Every finding on record at Goldwater Care Marseilles

Based on observation, interview, and record review, the facility failed to ensure weekly skin assessments were completed, failed to timely identify and assess skin breakdown, failed to implement ordered pressure relieving interventions, and failed to ensure prescribed wound treatments were consistently completed to 1 of 3 residents (R1) reviewed for pressure injury in the sample of 3. These failures resulted in a facility acquired pressure injury to R1's left heel which was identified at a stage 3 pressure injury. The findings include:R1's Physician Order Sheet (POS)dated 8/26 shows R1 had diagnoses that include polyneuropathy and diabetes mellitus. The same POS shows R1 has a wound treatment order of Cleanse with NS apply Medi honey and calcium alginate, apply foam dressing daily, secure with ABD pad daily and as needed (PRN) when soiled or removed.R1's facility assessment, dated 5/28/26, shows R1 is alert and able to verbalize his needs. The same facility assessment shows R1 has no behaviors of rejection of care.R1's care plan, dated 11/12/25, shows R1 needs assistance with personal care, transfers and bed mobility.R1's Braden Scale, dated 7/22/26, shows R1 was at risk for skin breakdownR1's weekly skin observation assessments, dated 5/26/26, shows R1 had no skin issues, skin was intact.R1's skin observation assessment, dated 6/30/26, documents, wound on the plantar surface ball of the patient's foot. There were no other skin assessments documented in the month of June until the 6/30/26.R1's progress notes, dated 6/30/26, shows, the writer was notified by an aide who was giving the resident a shower at the time. During assessment, an open area was observed on the plantar surface of the left foot. Area cleansed and dressing applied.R1's Wound Evaluation and Management summary, dated 6/30/26 by V8 (Wound Physician) shows, Patient found to have a pressure wound to his left heel, likely from resting it on the floor while in his wheelchair. Stage 3 to left heel measuring 3.2 x 2.5 x 0.2 centimeters (cm) with moderate serous drainage. The same document shows an order to float heels in bed.R1's wound evaluation and management summary dated 7/7/2026 by V8 (Wound Physician) show an order of float heels use (specialized) boots (or similar), in bed and while in chair.On 8/14/26 at 9:15 AM, R1 was in bed, alert and pleasant. R1's both heels were lying directly on the bed. R1 did not have the pressure relieving heel boots on. R1's heels were not off loaded.On 8/14/26 at 10 AM, R1 was sitting in his wheelchair. Both of R1's feet were resting directly on the floor. R1 did not have pressure relieving heel boots on. R1 said he does not recall having any boots. R1 said he has a wound to his left heel. At 10:15 AM, V3 (Assistant Director of Nursing-ADON) was in R1's room to perform treatment. R1 was in bed. V3 performed wound treatment to R1's left heel, cleansed wound, applied Medi honey to wound, with calcium alginate, covered with a dressing, secured with ABD pad and tape. V3 then applied socks to R1's left heel. V3 did not offload R1's left heel. It was positioned directly against the mattress. R1 had no pressure relieving boots on. At 11 AM and at 2PM, R1 was in bed, both feet were resting firmly in bed. No pressure relieving boots on.At 3 PM, both V6 and V7 (both Agency Certified Nursing Assistants-CNAs) said they did not know R1 was supposed to wear heel protectors; all they were told was to monitor R1.Review of R1's Treatment Administration Record (TAR), dated July 2026, shows R1's TAR was blank (not signed) 7/2/26, 7/10/26, 7/12/26 and 7/17/26. R1's July TAR did not also show that the ordered pressure reliving boot was carried out. Review of R1's TAR in August 2026 shows R1's treatment was blank or not signed last 8/4/26.R1's August 2026 TAR did not show the ordered pressure reliving boot was carried out. On 8/14/26 at 1:15 PM, V3 (ADON) said R1's open area to his left heel was facility acquired. V3 confirmed in the month of June 2026, R1's skin assessment was only done once, on 6/30/26, when it was discovered R1 already had an open area to his left heel at stage 3. There were no other skin assessments done. V3 said residents' skin should be assessed weekly because they help identify skin changes early, allowing timely interventions. V3 also said when wound treatments are completed, the Nurse who did the treatment signs the (TAR) to show the treatment was done. If there was no signature (or blank) then the treatment was not done. V3 said was an issue before, wound treatments were not being done, so she had been doing the treatments when she was at the facility. V3 said R1's (specialized) boot was not carried out in R1's medical record so it was not applied to R1 since it was ordered last 7/7/26.On 8/14/26 at 2:45 PM, V2 (Interim Director of Nursing) said skin assessments should be done at least weekly to identify skin issues early. Residents wound treatment needs to be done as ordered to promote wound healing. Pressure relieving interventions should be implemented as ordered. V2 said R1's (specialized) boot will be ordered today, and it will be carried out in R1's TAR. R1's latest wound evaluation Management summary, dated 8/11/26, shows stage 3 pressure to left heel measuring 2.9 x 2.8 x0.1 cm with heavy serous drainage. Off load heels, use (specialized) boots, in bed and in wheelchair.On 8/14/26 at 2PM, V8, Wound Physician, said R1's left heel pressure injury was acquired at the facility, likely from resting the heels directly to the floor or bed. That was why a pressure relieving boots were ordered to float the heels to prevent tissue damage. V8 said there has been times during his wound visits that R1 still had the old dressing applied to his heels indicating the ordered wound treatment was not consistently done. R1's wound measurements show slow healing. Treatments should be done to promote healing, prevent further complications, and prevent further deterioration of the wound.On 8/14/26 at 3PM, V1 (Administrator) said the facility has a lot of work to do with the facility's Wound and Skin program. V1 said the previous Nurse in charge of the program was no longer employed at the facility. V3 (ADON) was now in charge of the program. The facility policy entitled Pressure Ulcer Prevention shows, 2. inspect the skin several times daily during bathing hygiene and repositioning measures. 11. Use positioning devices or pillows/roll blankets to reduce pressure and friction shearing from heels toes as indicated.

