (VPO) stated V43 reviewed the facility abuse policy on 6/11/24 and found that there were no updates to be made. V43 stated the facility abuse policy follows the state and federal guidelines for recognizing and reporting abuse and inappropriate behavior, abuse identification, definitions, reporting and preventing. 6. R2's Care Plan dated 4/23/24 documents R2 has physical inappropriate behaviors of touching towards female residents and was updated with an intervention dated 6/11/24 that R2 was hospitalized for sexual behaviors and psychiatric evaluation. This care plan documents interventions dated 6/12/24 for one to one monitoring 24 hours per day, not to be around female residents, prompt intervention when approaching female residents, remove from setting when displaying inappropriate behaviors, and report these behaviors to the abuse coordinator and supervisor. 7. R2's Nursing Note dated 6/11/2024 at 2:58 PM documents R2 was transferred to the local hospital for evaluation of sexual behaviors and a request for psychiatric evaluation was requested through the hospital's electronic communication system by R2's physician. R2 remained at the hospital as of 6/13/24. On 6/12/24 at 1:35 PM V23, Medical Director, stated R2 was transferred to the hospital on 6/11/24 for requested psychiatric evaluation of R2's behaviors, R2 was admitted to the hospital, and R2's medications have been adjusted. 8. On 6/11/24 the facility held an Emergency Quality Assurance Performance Improvement (QAPI) meeting with V23 and the interdisciplinary team to discuss the deficiency and the facility's action plan. The QAPI Meeting Minutes dated 6/11/24 document a meeting was held to review the deficiency and develop action plan, and attendees included V1 Administrator, V23, and nurse management staff. On 6/12/24 at 1:35 PM V23 confirmed V23 attended the QAPI meeting, the deficiency and action plan were reviewed. 9. The facility has identified residents at risk for sexual abuse by completing the Abuse/Neglect Screening assessment. The Abuse/Neglect Screening assessment report documents the facility completed this assessment for all residents on 6/11/24 which identified residents at risk for abuse. R1's, R3's, and R7's Abuse/Neglect Screening assessments dated 6/11/24 are not accurate to include a history of abuse from R2's inappropriate touching. R2's Abuse/Neglect Screening assessment dated [DATE] is not accurate to include R2's inappropriate sexual behaviors towards others. On 6/13/24 at 9:29 AM V32 Social Services Director confirmed all resident Abuse/Neglect Screenings were completed on 6/11/24. On 6/13/24 at 9:50 AM V32 confirmed R1's, R2's, R3's, and R7's Abuse/Neglect Screenings are not accurate. V32 stated V32 will update their assessments. On 6/13/24 at 11:37 AM V32 provided R1's, R2's, R3's, and R7's revised Abuse/Neglect Screenings dated 6/13/24. 10. V1 Administrator stated on 6/13/24 that R2's continual supervision was on-going prior to the approval of the Abatement plan. V1 Administrator stated R2 left the facility en route to the emergency room for evaluation on 6/11/24. R2 remains out of the facility during remainder of survey timeframe. V37 MDS/RN stated V37 and V40 MDS/RN will review the hospital documentation and update R2's Electronic Medical Record (EMR)/Careplan upon R2's return from the hospital. V1 Administrator stated R2 will remain on continual supervision upon return from the hospital. V36 Scheduler stated V36 schedules the staff who are supposed to provide continual observations of R2. V36 stated if there is a problem finding staff or if a scheduled staff member calls in then the manager on duty is responsible for filling the position or providing continual observations of R2. V1 Administrator stated on 6/13/24 that the Quality Assurance (QA) tool designed and being completed will continue daily for six weeks. V1 Administrator stated V1 is responsible for completing the audits and has no further issues. 11. V37 Minimum Data Set (MDS)/Registered Nurse (RN) stated V37 MDS/RN and V40 MDS/RN both reviewed and updated R1, R2, R15, R16's Care plans on 6/11/24.

Based on interview and record review, the facility failed to implement fall prevention interventions according to resident's plans of care. This failure affects one resident (R69) out of five reviewed for accidents and falls on the sample list of 50. This failure resulted in R69 experiencing a femur fracture requiring surgical intervention to repair. Findings include: R69's Nurses Notes dated 1/8/24 document R69 was admitted to the facility on this date, 1/8/24. R69's Medical Diagnoses (undated) list documents R69 was admitted to the facility with medical diagnoses including Anxiety, Dementia, Difficulty in Walking, and Osteoarthritis. R69's Fall Risk assessment dated [DATE] documents R69 was at risk for falls. R69's Care Plan, initiated 1/8/24, documents R69 experiences mobility performance deficits related to dementia and de-conditioning. This same Care Plan documents R69 is at high risk for falls with fall prevention interventions initiated 1/8/24 including for R69 to wear non-skid footwear when ambulating or in the wheelchair. R69's Nurses Notes dated 1/10/24 document R69 experienced a fall in the doorway of her room while attempting to go to the bathroom. R69's Fall Risk assessment dated [DATE] documents R69 was rated at risk for falls. R69's Minimum Data Set for admitted d 1/11/24 documents R69 experienced at least one fall in the month prior to admission, and at least one fall in the period of two to six months prior to admission. This same Minimum Data Set documents R69 received a score of three out of a possible 15 on a Brief Interview for Mental Status, rating R69 with severe cognitive impairment. This Minimum Data Set documents R69 could not dress her lower body without substantial to maximal assistance from staff and could not put on footwear without at least verbal cues, if not physical touching assistance. R69's Nurses Notes dated 1/27/24 document R69 experienced a fall by sliding