Based on observation, interview and record review the facility failed to provide dressing changes to a scalp wound. This failure resulted in the wound increasing in size. The facility failed to follow physician treatment orders for a resident's non-pressure wound and failed to follow physician orders to schedule an orthopedic appointment for 3 of 37 residents (R50, R53, R59) reviewed for quality of care in the sample of 37. The findings include: 1.On 07/14/26 at 9:24 AM, R50 was sitting in his wheelchair in the dining room. R50 said he had a sore on his head. R50 removed his ball cap to reveal a foam dressing that was dated 7/9/2026. The dressing had visible dried drainage and was rolling on the edges. On 07/15/26 at 10:26 AM, V19 (Treatment Nurse) said R50 was seen on 7/7/26 by V29 (Wound Doctor) and had a skin graft done on his scalp wound. On 07/15/26 at 12:07 PM, V3 (Assistant Director of Nursing) removed the dressing from R50's scalp wound. The wound appeared red and irregular. V3 measured the wound to be 5.0 x 2.5 cm (centimeters). V3 said cleansed the wound and applied collagen pads and covered with a foam dressing. R50's Wound Progress Note dated 7/7/26 shows R50 has a non-pressure scalp wound measuring 1.0 x 3.5 x 0.1 cm. R50's Treatment Administration Record for July 2026 shows the most current order for R50's scalp wound is dated 5/24/26 and shows Right lateral scalp. Cleanse with normal saline. Pat dry. Apply iodosorb and collagen and cover with foam dressing. Change daily and as needed if soiled, saturated, or dislodges. On 07/15/26 at 12:52 PM, V29 said R50's wound is supposed to be changed daily. V29 said the increase in size of the wound could be due to maceration of the skin from the dressing being soaked and not changed as ordered. The facility's Skin Condition Assessment and Monitoring Pressure and Non-Pressure Policy dated 6/8/2012 shows Purpose: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries, and other non-pressure skin conditions and assuring interventions are implemented. 2. On 7/14/26 at 1:03 PM, R53 was sitting up in his wheelchair. R53's bilateral lower legs had patches of dry scaly skin present. R53 did not have any compression stockings on. R53 said that he has neuropathy in his feet and they are very painful. R53 said that his legs are very itchy and they sometimes put cream on them. R53 said that he does not recall every having any testing done on his legs. R53's Wound Evaluation and Management Summary dated 6/30/26 shows that he was seen for epidermal thickening/dyskeratosis of his bilateral legs and had hyperkeratosis, scaly patches of his left and right lower extremities. The treatment order shows to apply ammonium lactate cream twice a day for 30 days and initiate compression therapy to his legs to reduce scaling and build up. The report shows that a bilateral venous doppler and arterial doppler was recommended on 6/30/26. On 7/15/26 at 10:25 AM, V19 (Treatment Registered Nurse) said that when the wound physician saw R53 for his legs, he ordered an acid cream and compression stockings. V19 said that she relayed the information to the nurse practitioner to order but she does not know if it was ordered. V19 said that she did not know anything about dopplers needing to be done. V19 said that typically the wound physician will make recommendations and she would forward the recommendations to the nurse practitioner to order. On 7/15/26 at 12:50 PM, V29 (Wound Physician) said that he did see R53 and wanted the treatments done as he ordered. V29 said that the nurse that rounds with him is responsible for putting any new treatment orders in the system. On 7/15/26 at 12:03 PM, V10 (Nurse Practitioner) said that the wound care team puts in all of their own orders and she does not know anything about R53 needing dopplers ordered. On 7/15/26 at 8:53 AM, V4 (Regional Director of Operations) verified that R53 did not have any of the ordered treatments or dopplers done as ordered by the wound physician on 6/30/26. R53's July Treatment Administration Record does not show that ammonium lactate cream was ordered or applied. R53's Physician's Order Sheet did not show an order for compression therapy to his legs. The facility's Physician Orders-Entering and Processing Policy shows, Following a physician visit, a licensed nurse will check for any orders that require confirmation.The orders will be confirmed by the nurse and the instructions for the order will be completed. Verbal and Telephone orders will be documented as such in the electronic medical record. 3. On 7/13/26 at 10:47 AM R59 was sitting in her room with her roommate. R59 stated that she had a cyst in the back of her leg for over a month and there had been no follow-up. Resident stood up and asked Surveyor to look at it. Surveyor was unable to see anything but R59 stated it was very painful in the back on her right knee. R59 stated she had a sonogram that showed the cyst, but no one is doing anything about it. R59's Progress Notes dated 5/27/26 states, The resident had lower extremity Doppler completed this AM. Per tech the resident is negative for DVT (Deep Vein Thrombosis) but does have a Baker's Cyst noted behind (right) knee. No other findings. The writer will await the final report once read by the physician. R59's Physician's Order Sheet shows an order for: Order to Orthopedic Surgery for management of popliteal cyst dated 6/12/26. On 7/14/26 at 1:20 PM V13 (RN- Registered Nurse) stated, We did the initial assessment that showed the Baker's Cyst, and we were hoping it would heal on its own. We were giving her Tylenol and that was not strong enough, so we got an order for Norco and now we are waiting on an appointment for surgical removal. I will have to ask V11 (Scheduler/Medical Records) if she has heard anything yet. On 7/14/26 at 1:30 PM V11 stated, I don't know anything about R59 and an appointment. (V10- Nurse Practitioner) asked me about that yesterday. On 7/14/26 at 2:30 PM V10 stated, We did interventions hoping it would just resolve itself. We gave her Tylenol and then Norco. Then I wrote an order for the Orthopedic Surgeon Consult on June 12th. (Previous Employee) was supposed to make an appointment then (Previous Employee) passed it on to (V11) because (Previous Employee) is no longer here. I don't know if (V11) was actually trained on how to make the appointments or not but it has been quite a while since I wrote the order.

Based on observation, interview and record review the facility failed to have pressure ulcer prevention intervention in place and failed to follow pressure ulcer treatment orders for 2 of 5 residents (R50 and R53) reviewed for pressure ulcers in the sample of 37. This failure resulted in R53 developing pressure ulcers to his bilateral heels. The findings include:1.On 7/13/26 at 9:36 AM, R53 was lying in bed. R53's knees were bent and unable to be extend and his toes were pressing up against the foot board. R53's heels were pressing firmly into the mattress. R53's right heel was red/purple in color. R53 said that he is six feet tall and his bed is too small for him making it impossible to extend his legs straight. On 7/13/26 at 11:45 AM and 7/14/26 at 9:14 AM, R53 was lying in bed and his feet were in the same position and his heels were still pressing firmly on the mattress. On 7/14/26 at 1:03 PM, V14 (Registered Nurse) did an assessment to R53's heels. R53's heels were directly on the mattress. R53's bilateral heels were red/purple in color. R53 stated, It's because the bed is too small and I have to keep my knees bent which makes my heels dig into the bed. R53 said that his right heel is very painful. R53 said that he worries about getting wounds on his hands and feet because he is diabetic. On 7/15/26 at 10:55 AM, V19 (Treatment Nurse) did an assessment on R53's heels. R53 did not have pressure relieving boots on. R53's left heel was red/purple in color and R53's right heel was a dark purple color. V19 stated, This one (right heel) is definitely worse than the other. It is definitely a deep tissue injury. V19 said that last week he did not have any pressure ulcers on his heels but she got him a pair of pressure relieving boots and instructed staff to make sure that he was wearing them at all times. R53 said that his boots got lost somewhere last week and he kept telling the staff that he really needed them but they didn't seem to care. V19 said that the heel discolorations are from pressure on his heels. R53's Wound Evaluation and Management Summary dated 6/30/26 does not document that he has any pressure ulcers on his heels. R53's Braden Scale for Predicting Pressure Sore Risk dated 3/22/26 shows that he is at moderate risk for developing pressure ulcers. R53's Skin-Other Skin Condition Report dated 7/14/26 shows that he has a new skin concern. It shows that he has non-blanchable redness, mushy heels. R53's Care Plan shows that he needs substantial/maximal assist for bed mobility. R53's Care Plan does not document that he is at risk for pressure ulcers and does not have pressure ulcer prevention interventions documented. The facility's Pressure Ulcer Prevention Policy shows, Use Positioning devices or pillows, rolled blankets, etc. to reduce pressure and friction/shearing from heels, toes, and malleoli as indicated. 2. On 07/14/2026 at 9:24 AM, R50 was sitting up in his wheelchair in the dining room. R50 had visible wrap bandages on his legs and a bandage on the top of his right foot near his ankle. R50 said he has a sore on his foot from the bandages. At 9:27 AM, V30 Certified Nursing Assistant removed R50's right shoe and R50 had a square foam dressing dated 7/7/2026 that was visibly soiled with drainage. On 07/15/2026 at 10:26 AM, V19 Treatment Nurse said R50 has a pressure wound on the top of his foot. V19 said she rounds with the V29 Wound MD and then enters V29's treatment orders. V19 said she rounded with V29 last week on 7/7/2026. V19 said V29 did give treatment orders for R50's ankle pressure wound. V19 said she should have put the treatment orders into the system, and the orders should have been followed. V19 said R50's ankle wound should have been changed three times per week. R50's Treatment Administration Records (TAR) shows a treatment order for R50's right lower ankle wound that was discontinued on 7/7/2026. The same TAR does not contain current treatment orders for R50's right lower ankle wound. R50's Wound Progress Note dated 7/7/2026 shows Right Ankle stage 4 pressure wound. Dressing Treatment Plan: xeroform gauze apply once weekly and as needed. Then apply calcium alginate three times per week and as needed if saturated. Secondary Dressings: Foam silicone border dressing apply three times a week and as needed if saturated. The facility's Skin Condition Assessment and Monitoring Pressure and Non-Pressure Policy dated 6/8/2012 shows Purpose: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries, and other non-pressure skin conditions and assuring interventions are implemented.

Based on observation, interview and record review the facility failed to provide sufficient staffing to meet the needs of the residents. This failure has the potential to affect all 58 residents in the facility. The findings include:The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 7/13/26 showed a resident census of 58.From 7/13/26-7/15/26, during the onsite annual survey, concerns related to a lack of wound care, activity of daily living cares, infection control practices, and medication administration errors were observed due to a lack of staff. On 7/13/2026 at 11:45 AM, R54 had multiple white whiskers growing across the entire width of her chin. R54 stated, It is awful and there is only one CAN (certified nursing assistant) that will shave me. On 07/14/2026 at 9:24 AM, R50 was sitting in his wheelchair in the dining room. R50 said he had a sore on his head. R50 removed his ball cap to reveal a foam dressing that was dated 7/9/2026. The dressing had visible dried drainage and was rolling on the edges. R50's Treatment Administration Record for July 2026 shows the most current order for R50's scalp wound is to change his dressing daily and as needed if soiled. On 07/15/2026 at 12:52 PM, V29 Wound Physician said R50's wound dressing is supposed to be changed daily. On 7/14/26 at 1:03 PM, R53's bilateral lower legs had patches of dry scaly skin present. R53 did not have any compression stockings on. R53 said that he has neuropathy in his feet and they are very painful. R53 said that his legs are very itchy and they sometimes put cream on them. R53's records showed R53 was seen by his physician on 6/30/26 with new treatment orders to apply ammonium lactate cream twice a day for 30 days and initiate compression therapy to his legs to reduce scaling and build up. The report shows that a bilateral venous doppler and arterial doppler was recommended on 6/30/26. On 7/15/26 at 8:53 AM, V4 (Regional Director of Operations) verified that R53 did not have any of the ordered treatments or dopplers done as ordered by the wound physician on 6/30/26. R53's July Treatment Administration Record does not show that ammonium lactate cream was ordered or applied. R53's Physician's Order Sheet did not show an order for compression therapy to his legs. On 07/14/2026 at 9:24 AM, R50 was sitting up in his wheelchair in the dining room. R50 had visible wrap bandages on his legs and a bandage on the top of his right foot near his ankle. R50 said he has a sore on his foot from bandages. At 9:27 AM, V30 Certified Nursing Assistant removed R50's right shoe and R50 had a square foam dressing dated 7/7/2026 that was visibly soiled with drainage. On 07/15/2026 at 10:26 AM, V19 Treatment Nurse said she rounded with V29 Wound Physician last week on 7/7/2026. V19 said V29 did give treatment orders for R50's ankle pressure wound. V19 said R50's ankle wound should have been changed three times per week. On 7/13/26 at 1:45 PM, R35 had a PICC line in her left upper arm. The PICC line dressing was dated 7/2/26. The edges of the dressing were loosened. On 7/14/26 at 9:43 AM, R35 dressing to her PICC line was still dated 7/2/26. On 7/14/26 at 2:03 PM, V3 (Quality Assurance Nurse) said that PICC line dressing changes should be done weekly by the nurse. R31's Post Acute Care Transition Document dated 6/13/26 shows a diagnosis of wound infection. The document shows to start cephalexin (antibiotic) 500 milligrams (mg) three times a day and doxycycline hyclate (antibiotic) 100 mg two times a day for 26 days for an infection of the skin and/or soft tissue with the last doses given on 6/13/26 at 8:59 AM. R31's June Medication Administration Record shows that doxycycline 100 mg twice a day was ordered to start on 6/13/26 at 6:00 PM. R31 did not receive that dose. The MAR shows that R31 received one dose on 6/14 at 9:00 AM, one dose on 6/15 at 8:00 PM, one dose on 6/16 at 8:00 AM and then did not receive any more doses until 6/19 at 8:00 PM. R31's July MAR shows that she received Doxycycline twice a day until 7/13/26 at 8:00 AM. R31's June MAR shows that Cephalexin 500 mg three times daily was ordered to start on 6/13/26 at 10:00 PM. R31 did not receive that dose. The MAR shows that R31 received one dose on 6/14/26 and then did not receive another dose until 6/16 at 1:00 PM. The MAR shows that R31 did not receive a dose on 6/20 at 1:00 PM and 5:00 PM. The MAR shows that R31's last dose of Cephalexin was given on 6/25/26 at 9:00 AM. R31's July MAR does not show that she received any does of Cephalexin. R31's June and July MAR shows that she received 23 doses of Cephalexin out of the 78 doses that were ordered. A facility list dated 7/13/26 showed the facility did not have a Director of Nursing (DON) from 5/12/26-6/28/26. On 7/14/26 at 11:08 AM, V4 Regional Director of Operations confirmed the facility had been without a DON during that time. On 7/13/26 at 10:23 AM, V4 Regional Director of Operations stated the facility did not have an Infection Preventionist and had been without one for an unknown amount of time. On 7/15/26, V4 stated she was unable to provide any consistent records to show the facility had an antibiotic stewardship program or were monitoring resident infections in the facility from July 2025-July 2026. On 7/15/26 at 10:15 AM V4 Regional Director of Operations stated the facility's nurse and CNA staffing ratios are based on resident census and acuity. V4 stated the facility is to provide enough staff to meet the needs of the residents. The facility's Facility Assessment Tool dated 5/30/26 showed the facility will provide sufficient staff to meet residents needs, preferences, and acuity of care.

Based on interview and record review the facility failed to employ a full-time Director of Nursing (DON). This failure has the potential to affect all 58 residents in the facility.The findings include:The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 7/13/26 showed a resident census of 58. A facility list dated 7/13/26 showed the facility had four different Directors of Nursing, from 7/4/25-6/29/26, due to staff turnover. The list showed the facility did not have a DON from 5/12/26-6/28/26. On 7/14/26 at 11:08 AM, V4 Regional Director of Operations stated the facility had just recently hired V2 DON two weeks ago. V4 stated the facility had been without a DON for over a month prior to hiring V2 DON. V4 stated a facility must have a DON because the DON is ultimately responsible for all resident cares and overseeing everything related to resident cares such as wounds and infections. The facility's Facility Assessment Tool dated 5/30/26 showed the facility will provide a full time DON to oversee all resident cares.The facility's Director of Nursing Job Description dated 5/2/17 showed, The primary purpose of the Director of Nursing position is to plan, organize, develop and direct the overall operation of our Nursing Department in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility, and may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times.