out of the wheelchair, landing on her buttocks. R69's Nurses Notes dated 1/28/24 document R69 began to complain of pain in the right trochanter (hip) and was sent to the emergency room for evaluation. R69's Hospital Reports dated 1/28/24 document R69 received a computed tomography study (CT scan) and was determined to have experienced an acute impact fracture of the right femur neck. These same Hospital Reports include a review of R69's injury resulted from a fall at her wheelchair on 1/27/24, and documented R69 underwent a surgical open reduction internal fixation to repair the right femur fracture. R69's Nurses Notes dated 1/29/24 include an Interdisciplinary Team Investigation Note for R69's fall on 1/27/24, documenting R69 landed on her bottom with her legs straight out in front of her. This same note documents the root cause of R69's fall as resident was wearing regular socks on carpeted area and slid out of chair. On 2/20/24 at 11:33 AM, V5 (Director of Rehabilitation Services) stated, (R69's) transfer status has declined since her fall. (R69) is on the skilled therapy caseload, receiving Physical Therapy, Occupational Therapy, and Speech Therapy (ST). V5 continued, (R69) is receiving ST for cognitive rehabilitation, she has been a lot more unable to comprehend what she needs to do to maintain her balance since she had a fall a few weeks ago. (R69) was fairly independent only requiring contact with hands on assist with transfers, now she needs a maximum assist with verbal, physical, and tactile cues. (R69) doesn't seem to comprehend standing positions and she tries to stand with her hips protruding forward and her upper body leaning backwards. V5 concluded by stating, (R69) was already in skilled Physical Therapy and Occupational Therapy prior to fall and her physical recovery as far the healing of the fracture is going well, but her mobility has declined. R69's Minimum Data Set, dated dated dated [DATE] documents R69 was experiencing a significant change in condition that was not expected to resolve itself. This Minimum Data Set documents R69 had experienced declines in functional status including eating, putting on or taking off footwear, all aspects of bed mobility, transitioning from sitting to standing positions, surface to surface transfers, and her ambulation was limited to ten feet as opposed to fifty feet with two turns. On 2/22/24 at 11:27 AM, V2 (Director of Nursing) stated, It is a true statement (R69 was not wearing non-skid socks at the time of her fall on 1/27/24). V2 further stated, I think (R69) would not have the cognitive ability to know what kind of socks she had on, even if she could put them on herself. I think (R69) was declined when she first got here. V2 continued, (R69's) care plan did have to put the non-skid socks on her feet before the fall on 1/27/24 and I don't know why they (staff) didn't, but I could only imagine she was already in bed and trying to get up so they (staff) brought her out by the nurses station to keep an eye on her and just didn't put them on.

Based on observation, interview, and record review the facility failed to re-evaluate a resident's transfer status (R1) and utilize a gait belt to safely transfer a resident (R2). This resulted in R1 sustaining a laceration that required 10 sutures to close the wound and R2 sustaining a fall that resulted in fractures of the right medial and lateral malleolus (ankle). The facility also failed to accurately assess fall history and fall risk, develop, and implement fall interventions, and thoroughly investigate falls for R2 and R3. R1, R2, and R3 are three residents reviewed for falls in the sample list of three. Findings include: 1.) The facility's Report to Illinois Department of Public Health documents on 7/30/23 at 9:45 AM R1 sustained a laceration of the right leg during a transfer. R1 was sent to the emergency room and received 10 sutures. This report documents the cause of R1's laceration was R1 bumped R1's right leg on the bracket of R1's wheelchair during a transfer. R1's emergency room Provider Note dated 7/30/23 at 11:38 AM documents R1 presented with a 4-centimeter laceration of the right lower leg that required 10 sutures to close. R1 reported the laceration occurred when staff transferred R1 from the wheelchair. R1's Minimum Data Set (MDS) 6/24/23 documents R1 transfers and walks in the room and corridor with extensive assistance of one staff person. R1's Care Plan dated 4/5/23 documents R1 transfers with assistance of one staff person. R1's Care Plan with revised dated 8/14/23 documents R1 is at risk for impaired skin integrity and R1 received a skin tear to the lower extremity during a transfer. R1's Order Summary Report Dated 8/14/23 documents an order dated 3/17/23 for stand/pivot transfers with one assist and use of sit to stand mechanical lift as needed, Apixaban (anticoagulant) give 2.5 milligrams twice daily, and an order dated 7/20/23 for physical and occupation therapy. R1's Response History Report for R1's transfers from chair/bed dated 8/14/23 documents R1 required dependence on two staff six days between 7/16/23 and 7/29/23. R1's Nursing Notes document the following: On 6/29/23 at 7:17 PM documents R1 continues to work with physical therapy for left shoulder pain and range of motion, and R1 needs moderate assistance for sit to stand transfers. On 07/20/2023 at 7:00 PM documents an interdisciplinary team meeting summary note that R1 continues to receive therapy for shoulder pain, nursing staff notes R1 has not been stand/pivot transferring as well as R1 had previously, and an agreement for Physical Therapy to evaluate transfer status and Occupational Therapy to evaluate for wheelchair seating. On 07/30/2023 at 9:45 AM a Certified Nursing Assistant (CNA) reported that during R1's transfer R1's right leg hit the wheelchair, R1 sustained a bleeding laceration below R1's right knee that measured 6 centimeters (cm) by 1 cm. A pressure dressing was applied and R1 was transferred to the emergency room . R1 received 10 stitches