Based on interview and record review the facility failed to ensure the required Quality Assessment and Assurance (QAA) committee members attended the facility's QAA meetings. This failure has the potential to affect all 58 residents in the facility.The findings include:The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 7/13/26 showed a resident census of 58. The facility's QAA meeting member sign-in sheets dated July 2025-June 2026 were reviewed. The sheets dated 7/23/25, 8/29/25, 9/30/25,11/24/25, and 2/24/26 showed the facility's Medical Director did not attend the meetings, in house or via phone. The sheets dated 9/30/25, 11/24/25, 2/24/26, and 5/26/26 showed the facility's Infection Preventionist did not attend the meetings. The sheets dated 7/23/25, 8/29/25, 9/30/25, 2/24/26, and 5/26/26 showed the facility's wound nurse did not attend the meetings.On 7/14/26 at 11:08 AM V4 Regional Director of Operations stated all the facility's department heads, including the Infection Preventionist and wound nurse, and the Medical Director are required to attend the QAA meetings either in person or by phone. V4 stated the facility had not had an Infection Preventionist for a while due to staff turnover. V4 stated, The department heads and our Medical Director each see residents in a different way so it's important these members attend the meetings for the well-being of each resident. On 7/14/26 at 11:25 AM, V9 Social Services Director stated the facility's Medical Director had not attended any QAA meetings, in person, for a while. The facility's QAA policy dated 2026 showed the QAA committee of the nursing center will develop a culture that involves leadership-seeking input from nursing center staff, residents, their families, and other stakeholders; encourages and requires staff participation in QAA initiatives when necessary; holds staff accountable for taking ownership and responsibility of assigned QAA activities and duties.

Based on observation, interview and record review the facility failed to have an infection surveillance program in place to track and trend resident infections in the facility. This failure has the potential to affect all 58 residents in the facility. The facility failed to ensure staff donned PPE (personal protective equipment) prior to entering the room of a resident on isolation. The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident. The findings include: 1.The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 7/13/26 showed a resident census of 58. On 7/13/26 at 1:00 PM, V3 Assistant Director of Nursing (ADON) stated the facility currently did not have an Infection Preventionist (IP) overseeing the resident immunizations/vaccine program, resident infections, or antibiotic stewardship. V3 stated she was unsure how long the facility had been without an IP as V3 had just been hired by the facility two weeks prior. V3 stated she did not know if any resident illness outbreaks had occurred in the facility from July 2025-July 2026. V3 stated she was also not 100% sure which residents currently had infections that required isolation. On 7/14/26 at 9:14 AM, V4 Regional Director of Operations stated the facility was currently without an Infection Preventionist and had been without one for quite some time. V4 stated she was unsure when the facility last had an IP. When V4 was asked any staff, in house, had been monitoring resident infections and antibiotic use (from July 2025-July 2026), V4 stated, No I don't think so. I can't find any records, showing anyone was monitoring infections, for 2026 at all. V4 stated she would call the facility's corporate office to see if they had any monthly records showing infections in the facility. When V4 was asked if she knew if the facility had any illness outbreaks in 2026, V4 stated, I don't know. I can't find any records. On 7/14/26 at 10:16 AM, V4 showed this surveyor facility monthly infection tracking records from July 2025-September 2025, December 2025, January 2026, and April 2026 however, V4 stated she received these records from corporate, and she was unsure if any staff in the facility had actually reviewed these records. V4 was unable to find records from October 2025, November 2025, February 2026, March 2026, May 2026 or June 2026. The facility's Infection Surveillance, Tracking and QA Reporting policy dated 2/14/28 showed, Purpose: To identify, monitor, track and report infections and monitor adherence to infection control practices. Infection Tracking includes but is not limited to: Completing Infection Tracking Log for all resident with an infection and/or treated with antibiotics. Monitor for trends by unit/location, clusters of same infection types/organisms, outbreaks, employee illnesses. Track resident and staff outbreaks. 2. On 7/14/26 at 9:43 AM, R35 was laying in bed. R35 had a PICC line in her left arm and had an indwelling urinary catheter. R35's room door did not have a sign on the door showing that she was on Enhanced Barrier Precautions (EBP). V21 and V22, Certified Nursing Assistants (CNAs) provided incontinence care to R35. V21 and V22 did not have a gown on. 3. On 7/13/26 at 11:35 AM, R31's room door had a sign on it that said she was on contact isolation. V23 (CNA) was in the room providing care to R31. V23 said that she assisted R31 to the commode, provided perineal care and assisted her back to her wheelchair. V23 said that she did not wear a gown during the cares. V23 stated, I thought it was just when she was contagious. It's been really busy today so I just didn't put it on. On 7/14/26 at 2:03 PM, V3 (Quality Assurance Nurse) said R31 should not be on contact isolation but should be on EBP due to having a pressure wound on her coccyx and an indwelling urinary catheter. V3 said that staff should wear gown and gloves when providing cares to any resident on EBP. R31's Care Plan shows that she has the need for EBP related to the presence of a chronic pressure ulcer stage 4 and due to use of a urinary catheter. The interventions include: Follow Enhanced Barrier Precautions per protocol. The facility Enhanced Barrier Precautions Policy shows, Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .EBP are indicated for resident with any of the following: .Chronic wounds and/or indwelling medical devices Examples: Pressure ulcers PICC lines urinary catheters EBP is employed when performing the following high-contact resident care activities .changing briefs or assisting with toileting.

Based on interview and record review the facility failed to maintain an antibiotic stewardship program. This failure has the potential to affect all 58 residents in the facility.The findings include:The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 7/13/26 showed a resident census of 58.On 7/13/26 at 1:00 PM, V3 Assistant Director of Nursing (ADON) stated the facility currently did not have an Infection Preventionist (IP) overseeing the resident immunizations/vaccine program, resident infections, or antibiotic stewardship. V3 stated she was unsure how long the facility had been without an IP as V3 had just been hired by the facility two weeks prior. V3 stated she was unsure if there was any staff member currently monitoring resident antibiotic usage in the facility. V3 stated she thought the facility used the McGeer Criteria identify infections and track antibiotic usage. On 7/14/26 at 9:14 AM, V4 Regional Director of Operations stated the facility was currently without an Infection Preventionist and had been without one for quite some time. V4 stated she was unsure when the facility last had an IP. When V4 was asked any staff, in house, had been monitoring resident infections and antibiotic use (from July 2025-July 2026), V4 stated, No I don't think so. I can't find any records, showing anyone was monitoring infections, for 2026 at all. V4 stated she would call the facility's corporate office to see if they had any monthly records showing infections in the facility. On 7/14/26 at 10:16 AM, V4 showed this surveyor facility monthly infection tracking records from July 2025-September 2025, December 2025, January 2026, and April 2026 however, V4 stated she received these records from corporate, and she was unsure if any staff in the facility had actually reviewed these records. These records showed resident infections in the facility and the prescribed antibiotics if applicable, however these records showed no documentation if the appropriate infections were cultured. V4 was unable to find records from October 2025, November 2025, February 2026, March 2026, May 2026 or June 2026. The facility's Antibiotic/Antimicrobial Stewardship Program policy dated 8/1/25 showed, This facility is dedicated to implementing an Antibiotic/Antimicrobial Stewardship program to reduce the unnecessary use of antibiotics. This program helps ensure that our residents get the right antibiotics at the right time for the right duration, and can improve individual patient outcomes, prevent deaths from resistant infections, slow antibiotic resistance, decrease Clostridium difficile infections, and reduce healthcare costs. The policy showed the Medical Director, Director of Nursing, Infection Control Coordinator and Consultant Pharmacist will implement the program. It showed data will be gathered each month related to antibiotic use and treatment of infections.