and returned to the facility. R1's Physical Therapy Treatment Encounter Notes dated 7/27/23 documents Patient (R1) is mod (moderate) A (assist) for sit<>stand and max (maximum) A with transfers. Patient movement is slow, and patient requires extra time. Patient has decreased co-contraction in BLE (Bilateral Lower Extremities) resulting in segmented movements. R1's Occupational Therapy Evaluation & Plan of Treatment with a start date of 7/21/23 documents R1 requires substantial/maximum assistance with transfers. There is no documentation in R1's medical record that R1's transfer status was changed after 4/5/23. On 8/14/23 at 2:54 PM R1 was sitting in R1's wheelchair in R1's room. There was a full mechanical lift sling positioned underneath of R1. V2 (Director of Nursing/DON) pulled up R1's right pant leg and there was a healing, closed, pink wound to the right outer calf and dark pinpoint areas where sutures were previously. V2 stated R1 had R1's stitches removed today. On 8/14/23 at 8:58 AM V4 (CNA) stated R1 had been walking well when R1 first admitted to the facility, but R1 started walking slower and having more difficulty with transfers. V4 stated before R1's injury R1 had difficulty with transfers, R1 transferred with one staff person and use of gait belt, and staff had to use more weight bearing extensive assistance. V4 stated after R1's injury therapy evaluated R1 and R1 now uses a full mechanical lift for transfers. V4 stated V4 had reported R1's difficulty with transfers to V2, prior to R1's injury. On 8/14/23 at 9:40 AM V5 (CNA) stated V5 was the CNA who transferred R1 at the time R1's injury occurred. V5 stated V5 transferred R1 from the bed to the wheelchair and no other staff assisted with R1's transfer. V5 stated R1 stood and pivoted for the transfer but was weak and slow. During the transfer R1 bumped R1's right lower leg into the bracket on the wheelchair where foot pedals attach. V5 stated R1 sliced open an area to R1's right lower leg where a previous bruise was. V5 stated R1 was transferred to the hospital and received stitches. Therapy informed us that R1 is a strict full mechanical lift now for all transfers. On 8/14/23 at 11:06 AM V9 (Physical Therapist) stated R1 was requiring 50-75% assistance, moderate/maximum assistance, for transfers prior to R1's right leg injury. V9 stated the facility is a no lift facility so residents requiring maximum assistance use a sit to stand or full mechanical lift. V9 stated V9 would not have recommended the use of a sit to stand lift for R1 due to R9's shoulder pain, so would have recommended a full mechanical lift for transfers. V9 stated R1 is now a full mechanical lift for all transfers. On 8/14/23 at 11:19 AM V10 (Certified Occupational Therapy Assistant) stated V10 did not recommend R1's transfer status to change to full mechanical lift until after R1's right leg injury. V10 stated staff can always downgrade a resident's transfer status if they are having difficulty with transfers, and since this is a no lift facility staff would downgrade to the use of mechanical lifts for transfers. On 8/14/23 at 12:54 PM V13 (Nurse Practitioner) stated on 7/30/23 V13 received a call from the nurse reporting R1's laceration and during a transfer R1's leg had caught on the hardware of the wheelchair where the foot pedals attach. V13 stated V13 has seen that type of injury before caused by bumping into the wheelchair hardware. V13 stated it was a big laceration and R1 is on Eliquis (anticoagulant) and bleeds. Due to R1's fragile skin, any kind of protruding edge could have caused it. V13 was not aware that R1 had a decline in transfers prior to the injury. On 8/14/23 at 2:07 PM V2 (Director of Nursing/DON) stated resident transfer status is reviewed during the Medicare meetings and morning meetings, and the facility doesn't make changes in transfer status unless recommended by therapy. V2 stated R1 was a stand pivot one assist transfer, CNAs reported R1 was weaker for transfers, and we did not downgrade R1's transfer status prior to R1's injury. V2 stated R1 required staff assist/performance of 50-75% of R1's transfers, then therapy should have given us a recommendation for R1's transfer status. V2 stated we do not have access to therapy notes and V2 was not aware that R1 was requiring that much assistance from staff for transfers. V2 stated if V2 was aware V2 would have asked therapy if they felt R1 should be a full mechanical lift for transfers. At 3:00 PM V2 confirmed if R1 was transferred with a full mechanical lift, R1 would have been lifted from above the chair, potentially avoiding contact with the wheelchair hardware. On 8/14/23 at 3:40 PM V1 (Administrator) stated V1 conducted the investigation for R1's injury. V1 stated V1 had V5 re-intact R1's transfer and during the transfer R1 bumped R1's right leg on the bracket of the wheelchair causing the laceration. After the injury we padded the brackets on R1's wheelchair. V1 stated CNAs can report difficulty with transfers to the nurses, nurses and therapy can direct the CNAs on resident transfer status. V1 stated therapy attends the morning interdisciplinary team meetings and never mentioned changing R1's transfer status. 