Based on interview and record review the facility failed to have to an Infection Preventionist in place to oversee the facility's infection control program. This failure has the potential to affect all 58 residents in the facility. The findings include:The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 7/13/26 showed a resident census of 58. On 7/13/26 at 1:00 PM, V3 Assistant Director of Nursing (ADON) stated the facility currently did not have an Infection Preventionist (IP) overseeing the resident immunizations/vaccine program, resident infections, or antibiotic stewardship. V3 stated she was unsure how long the facility had been without an IP. On 7/14/26 at 9:14 AM, V4 Regional Director of Operations stated the facility was currently without an Infection Preventionist and had been without one for quite some time. V4 stated she was unsure when the facility last had an IP. V4 stated the facility needs an Infection Preventionist so infections and outbreaks don't occur. An IP monitors resident infections. The IP is also responsible for monitoring antibiotic use. When V4 was asked any staff, in house, had been monitoring resident infections and antibiotic use (from July 2025-July 2026), V4 stated, No I don't think so. I can't find any records, showing someone was monitoring infections, for 2026 at all.The facility's QAA meeting member sign-in sheets dated July 2025-June 2026 were reviewed. The sheets showed the last time an IP attended a QAA meeting was in August 2025. The facility's Infection Prevention and Wound Care Nurse job description dated 5/2/17 showed the Infection Prevention Nurse will be responsible for implementing and overseeing infection prevention and control measures to ensure compliance with regulatory standards and well-being of our community.

Based on interview and record review the facility failed to administer the influenza vaccine to a resident during flu season. The facility failed to educate, offer, and administer pneumococcal immunizations to residents. These failures apply to 4 of 5 residents (R21, R22, R5, R32) reviewed for immunizations in the sample of 37.The findings include:R21's admission Record showed R21 was admitted to the facility on [DATE]. R21's immunization record dated 7/14/26 showed no documentation the facility educated, offered, or administered the pneumococcal immunization to R21.R22's admission Record showed R22 was admitted to the facility on [DATE]. R22's immunization record dated 7/14/26 showed no documentation the facility educated, offered, or administered the pneumococcal immunization to R22.R5's admission Record showed R5 was admitted to the facility on [DATE] (during flu season). R5's immunization record dated 7/14/26 showed no documentation the facility educated, offered, or administered the influenza or pneumococcal immunization to R5.R32's admission Record showed R32 was admitted to the facility on [DATE]. R32's pneumococcal vaccine consent form dated 12/10/25 showed R32 was educated on the vaccine and consented to receiving the vaccine. R32's immunization record dated 7/14/26 showed R32 had never received the pneumococcal vaccine in the facility.On 7/13/26 at 1:00 PM, V3 Assistant Director of Nursing (ADON) stated the facility currently did not have an Infection Preventionist (IP) overseeing the resident immunizations/vaccine program. V3 stated she was unsure how long the facility had been without an IP. V3 stated residents should be educated on and offered the pneumococcal vaccine upon admission to the facility. V3 stated residents should be educated on and offered the influenza vaccine when admitted during flu season (September 1-March 31) and yearly during flu season. V3 stated it was the admitting nurse's responsibility to educate and administer each vaccine to a resident upon admission. V3 stated R21 and R22 had never been educated on or offered the pneumococcal vaccine in the facility. V3 stated R5 had never been educated on or offered the influenza vaccine in the facility. V3 stated R32 had never received the pneumococcal vaccine in the facility. The facility's Influenza and Pneumococcal Immunizations Policy dated 4/21/22 showed residents will be educated on and offered the influenza and pneumococcal vaccines upon admission to the facility. Once the resident consents to receiving either vaccine, the vaccine will be administered by a licensed nurse.

Based on interview and record review the facility failed to educate and offer the COVID-19 immunization to residents. The facility failed to administer the COVID-19 immunization to a resident. These failures apply to 4 of 5 residents (R21, R22, R5, R32) reviewed for immunizations in the sample of 37. The findings include:R21's admission Record showed R21 was admitted to the facility on [DATE]. R21's immunization record dated 7/14/26 showed no documentation the facility educated, offered, or administered the COVID-19 immunization to R21.R22's admission Record showed R22 was admitted to the facility on [DATE]. R22's immunization record dated 7/14/26 showed no documentation the facility educated, offered, or administered the COVID-19 immunization to R22.R5's admission Record showed R5 was admitted to the facility on [DATE]. R5's immunization record dated 7/14/26 showed no documentation the facility educated, offered, or administered the COVID-19 immunization to R5.R32's admission Record showed R32 was admitted to the facility on [DATE]. R32's COVID-19 vaccine consent form dated 12/10/25 showed R32 was educated on the vaccine and consented to receiving the vaccine. R32's immunization record dated 7/14/26 showed R32 had never received the COVID-19 vaccine in the facility.On 7/13/26 at 1:00 PM, V3 Assistant Director of Nursing (ADON) stated the facility currently did not have an Infection Preventionist (IP) overseeing the resident immunizations/vaccine program. V3 stated she was unsure how long the facility had been without an IP. V3 stated residents should be educated on and offered the COVID-19 vaccine upon admission to the facility and yearly as vaccine boosters become available. V3 stated R21, R22, and R5 had never been educated on or offered the COVID-19 immunization in the facility. V3 stated R32 had never received the COVID-19 immunization in the facility. The facility's COVID-19 Vaccination Guidelines- Residents and Employees policy dated 6/6/23 showed residents will be educated on and offered the COVID-19 vaccine upon admission to the facility. Once the resident consents to receiving the vaccine, the vaccine will be administered by a licensed nurse.

Based on observation, interview and record review the facility failed to ensure a resident was provided an appropriate sized bed to 1 of 37 residents (R53) reviewed for accommodation of needs in the sample of 37. The findings include:R53's Face Sheet shows that he admitted to the facility on [DATE]. R53's Vitals Summary shows that his height is 72 inches. On 7/13/26 at 9:36 AM, R53 was laying in bed. R53's toes were pressing up against the foot of the bed. R53's heels were pressing into the mattress. R53's knees were bent and his legs were unable to be extended straight. R53 said that he is six feet tall and his bed is way too small for him. R53 said that he has to sleep on his side because he can not extend his legs all the way straight if he is laying on his back. R53 said that he has told them that he wants a bigger bed but has not received one yet and his bed is very uncomfortable. On 7/13/26 at 11:45 AM, R53 was in the same position in bed. On 7/14/26 at 9:14 AM, R53 was in the same position in bed. On 7/15/2026 at 9:30 AM, V9 (Social Service Director) said that she spoke with R53's insurance case manager on Monday and she had told her that R53 needed a longer bed because his feet were pressing up against the foot board. V9 said that she relayed the information to maintenance and they are looking for an extender. The facility was unable to provide an Accommodation of Needs Policy.

Based on observation, interview and record review the facility failed to protect a resident from abuse from an agency staff member. This applies to 1 of 37 residents (R11) reviewed for abuse in the sample of 37. The findings include: On 7/13/26 at 10:38 AM R11 stated, On June 15th on the night shift I was out getting ice out of the cooler, filling my cups, like I always do, she [V12 Certified Nursing Assistant/CNA] tried to take the ice scoop from me and ended up banging my hand on the ice chest. She was fighting with me to get the ice scoop. I was not going to let it go. Several people talked to me about it already. I talked to my lawyer about it. [V19 Treatment Nurse] took a picture of it. R11's left hand, first knuckle, still appeared slightly swollen. R11's Minimum Data Set Assessment of 5/15/26 shows that R11 has no cognitive deficit. On 7/15/26 at 10:40 AM V19 stated, He said he [R11] was going to get ice- he was on North Wing. The CNA grabbed his hand and slammed the top of the cooler onto his hand. His left hand was swollen, red, painful and there was a small skin tear. It was red for probably 2-3 weeks after the incident. There was nothing there prior to the incident that I am aware of. R11's Progress Notes dated 6/15/26 state, Resident was grabbing ice from the cooler, CNA grabbed his hand closed the lid on his hand. This was overnight shift, there is a skin tear on hand that is closed and healed over, there is a bruise to knuckle on pointer finger. MD is aware, resident did call his POA. The facility Abuse Investigation shows a statement from R11 that reads, [R11] went out to fill his cup with ice. He filled 1 cup and while filling the 2nd cup a CNA tried to take ([he] cup out of his hand, he didn't let go and she hit his hand on the ice chest 2 times to take the scoop away from him. She told him, CNA's have to get ice, not residents. [R11] had some blood coming from a skin tear on his hand. He did not report incident to nursing at time of incident. 6/15/26 He came to Social Service Director to show swollen left hand. he also spoke to CNA scheduler. I notified nurse and [Nurse Practitioner]. A stat X-ray ordered. Administrator notified. This statement is signed by R11 but it is unclear who actually took the statement. At the bottom on the statement, it shows 7:00 Northwest. A second handwritten document shows a statement/interview with V12 [CNA]. This document states, Taking care of patients, noticed ice was on floor/hallway with resident. He was filling 2 containers with ice. Told him, No, you are not supposed to do that. Took the ice scoop, he wouldn't release it, I let him go ahead and do this. He called me Black B**** and N***** and rolled into my ankles. They had warned me. Asked a couple of people-front desk- told her about incident. She dumped ice. Blood coming out (of) hands- (where did blood come from?) Vein- (Sore present) When he didn't let it go- I let him finish. The Final Abuse Investigation Report date 6/17/26 states, Upon investigation, the following was revealed. The resident was interviewed regarding the allegation, assessed for injury, and appropriate notifications were made. The accused staff member was interviewed, and statements were obtained from staff and residents who may have been present in the area at the time of the alleged incident. Video Surveillance footage from the date and time in question were reviewed. The footage did not reveal any physical interaction between the resident and the CNA. Interviews conducted with the staff and residents did not provide evidence supporting the reported event. Based upon the review of video surveillance, staff and resident interviews, the allegation is unfounded. MD notified and is in agreement with outcome. On 7/13/26 Surveyor asked V4 (Regional Director of Operations) if Surveyor could view the video surveillance mentioned in the abuse investigation. V4 stated she would get a hold of V5 (Regional Human Resources Director) so she could get us access to that. On 7/14/26 Surveyor asked again to view the video surveillance of the alleged abuse. V4 stated V5 would be in the facility on 7/15/26 and she would be able to show Surveyor the snip-it of just that incident. On 7/15/26 at 10:10AM, V5 pulled up the video surveillance in V1 (Administrator's) Office. V5 began showing Surveyor video of the South end of the facility on 6/14/26 at 7PM. R11 was not seen in the video. Surveyor asked V4 why we are looking at the South unit when R11 resides on the North unit. V4 stated, He pretty much goes wherever he wants. (The South unit is a locked unit that requires a code to enter and exit the unit.) Surveyor and V5 continued to watch the video and Surveyor asked V5 to look at the video surveillance for the North Unit as that is where R11 resides and where V12 was assigned. V5 stated she was told V12 was assigned to the South Unit. V5 switched camera views to the North unit and attempted to find the video of R11 and V12 but was moving very quickly through the footage. Surveyor asked V5 if she had viewed the footage before and V5 stated that it was over a month ago. V5 stated, We never found anything on the video. Never saw him [R11] getting ice at all. The facility schedule dated 6/14/26 shows that V12 was assigned to the North Unit. On 7/15/26 at 10:55AM Surveyor attempted to call V12 for interview. There was no answer and Surveyor was unable to leave a message. The facility policy entitled Abuse Prevention and Reporting dated 10/24/22 states, Physical abuse is the affliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment.

Based on interview and record review the facility failed to conduct psychotropic medication assessments and Abnormal Involuntary Movement Scale (AIMS) assessments for 1 of 5 residents (R3) reviewed in the sample of 37.The findings include:R3's admission Record, dated 7/13/26 shows an admission date of 1/3/26 and diagnoses of anxiety disorder, major depressive disorder without psychotic features, and vascular dementia, moderate mood disturbances. R3's Minimum Data Sheet, dated 6/1/26 showed R3 exhibited no delusions, hallucinations, or behavioral symptoms. R3's care plan, with a last reviewed date of 6/22/26, showed the focus areas and interventions included: -I use antidepressant medication r/t (related to) Depression, Bipolar disorder. Monitor/document/report PRN (as needed) adverse reactions to antidepressant therapy.-I use anti-psychotic medication r/t major depressive disorder, recurrent severe without psychotic features, anxiety/agitation, vascular dementia, moderate, with mood disturbance. Monitor/record occurrence of target behavior symptoms (SPECIFY: delusions, hallucinations, agitation, anxiety, aggression, disruptive or inappropriate behaviors, incoherent speech, muddled thinking, psychosism, etc.) and document per facility protocol.On 7/14/26, R3's Physician Order Summary Report showed current orders for aripiprazole (antipsychotic) 5 milligrams (mg) one tablet daily related to major depressive disorder (MDD), venlafaxine HCl (antidepressant) 75 mg daily for MDD, mirtazapine (antidepressant) 7.5 mg daily at bedtime for bipolar disorder related to MDD, and divalproex sodium (mood stabilizer) 500 mg tablet delayed release twice a day for bipolar disorder related to MDD. Review of R3's medical record showed no documentation of psychotropic medication assessments or AIMS assessments since her admission.On 7/14/26, V25 (Regional Registered Nurse), stated the assessments for R3's psychotropic medications and her AIMS assessments had not been completed. V25 stated psychotropic medications assessments should be done quarterly or with changes in status and AIMS assessments are to be completed every six months, The facility's policy for Psychotropic Medications-Gradual Dose Reduction, revised 2/1/2018, showed, Monitoring: The licensed pharmacist will review the resident's drug regimen on a monthly basis and document findings. The pharmacist will report any irregularities to the Director of Nursing. The Director of Nursing will notify or direct licensed staff to notify attending physician as necessary. The facility will maintain a copy of the consultant report. The policy further stated that residents on anti-psychotic drug therapy will be monitored for tardive dyskinesia side effects every 6 months through the use of the AIMS scale.