2.) On 8/14/23 at 10:10 AM R2 was lying in bed and had an elastic bandage wrapped around R2's right lower leg, from R2's toes to R2's knee. R2 stated a CNA was assisted R2 to a standing position from the bed so that R2 could pull up R2's pants which were around R2's knees. R2 stated the CNA instructed R2 to take a step forward and when R2 took a step R2's right knee buckled causing R2 to twist R2's right foot and ankle and fall to the floor. R2 stated R2 has a triple fracture, all three bones in R2's ankle are fractured. R2 stated R2 has a history of R2's right knee buckling and had fallen at home prior to R2's admission to the facility. R2 stated a gait belt was only used by therapy during R2's transfers, and a gait belt was not used during R2's transfer that resulted in the fall. R2's Admission MDS dated [DATE] documents R2 admitted to the facility on [DATE], is cognitively intact, weighs 218 pounds, requires assistance of one staff for transfers (occurred only 1-2 times during the 7-day period), and R2 had no falls within the last six months prior to R2's admission. R2's Hospital Admission History & Physical dated 7/1/23 documents R2 presented to the emergency room after falling twice at home. R2's Fall Risk assessment dated [DATE] completed by V2 (Director of Nursing documents R2 has not had any falls within the prior 3 months, and a fall risk score of 9 indicating R2 is not at risk for falls. R2's Admission Assessment/Baseline Care Plan dated 7/31/23 documents the section for fall risk is incomplete and does not document R2's fall risk or interventions. There is no documentation that R2 had a fall risk care plan prior until 8/9/23 when R2 fell . R2's Physical Therapy Evaluation & Plan of Treatment with start date of 8/1/23 documents R2 requires partial/moderate assistance when moving from sitting to standing position and with transfers, and R2 has poor standing balance. R2's Nursing Note dated 8/9/2023 at 2:15 PM documents R2 fell at 9:35 AM in R2's room while staff was assisting R2 with dressing. R2 was standing next to the bed, took a step with R2's walker, R2's right leg buckled and R2 fell twisting R2's right leg. R2 complained of right ankle pain. R2's X-rays dated 8/9/23 at 2:17 PM documents the indication for the x-ray was a fall with right knee and ankle pain, R2 has a minimally displaced oblique intratracheal fracture of the medial malleolus with associated soft tissue swelling, a minimally displaced intra-articular fracture of the medial malleolus with associated soft tissue swelling, and a minimally displaced comminuted fracture of the lateral malleolus with associated soft tissue swelling. R2's Hospital After Visit Summary dated 8/9/23 documents R2 was evaluated in the emergency room for a fall, R2 had pain/swelling of right ankle and a diagnoses of right ankle bimalleolar fracture. The facility's Report to Illinois Department of Public Health Regional Office dated 8/11/23 documents on 8/9/23 at 9:35 AM R2 was standing while a CNA (V7) assisted R2 with dressing. R2 took a step forward, R2's right knee buckled, R2 fell to the floor and as R2 complained of right ankle pain while falling. R2 was transferred to the hospital, diagnosed with right ankle bimalleolar fracture, R2 is non-weight bearing to the right lower leg, and a soft cast was applied. The facility's investigation of R2's fall documents V7 and R2 were interviewed but does not document if a gait belt was utilized during this transfer/fall. On 8/14/23 at 11:06 AM V9 (Physical Therapist) stated on R2 required moderate assistance with 50% effort from staff for transfers prior to R2's fall. V15 stated R2 wore a knee brace and had a history of R2's knee buckling. V9 stated a gait belt should be used with hands on assistance during R2's transfer. On 8/14/23 at 10:59 AM V7 (CNA) confirmed V7 transferred R2 during the fall on 8/9/23. V7 stated V7 had R2 stand up from the bed. V7 asked R2 to take a step forward and R2 fell . V7 stated R2 was using R2's walker and a gait belt was on R2. V7 stated V7 was standing beside R2 but did not have hold of R2's gait belt when R2 fell . On 8/14/23 at 12:51 PM V8 (Nurse Practitioner) stated R2's right knee buckled and R2 fell during staff assist. V8 confirmed R2's right ankle fractures are consistent with a fall injury. V8 confirmed if the CNA had utilized a gait belt and had a hold on the belt it could have prevented R2's fall. On 8/14/23 at 2:07 PM V2 (DON) stated gait belts should be used each time staff assist with transfers or walking with a resident who is not able to self-ambulate. V2 stated staff should have a hold on the gait belt if the resident is unsteady or requires one assist. V2 confirmed with R2's history V7 (CNA) should have held onto R2's gait belt. V2 stated V7 had turned her back to R2 during the transfer and V2 would have had R2 sit down to assist with dressing. V2 stated R2 was educated not to take a step without staff assistance for the fall intervention. V2 stated R2 is alert and oriented to person, place, time, and situation and V2 did not ask R2 about R2's fall history upon admission. V2 stated the referral and hospital records are reviewed to determine fall history. V2 confirmed R2's 7/31/23 fall risk assessment does not document R2's history of falls and confirmed this would change R2's fall risk score placing R2 at a higher risk for falls. At 4:00 PM V2 stated the nurses are supposed to initiate/document the baseline care plan and fall interventions as part of the admission assessment. V2 confirmed R2's baseline admission care plan was incomplete and did not document R2's fall risk and interventions. On 8/14/23 at 3:04 PM V14 (MDS Coordinator) stated V14 reviews hospital documentation and talks to the resident to determine fall history upon admission. V14 confirmed R2's MDS does not identify R2's falls prior to admission. On 8/14/23 at 3:40 PM V1 (Administrator) stated V1 conducted R2's fall investigation. V1 stated R2 told V1 that R2 was standing with the walker and V7 was helping R2 dress. R2 took a step forward, R2's knee buckled, R2 felt R2's right ankle turn funny during the fall and R2 had right ankle pain. V1 stated V1 interviewed V7 and R2 regarding the fall and V1 did not see documentation that a gait belt was used during R2's transfer/fall. 3.) R3's MDS dated [DATE] documents R3 admitted to the facility on [DATE], has moderate impaired cognition, and requires extensive assistance of one staff person for toileting and two staff for transfers. R3's Fall Risk assessment dated [DATE] documents R3 has had four or more falls within the last three months and is at risk for falls with a fall risk score of 16. There are no prior documented Fall Risk Assessments in R3's medical record. R3's Care Plan revised on 7/14/23 documents R3 is at risk for falls but does document R3's falls since admission or the use of chair and bed