Based on observation, interview and record review the facility failed to implement their abuse policy and procedures. This applies to 1 of 37 residents (R11) reviewed for abuse in the sample of 37. The findings include: On 7/13/26 at 10:38 AM R11 stated, On June 15th on the night shift I was out getting ice out of the cooler, filling my cups, like I always do, she [V12 Certified Nursing Assistant/CNA] tried to take the ice scoop from me and ended up banging my hand on the ice chest. She was fighting with me to get the ice scoop. I was not going to let it go. Several people talked to me about it already. I talked to my lawyer about it. [V19 Treatment Nurse] took a picture of it. R11's left hand, first knuckle, still appeared slightly swollen. The facility Abuse Investigation shows a statement from R11 that reads, [R11] went out to fill his cup with ice. He filled 1 cup and while filling the 2nd cup a CNA tried to take [the] cup out of his hand, he didn't let go and she hit his hand on the ice chest 2 times to take the scoop away from him. She told him, CNA's have to get ice, not residents. (R11) had some blood coming from a skin tear on his hand. He did not report incident to nursing at time of incident. 6/15/26 He came to Social Service Director to show swollen left hand. he also spoke to CNA scheduler. I notified nurse and [Nurse Practitioner]. A stat X-ray ordered. Administrator notified. This statement is signed by R11 but it is unclear who actually took the statement. At the bottom on the statement, it shows 7:00 Northwest. A second handwritten document shows a statement/interview with V12 [CNA]. This document states, Taking care of patients, noticed ice was on floor/hallway with resident. He was filling 2 containers with ice. Told him, No, you are not supposed to do that. Took the ice scoop, he wouldn't release it, I let him go ahead and do this. He called me Black B**** and N***** and rolled into my ankles. They had warned me. Asked a couple of people-front desk- told her about incident. She dumped ice. Blood coming out [of] hands- (where did blood come from?) Vein- (Sore present) When he didn't let it go- I let him finish. The Final Abuse Investigation Report date 6/17/26 states, Upon investigation, the following was revealed. The resident was interviewed regarding the allegation, assessed for injury, and appropriate notifications were made. The accused staff member was interviewed, and statements were obtained from staff and residents who may have been present in the area at the time of the alleged incident. Video Surveillance footage from the date and time in question were reviewed. The footage did not reveal any physical interaction between the resident and the CNA. Interviews conducted with the staff and residents did not provide evidence supporting the reported event. Based upon the review of video surveillance, staff and resident interviews, the allegation is unfounded. MD notified and is in agreement with outcome. On 7/15/26 at 10:10AM V5 (Regional Human Resources Director) pulled up the video surveillance in V1's (Administrator) Office. Surveyor asked V5 if she had viewed the footage before and V5 stated that it was over a month ago. V5 stated, We never found anything on the video. Never saw [R11] getting ice at all. The facility policy entitled Abuse Prevention and Reporting dated 10/24/22 states, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefor prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by : . Implementing systems to promptly and aggressively investigating all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment and making necessary changes to prevent future occurrences .

Based on interview and record review the facility failed to do a thorough investigation of a resident's allegation of physical abuse. This applies to 1 of 1 resident (R11) reviewed for abuse in the sample of 37. The findings include: On 7/13/26 at 10:38 AM R11 stated, On June 15th on the night shift I was out getting ice out of the cooler, filling my cups, like I always do, she [V12 Certified Nursing Assistant/CNA] tried to take the ice scoop from me and ended up banging my hand on the ice chest. She was fighting with me to get the ice scoop. I was not going to let it go. Several people talked to me about it already. I talked to my lawyer about it. [V19 Treatment Nurse] took a picture of it. R11's left hand, first knuckle, still appeared slightly swollen. The facility Abuse Investigation shows a statement from R11 that reads, (R11) went out to fill his cup with ice. He filled 1 cup and while filling the 2nd cup a CNA tried to take (the) cup out of his hand, he didn't let go and she hit his hand on the ice chest 2 times to take the scoop away from him. She told him, CNA's have to get ice, not residents. (R11) had some blood coming from a skin tear on his hand. He did not report incident to nursing at time of incident. 6/15/26 He came to Social Service Director to show swollen left hand. he also spoke to CNA scheduler. I notified nurse and (Nurse Practitioner). A stat X-ray ordered. Administrator notified. This statement is signed by R11 but it is unclear who actually took the statement. At the bottom on the statement, it shows 7:00 Northwest. A second handwritten document shows a statement/interview with V12 (CNA). This document states, Taking care of patients, noticed ice was on floor/hallway with resident. He was filling 2 containers with ice. Told him, No, you are not supposed to do that. Took the ice scoop, he wouldn't release it, I let him go ahead and do this. He called me Black B**** and N***** and rolled into my ankles. They had warned me. Asked a couple of people-front desk- told her about incident. She dumped ice. Blood coming out (of) hands- (where did blood come from?) Vein- (Sore present) When he didn't let it go- I let him finish. The Final Abuse Investigation Report date 6/17/26 states, Upon investigation, the following was revealed. The resident was interviewed regarding the allegation, assessed for injury, and appropriate notifications were made. The accused staff member was interviewed, and statements were obtained from staff and residents who may have been present in the area at the time of the alleged incident. Video Surveillance footage from the date and time in question were reviewed. The footage did not reveal any physical interaction between the resident and the CNA. Interviews conducted with the staff and residents did not provide evidence supporting the reported event. Based upon the review of video surveillance, staff and resident interviews, the allegation is unfounded. MD notified and is in agreement with outcome. On 7/14/26 at 2:00 PM, V4 (Regional Director of Operations) was asked if she had any of the other interviews with staff or residents mentioned in the investigation report. V4 stated, All I have is what is in the folder. (There were no other interviews in the folder.) On 7/15/26 at 10:10 AM, V5 (Regional Human Resources Director) pulled up the video surveillance in V1 (Administrator's) Office. V5 began showing Surveyor video of the South end of the facility on 6/14/26 at 7PM. R11 was not seen in the video. Surveyor asked V4 why we are looking at the South unit when R11 resides on the North unit. V4 stated, He pretty much goes wherever he wants. (The South unit is a locked unit that requires a code to enter and exit the unit.) Surveyor and V5 continued to watch the video and Surveyor asked V5 to look at the video surveillance for the North Unit as that is where R11 resides and where V12 was assigned. V5 stated she was told V12 was assigned to the South Unit. V5 switched camera views to the North unit and attempted to find the video of R11 and V12 but was moving very quickly through the footage. Surveyor asked V5 if she had viewed the footage before and V5 stated that it was over a month ago. V5 stated, We never found anything on the video. Never saw him [R11] getting ice at all. V5 was asked if she ever did any interviews with any other staff or residents and V5 stated that she had not. The facility policy entitled Abuse Prevention and Reporting dated 10/24/22 states, Investigation Procedures: The appointed investigation will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of resident property by the accused individual.

Based on observation, interview and record review the facility failed to ensure a female resident received assistance to remove facial hair. This applies to 1 of 37 residents reviewed for ADLs (Activities of Daily Living) in the sample of 37. The findings include: On 7/13/2026 at 11:45 AM R54 was sitting in her room in her wheelchair. R54 is alert and oriented and very pleasant to talk to. R54 had multiple white whiskers growing across the entire width of her chin. R54 stated, It is awful and there is only one CNA (Certified Nursing Assistant) that will shave me. R54's whole face was bruised and purple from and fall out of her wheelchair about 5 days ago and R54 stated she had had a stroke at home affecting her left side. R54's Current Care Plan states, I have an ADL [Activities of daily Living] self-care performance deficit with a varying level of assistance needed related to Activity intolerance, Confusion, Fatigue, Impaired balance, Limited mobility, left sided hemiparesis due to stroke effects. R54's CNA Task List in R54's Electronic medical Record shows: Personal hygiene: The resident is usually provided with Substantial Maximum assist by staff - Date Initiated: 05/18/2026 Revision on: 06/01/2026 The undated facility policy entitled Shaving Male and Female Residents states, To provide cleanliness, comfort and improved morale.