alarms. This care plan includes interventions the use of a fall mat and bed in low position initiated on 6/1/23. There are no documented interventions after 7/14/23. R3's Nursing Notes document the following: On 7/1/23, 7/3/23, 7/4/23, 7/6/23, and 7/9/23 R3 was using bed and chair pressure sensor alarms. On 7/28/2023 at 6:00 AM R3 was found lying on R3's bottom next to the right side of R3's bed. R3 did not have any injuries. There is no documentation to indicate the positioning of R3's bed or if a fall mat and pressure sensor alarms were in place. On 7/29/23 at 9:40 AM R3 had an unwitnessed fall in R3's room and was found by housekeeping staff on hands and knees on the fall matt beside the bed in low position. R3 had no injuries and there is no documentation that a sensor alarm was in place or sounding at the time of R3's fall. On 7/30/2023 at 8:15 PM R3 was heard yelling help. Staff went to R3's room and found R3 lying face down on the fall mat covered in urine. R3 had no injuries and R3's urostomy bag was leaking and changed. There is no documentation to indicate a fall mat or sensor alarms were in place. R3's Fall Investigation dated 7/28/23 provided by V2 (DON) documents R3 was last checked around 5:00 AM. R3 was confused thinking R3 was at home and the back door was open and was re-oriented by the nurse. The root cause of the fall was confusing/possibly dreaming and the intervention was to reorient R3 to location. There is no documentation to indicate what R3 was doing when last observed at 5:00 AM, when R3's urostomy was last emptied/checked, the positioning of R3's bed, or the use of sensor alarms and a fall mat. R3's Fall Investigation dated 7/30/23 provided by V2 documents R3's bed sensor alarm was off. The root cause of the fall was R3 climbed out of bed and the urostomy bag was off, and R3 was disoriented. The intervention was to check the urostomy bag more frequently and staff were educated on bed alarm activation when R3 is in bed. There is no documentation that R3's fall on 7/29/23 was investigated. On 8/14/23 at 12:27 PM R3 was sitting in a wheelchair in R3's room. There was a pressure sensor alarm on the back of R3's wheelchair and on R3's bed. On 8/14/23 at 2:07 PM V2 stated R3 fell on [DATE] and 7/30/23. V2 confirmed R3's 7/28/23 fall investigation does not document fall interventions that were in place at the time of R3's fall. V2 stated we recently transitioned to a different style of incident reports, we used to use investigation forms filled out by the nurse. V2 was unable to locate this form for R3's 7/28/23 fall. V2 stated R3's fall interventions include a fall matt, low bed, bed alarm, chair alarm, and gripper socks. V2 stated R3's bed alarm did not sound when R3 fell on [DATE], and the alarm had not been activated. V2 stated staff were educated on bed alarm activation after R3's fall. V2 stated fall interventions should be documented on the care plan. V2 confirmed R3's care plan does not include any fall interventions after 7/14/23 or the use of bed/chair alarms. V2 stated V2 was unaware that R3 had fallen on 7/29/23 and confirmed there is no fall investigation to identify a root cause and post fall interventions. On 8/17/23 at 9:45 AM V2 stated fall risk assessments are completed upon admission and quarterly. At 10:18 AM V2 stated R3 did not have any fall risk assessments completed prior to 7/30/23 and that will have to be an educational piece for the staff since they were not used to doing all the extra charting/assessments. The facility's undated User Defined Assessment protocol documents to complete Fall Risk Assessments upon admission, quarterly, and after each fall. The facility's Fall Prevention Program dated 11/21/17 documents the following: The program includes determining the resident's needs by assessing fall risk, appropriate interventions will be implemented, and assistive devices will be utilized, as necessary. Care plans will include risk, interventions, preventative measures, and address each fall. The Fall Risk Assessment will be completed upon admission. The use of transfer conveyances will be used during transfers in accordance with the resident's care plan. The facility's Transfers-Manual Gait Belt and Mechanical Lifts dated as revised 1/19/18 documents the resident's transfer status will be assessed on an ongoing basis and will include the resident's mobility, weight bearing status, and cognition. Transfer status is categorized as independent, one person with 25% or less assistance from staff with use of gait belt, two-person (only when use of mechanical lift is not possible), sit to stand lift with two staff, and full mechanical lift with two staff. The care plan will include the resident's transfer and lifting needs. This policy documents the use of a gait belt is mandatory when performing physical assist transfers.

Based on observation, interview, and record review the facility failed to develop and implement fall interventions to prevent falls and injury for three of three residents (R1, R2, R3) reviewed for falls in the sample list of three. This failure resulted in two falls for R1 who sustained a Proximal closed fracture of Left Humerus and Intramedullary Component Crosses Proximal Femur Fracture, and R1 being admitted to the hospital. Findings include: The facility's Fall Assessment and Management policy with a revised date of 4/2019 documents, It is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned. Procedure: 1. Fall Risk and Planning Assessment A. Upon admission/readmission, a Fall Assessment will be completed based on the initial admission nursing assessment and the resident's history. B. Each resident will be assessed using the Minimum Data Set (MDS) upon admission, quarterly and with any significant change assessment. C. The potential for falls will be care planned when appropriate, based on the results of the Fall Risk Assessment. The interdisciplinary care plan will be person centered to reflect the specific needs and risk factors of the resident. The facility's Personal Alarms policy dated 12/1/05 documents, Objective: 1. A means of alerting resident and/or staff of a potentially harmful situation. Policy: 1. Personal alarms are used in this facility to alert the resident and/or staff when the resident is in danger of potentially harming himself/herself or others. If the resident is alert and oriented this alarm is used as a cue to remind the resident of a potential injury. Confused residents may not understand this alarm. In these instances, the personal alarm is used to alert the staff of the possibility of potential injury and to expedite their response. 3. The cognitive status is reflected on the MDS, and individual approaches are added to the care plan. The (medical-patient information system) (where used) also reflects the use of a personal alarm. The facility's Resident Assessment and Care Planning policy with a revised date of 11/2017 documents, The facility shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs, as well as preferences for care and goals. This comprehensive care plan is person centered and may be the continuation of the baseline care plan established within 48 hours of admission. 1. R1's Order Summary Report dated 5/9/22 documents diagnoses including Chronic Pain, Cervicalgia, [CONDITION(S)], Presence of Left Artificial Knee Joint, Age Related [CONDITION(S)], [NAME] Syndrome, [CONDITION(S)], Fusion of Spine Cervical Region, Primary Generalized Osteo Arthritis, Metatarsalgia Left Foot, [CONDITION(S)] Arthritis, [CONDITION(S)], Displaced Comminuted Fracture of Shaft of Humerus Left Arm and Displaced Intertrochanteric Fracture of left Femur. R1's Admission Minimum Data Set (MDS) dated [DATE] documents R1 had moderately impaired cognition, required limited assistance of one staff member physical assistance for bed mobility, transfers, walking and toileting. R1's balance was not steady but able to stabilize without staff assistance. R1 had impairment of one lower extremity on one side and used a walker and wheelchair. The Care Area Assessment Summary (CAAs) documents that falls were a triggered area and should have been addressed in the care plan. R1's Care Plan dated 1/11/22 only documents R1 was re-admitting to long term care placement and Social Services was to monitor adjustment back to long term placement. There is no further Care Plan on this date. R1's MDS dated [DATE] documents R1's transfer status had declined to extensive assistance of one staff physical assist. There was still no Care Plan or interventions developed and initiated at that time for falls or any other area. R1's Fall Risk assessment dated [DATE] documents R1 was at a moderate risk for falling. R1's Fall Risk assessment dated [DATE] documents R1 was at a high risk for falling. There was still no Care Plan or interventions developed at this time to help prevent falls or injuries from falls. R1's Fall Occurrence Report dated 4/11/22 at 4:15 AM, documents R1 was found sitting on the floor by the bed by a CNA (Certified Nursing Assistant). R1 was only oriented x (times) 1 and was readmitted to the facility on [DATE] after hospital stay for [CONDITION(S)] and Altered Mental Status. This report documents that R1 had a bed alarm, but the alarm was not sounding when R1 was found on the floor. This report documents that staff continued the low bed for R1 and they were to ensure that the alarm was working. R1's Fall Occurrence Report dated 4/11/22 at 5:30 AM, documents that a CNA heard a noise and went into R1's room and found R1 sitting on the floor at the foot of the bed. This report documents R1 was confused and stated R1 was looking for R1's keys to pick up R1's children. R1 complained of pain to buttocks and left hip/thigh area. R1 was sent to the hospital. This report documents that R1's bed alarm was again not sounding. This report documents that R1 returned from the hospital with a diagnosis of Proximal Closed Fracture of Left Humerus and had a sling in place. R1 still complained of hip pain and was seen in the facility by the Nurse Practitioner (NP) and the NP sent R1 to the hospital again for more x-rays. This report documents R1 returned with diagnosis of Intramedullary Component Crosses Proximal Femur Fracture. This report documents the bed alarm was replaced and a perimeter mattress was placed on R1's bed. R1 still did not have a Care Plan in place with interventions documented to help prevent falls and injuries. On 5/9/22 at 10:39 AM, R1's bed alarm pressure mat cord was not plugged in to the alarm box. There was also a severed cord laying on the floor under R1's bed. On 5/9/22 at 11:42 AM, V3 (Agency Registered Nurse/RN) confirmed the pressure pad alarm cord was not plugged into the alarm box. V3 stated it appears to have gotten pulled out. V3 confirmed that the severed cord was R1's call light cord. V3 pressed on R1's call light pressure pad and it did not sound or light up outside of the room. V3 was unsure how long the bed alarm or the call light were not functioning. On 5/11/22 at 9:05 AM, V4 (Agency RN) confirmed V4 was the nurse taking care of R1 the morning that R1 had both falls on 4/11/22. V4 stated that it looked like R1 slid out of bed. V4 stated that they checked the bed alarm to see if it was functioning because it was not sounding. V4 stated after this fall that V4 made sure the bed was in the lowest position, that R1 had nonskid socks on and that the bed alarm was functioning. V4 stated that about an hour later R1 fell again. V4 stated that V5 (Certified Nursing Assistant/CNA) found R1 on the floor. V4 stated that R1 recently returned from the hospital and had increased confusion. V4 stated R1 complained of leg and hip pain after the second fall so V4 sent R1 to the hospital. V4 stated that R1 came back, and the hospital said that R1 had a broken arm. V4 stated R1 did not complain of any arm pain only hip and leg pain. On 5/11/22 at 12:15 PM, V13 (Nurse Consultant) confirmed that R1 only had one page of a care plan initiated on 1/11/22 for re-admission. V13 confirmed that was all that they had for a Care Plan for R1 until 4/15/22 after the falls with fractures. R1's hospital radiology report dated 4/11/22 at 7:19 AM documents x-ray of Humerus Left, and impression from x-ray documents, Comminuted fracture of left humeral neck extending into the head. R1's hospital radiology report dated 4/12/22 at 2:35 AM, documents an x-ray of the pelvis and femur left side. This report documents the history as (R1) fell yesterday, worsening left leg/hip pain. This report documents the impression as nondisplaced intertrochanteric fracture of left femur. On 5/11/22 at 2:03 PM, V11 (R1's Physician) and V12 (R1's Nurse Practitioner) confirmed R1's fall from the bed would have caused the fractures. V11 stated that R1 had very soft bones from long term steroid use for R1's [CONDITION(S)] Arthritis. V11 stated that when R1 went to the hospital after the second fall the hospital only completed an x-ray of R1's shoulder. V11 stated that they did not x-ray the hip or leg. V12 stated that V12 saw R1 after R1 returned from the hospital and R1 still complained of leg/hip pain so V12 stated V12 sent R1 to a different hospital for x-rays of the left hip and left leg. V11 stated that this hospital completed a CT (Computerized Tomography) of the entire left leg. V11 stated that R1 previously had a knee replacement on the left leg that now shows a fracture in the femur. V12 stated that R1 had a pressure bed alarm in place prior to these two falls but after the second fall they placed a concave mattress on R1's bed. V11 stated that with R1's soft bones R1 would have probably had a fracture no matter what kind of fall. V11 stated that the hospital stated that R1 had extremely osteoporotic bones. On 5/11/22 at 2:18 PM, V5 (CNA) stated that V5 remembers R1's falls on 4/11/22. V5 stated that R1 was very confused that morning. V5 stated that it looked like R1 just slid out of bed with the first fall. V5 stated that the bed alarm was not sounding even though R1 was on the floor. V5 stated that they got R1 back in bed and checked R1's vital signs. V5 stated that V5 had other resident's that V5 had to take care of so V5 went to do that. V5 stated V5 heard a crash noise. V5 stated that it appeared that R1 climbed over the foot of R1's bed and came to a rest on R1's bottom on the floor at the foot of the bed. V5 stated that R1's bed alarm was not sounding again with this fall. V5 stated that they replaced the entire alarm, including the pressure pad and the alarm box. V5 stated that after the first fall they checked the alarm and tried to reorient R1 as to where R1 was. V5 confirmed they did not initiate anything new at that time. On 5/11/22 at 3:20 PM, V1 (Administrator) confirmed there was no documented interventions in place to help prevent falls and injuries for R1 prior to R1's falls with fractures. 2.) R2's Order Summary Report dated 5/9/22 documents diagnoses including Epileptic Syndromes with Complex Partial Seizures, Alzheimer's Disease, Dementia in other Diseases Classified Elsewhere with Behavioral Disturbance, Difficulty Walking and Unsteadiness on Feet. R2's MDS dated [DATE] documents R2 has severe cognitive impairment, requires extensive assistance from one staff for bed mobility and transfers and limited assistance from one staff for walking in R2's room and toileting. This MDS documents R2's is not steady and can only stabilize with staff assistance for surface-to-surface transitions. R2's Care Plan dated 7/18/19 documents R2 has had falls related to weakness, unsteadiness and new onset of seizures and has a history of falls. This Care Plan documents an intervention dated 2/22/21 that R2 has a bed alarm at night to remind R2's self to call for help when room is dark. R2's Fall Risk assessment dated [DATE] documents R2 is at high risk for falling. R2's Fall Occurrence Report dated 2/15/22 at 12:00 PM, documents that R2 was found on the floor in R2's room sitting on R2's buttocks with back leaning against the wall. This report documents no injuries. This report documents R2's chair alarm, that was not documented on the Care Plan as an intervention, was not sounding. R2's Fall Occurrence Report dated 3/5/22 at 11:50 PM, documents R2 was found on the floor in the hallway behind a recliner that R2 had been sitting in. This report documents that the chair alarm was not sounding and that the CNA did not turn the chair pressure alarm on. R2's Care Plan does not document a new intervention to help prevent falls and injury after this fall on 3/5/22. On 5/9/22 at 10:47 AM, V6 (CNA) was in the bathroom with R2. After finishing in the bathroom with R2, V6 turned on R2's pressure pad alarm in R2's wheelchair. On 5/11/22 at 12:15 PM, V13 (Nurse Consultant) confirmed there is no new intervention on R2's Care Plan after the 3/5/22 fall. 3.) R3's Order Summary Report dated 5/9/22 documents diagnoses including [CONDITION(S)], [CONDITION(S)], Unspecified Symptoms and Signs Involving Cognitive Functions and Awareness and Delusional Disorders. R3's MDS dated [DATE] documents R3 is severely cognitively impaired, requires extensive assistance of two staff for bed mobility and transfers, extensive assistance of one staff for toileting and R3 did not ambulate. R3's Care Plan dated 8/16/19 documents R3 had an actual fall related to weakness and activity intolerance due to [CONDITION(S)], use of diuretic, poor safety awareness, believes self-able to ambulate and [CONDITION(S)] medication. There are several interventions listed for 2019 and 2020. There are no interventions listed for 2022 until 4/21/22, a month after R3 fell on [DATE]. R3's Fall Occurrence Report dated 3/19/22 at 7:00 PM, documents R3 was found on the floor, laying on R3's back beside the bed. The pressure pad alarm in the bed was not sounding. No interventions were developed or implemented after this fall. There were interventions added to the Care Plan on 4/21/22. On 5/11/22 at 3:20 PM, V1 (Administrator) confirmed there was no new intervention developed or implemented after R3's fall on 3/19/22 until 4/21/22.

Based on interview and record review, the facility failed to safely transfer and ambulate a resident (R12) from the toilet. This failure resulted in R12 falling and sustaining a left hip fracture, an extensive ear laceration, subdural hematoma and a subarachnoid hemorrhage. R12 is one of five residents reviewed for falls in the sample of 73. Findings include: The Physician order [REDACTED]. The facility report titled "Fall Log" dated February 2015, documents R12 falling on 2/23/15, 2/24/15 and 3/19/15. The facility "Occurrence Reports" dated 2/23/15 and 2/24/15 document R12 falling in the bathroom on both dates. The 2/24/15 report documents that R12 is having increased confusion and has an elevated temperature with possible underlying infection. The facility transfer report dated 2/24/15 documents R12 going out to the hospital for falling and hitting his head, increased confusion, tremors and elevated temperature. The facility Occurrence Report for R12's fall dated 3/19/15, documents that R12 was up ambulating in R12's room. This same report documents that the facility's Licensed Practical Nurse (E6) saw R12 and assisted R12 to the bathroom. E6 turned away from R12 at the sink to flush the toilet and R12 fell backwards and hit the wall and went to the floor. R12 sustained an extensive laceration to the left ear and complained of left hip pain. R12's Care Plan dated for February 2015 and March 2015 documents R12 at high risk for falls due to history of falls, gait and balance problems and predisposing diseases. The same Care Plan directs staff to use a gait belt when assisting R12 with ambulation, transfers and toileting. R12's Minimum Data Set ((MDS) dated [DATE] documents that R12 is an extensive assist with transfers and is unable to steady self without the help of staff. The MDS also documents R12 as moderately cognitively impaired. R12's Fall Risk assessment dated [DATE] assesses R12 at High Risk. R12's Medical Record containing the trauma hospital progress notes dated 3/20/15 through 3/26/15 document the following: Progress Note dated 3/20/15 states R12 being received from the local hospital with report of a brain Computed Tomography, demonstrating a subdural hemorrhage and an intracranial hemorrhage. R12 also suffered an extensive left ear laceration. Interim repair was performed at the local hospital prior to R12's transfer. R12 was also noted to have a left femoral neck fracture. R12 was received at the trauma hospital for the intracranial bleed and polytrauma. Oral and Maxillofacial Surgery was subsequently consulted for repair of R12's left ear laceration. R12 is alert and awake with questionable orientation, speech is difficult to follow. Radiology report dated 3/20/15 documents X-ray of left hip and pelvis, showing a left femoral neck fracture with varus angulation and displacement. Surgical repair of hip completed 3/20/15. R12 was discharged back to the facility on comfort measures only per the Discharge Transfer Form and Orders dated 3/26/15 The facility policy titled "Gait Belt Policy and Procedure" dated 6/15/09 states "It is the policy of this facility to provide a safe environment for all residents. Using gait belts enables the facility to better provide security for the resident during standard non-mechanical assisted weight bearing transfers and assisted weight bearing ambulation. Gait belt use reduces the potential for injury to both the resident and staff, and allows the most effective use of body mechanics. This belt is used as an assistive and safety device during non-mechanical assisted weight bearing transfers and assisted weight bearing ambulation. Gait belts will be used on all residents requiring non-mechanical assistance with transfers and/or ambulation......" On 3/31/15 at 12:30 pm E7 and E9 both Registered Nurses, stated that all residents needing assistance with transfers or ambulation must have a gait belt on them when assisted. E7 stated "That's our policy." On 4/1/15 at 9:30 am E2, Director of Nursing acknowledged that all residents needing assistance from staff for transfers and ambulation are to have a gait belt used by staff during assistance. E2 stated "(R12) was already up and walking when (E6) saw (R12), so (E6) went ahead and helped (R12). E6 should have called for a Certified Nursing Assistant to come with a gait belt once (R12) was in the bathroom. It may have prevented the fall, I don't know, but (R12) should have had a gait belt on."

Based on interview and record review the facility failed to keep R14 safe from falls during assistance with ambulation. Facility staff failed to maintain control of R14 by turning away from her and letting go of the gait belt which permitted R14 to fall to the floor. R14 sustained a fractured left hip. R14 is one of six residents sampled for falls on the sample of 15. Findings include: An "Occurrence Reporting to IDPH (Illinois Department of Public Health)" form dated 8-12-11 transmitted via fax to the State Survey and Certification Agency on the same date details an incident that occurred on 8-9-11. The report states "...resident lost balance while walking to bathroom, fell backwards, hitting (right) hip on footboard of bed, then fell on to floor on left side...(complaint of) pain to left leg after fall...transferred to (local hospital) for eval (evaluation)...negative x-ray results for fracture...received call from (local hospital) at (5:30 p.m.) on 8-10-11 of error in reporting...Res. (resident) noted to have non displaced fx (fracture) of L (left) femur..." A nurse's noted dated 8-10-11 in R14's record states "...IDT (interdisciplinary team) met regarding fall of 8-9-11. Root cause res ambulating to BR (bathroom) (with) 1 assist, gait belt, (and) walker. CNA (Certified Nurse Aide) reached to open bathroom door, res lost balance (and) fell . No injury..." E3, Assistant Director of Nursing stated on 2-23-12 at 10:45 a.m. that she conducted an investigation and found that R14 was being assisted to the toilet room and E16, Certified Nurse Aide let go of the gait belt around R14's waist to momentarily open the bathroom door and could not stop R14's fall to the floor. E3's investigative report dated 8-9-11 states that E16 was "...ambulating res. to BR moved around res to open BR door. let go of gait belt. while opening door res lost balance. CNA still within reach of res but unable to intervene when res fell (secondary to) quickness of fall..." R14's quarterly minimum data set completed 8-9-11 reflected that she was severely cognitively impaired and required limited assist of 1 person for transfers in her room. R14 was assessed as being incontinent and required total assistance from staff for all activities of daily living. R14 was assessed as being "not steady, only able to stabilize with human assistance" while moving from a seated to standing position, walking, moving on/off the toilet, and for surface to surface transfers. R14's 5-17-11 Care Plan in force at the time of the fall states R14 "At risk for falls r/t (related to) impaired mobility, weakness, and confusion". A goal is stated as "(R14) will transfer safely with 2ww (wheeled walker) and 1 assist..." An intervention includes to "Assist to toilet..." R14's 8-8-11 Fall Risk Assessment documents that R14 was assessed as being a moderate fall risk. A diagnostic imaging report dated 8-10-11 and completed in the hospital emergency room reflected the following: "...left hip prosthesis in place. Nondisplaced oblique fracture of the proximal shaft of the left femur just below the level of the greater trochanter below the intertrochanteric region almost at the base of the greater trochanter..."