Based on observation, interview, and record review the facility failed to ensure a resident with a contracture had a splint in place and failed to have restorative assessments for 3 of 8 residents (R15, R35, R56) reviewed for range of motion in the sample of 37 The findings include: 1.On 07/13/2026 at 10:56 AM, R56 was sitting up in his wheelchair in the activity room. R56 held his left arm to his body and his left wrist was contracted. There was no brace or splint observed. On 07/14/2026 at 10:44 AM, R56 was up in his wheelchair in the dining room with his left arm resting on his stomach and his right-hand holding papers. R56 did not have a splint in place on his left wrist. On 07/14/2026 at 10: 46 AM, V17 Certified Nursing Assistant (CNA) said R56 had never had a brace for his left wrist that she was aware of. V17 said R56's left wrist is contracted and R56 uses his right hand to eat and hold things. On 07/14/2026 at 1:00 PM, V13 Registered Nurse said there was a time when R56 had a splint for his left wrist, but she was not sure what happened to it. V13 said we used to have to sign off that is was on. V13 said it must have fallen off the Treatment Administration Record. On 7/14/2026 at 1:10 PM, V18 Physical Therapist (PT) said he was not sure if R56 had a splint or not, he would have to check R56's Occupational Therapy (OT) Notes. V18 said therapy does not do the restorative assessments for the residents. V18 said PT/OT will write up the restorative program for the resident when they are discharged from therapy, and he was not sure who reassessed to make sure the program was meeting the resident's needs. On 07/14/2026 at 2:42 PM, V4 Regional Director of Operations said she was unable to find any restorative assessments for R56. V4 said the facility does not have a Restorative Nurse, and she was not aware of anyone assigned to do the Restorative Assessments. V4 said the CNAs do range of motion for the residents. V4 said the facility does not have a polciy on Restorative Therapy. R56's Therapy to Nursing Recommendations from OT dated 4/1/2025 shows splint or bracing: Wrist Hand Orthosis (left) 2-3 hours per days or as needed. R56's Care Plan dated 9/4/25 shows I require the use of a left wrist hand finger orthosis related to contractual management: II will develop no further loss of range of motion. Apply device per therapy recommendations. The facility did not provide any Restorative Assessments for R56. 2. R35's Face Sheet shows diagnoses of: monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting right side and contracture of right hand. On 7/13/2026 at 1:45 PM, R35 was sitting on the side of her bed. R35's right hand was contracted and her fingernails were pressing into the palm of her hand. R35 was able to use her left hand to open her hand partly. R35 said that they do not use any type of splint on her hand. On 7/14/26 at 9:43 AM, V22, Certified Nursing Assistant (CNA) said that she used to have a grey colored thing that they would put on her hand but she has not seen it in a long time. V21 (CNA) said that she has worked at the facility for about six months and has never seen her wearing a splint. On 7/14/26 at 1:33 PM, V18 (Physical Therapist) said that R35 should be using a splint on her right hand. V18 said that when a resident has a contracture, therapy assesses their need for splinting, orders the appropriate splints and instructs the staff on how to use them. V18 said that if the splint is missing, the staff should let the therapy department know so they can order a new one. V18 said that splints are important because they decrease the risk for further contractures. R35's Therapy to Nursing Recommendations Form dated 11/19/25 shows a restorative recommendation for a right hand roll brace to be worn every day with a minimum of two hours or as tolerated. The facility was unable to provide a Restorative Assessment for R35. V3 (Regional Director of Operations) said that they do not have a policy on splinting. 3. R15's Face Sheet shows that she has diagnoses to include: multiple sclerosis and contracture-right and left ankle. On 7/13/26 at 10:17 AM, R15 was sitting in a high back wheel chair. R15 had a contracted right hand. R15 had a beanie baby placed in her contracted right hand. R15's Minimum Data Set assessment dated [DATE] shows that she has a range of motion impairment of her bilateral upper and lower extremities and received zero days of passive range of motion in the last seven day. R15's Care Plan shows that she requires passive range of motion (PROM). R15's Physical Therapy Discharge summary dated [DATE] shows that she should be on a Restorative Range of Motion Program and should have PROM exercises to her bilateral lower extremities. On 7/15/26 at 11:47 AM, V24 (CNA) said that she does not do any PROM on R35. V24 said that they do not have any restorative aides at the facility so she is not sure who does PROM on residents. On 7/15/26 at 11:50 AM, V4 (Regional Director of Operations) said that PROM should be done by the CNAs for any resident that needs it. V4 said that she could not find any recent restorative assessments for R35 and they do not have a restorative program. V4 said that CNAs should document when PROM is performed and she could not find any documentation for R35 that it was being done. V4 said that they do not have a policy on range of motion.

Based on observation, interview and record review, the facility failed to investigate a fall for the root cause, implement post fall interventions and ensure care planned interventions were in place for one of one resident (R3) reviewed for falls on the sample list of 37. The findings include:R3's Progress Notes dated 5/17/26, 6/5/26 and 6/11/26 each contain documentation that R3 had a fall on these days. No investigation into the root cause was documented for the fall on 6/5/26. R3's Care Plan dated 6/22/26 does not contain any post fall interventions for the falls on 5/17/26, 6/5/26 and 6/11/26. This care plan does have an intervention from 12/2025 for a Call, Don't Fall sign to be visible in R3's room. On 7/13/26 at 2:14 PM and 7/14/26 at 11:54 AM, R3's room did not have a Call, Don't Fall sign posted. On 7/15/26 at 12:35 PM, V4 (Regional Director of Operations), stated interventions on the care plan should be in place and that after each fall, a root cause needs to be determined in order for an appropriate post fall intervention to be implemented to try and prevent further falls. V4 stated an investigation was not completed after R3'sfall on 6/5/26 and that new post- fall interventions were not implemented after R3's falls on 5/17/26, 6/5/26 and 6/11/26. The facility's Fall Prevention Program Policy, revised November 21, 2017, reads the facility will ensure the safety of all residents in the facility through prevention, implementation, investigation and reevaluation.

Based on observation, interview, and record review the facility failed to provide catheter care and incontinence care in a manner to prevent cross contamination and infection for 2 of 7 residents (R1, R3) reviewed for catheters/incontinence care in the sample of 37. The findings include: 1.On 07/13/2026 at 10:04 AM, R1 was sitting in a reclining wheelchair and was brought down the hall from the dialysis room to his room. R1's urinary catheter bag was sitting in the wheelchair next to him (even with the bladder). R1's urinary catheter tubing hung down and was filled with cloudy amber urine. R1 said he is currently on intravenous antibiotics that he gets during dialysis for an infection. R1 said he was recently in the hospital for a urinary tract infection. On 07/13/2026 at 10:12 AM, R1 remained in the reclining wheelchair in his room with his urinary catheter bag in the seat of the chair. V15 and V16 (Certified Nursing Assistants/CNA) began to transfer R1 to bed via a mechanical lift. During the transfer R1's urinary catheter bag was placed in R1's lap (unable to drain). When R1 was in bed, V16 hung R1's urinary catheter bag on the bed frame. R1's catheter bag began filling up. R1 asked V16 to empty the catheter bag, and V16 drained 600 ml of cloudy amber urine. On 07/14/2026 at 9:30 AM, V13 (Registered Nurse/RN) said R1 was sent out to the hospital and was treated for a urinary tract infection. V13 said R1 gets intravenous antibiotics in dialysis. On 07/15/2026 at 9:30 AM, V13 said urinary catheter drainage bags should be below the bladder to allow the urine to drain. V13 said if urine backs up into the tubing it can cause infection. R1's most recent Care Plan shows (R1) has diagnoses of infection and inflammatory reaction due to cystotomy catheter, urinary tract infection, and sepsis due to enterococcus. The same Care Plan shows R1 has a suprapubic catheter. The facility's Urinary Catheter Care Policy dated 2/14/2019 shows Catheters shall be positioned to maintain a downhill flow of urine to prevent a back flow of urine into the bladder or tubing, during transfer, ambulation, or body positioning. 2. On 7/14/2026 at 9:06 AM, V21 (Certified Nursing Assistant/CNA) and V22 (CNA) performed incontinence care for R3. R3's incontinence brief showed yellow discharge and smeared stool. V21 and V22 cleaned R3's vaginal area but did not cleanse the resident's perirectal area. After completing incontinence care, neither V21 nor V22 removed their contaminated gloves and performed hand hygiene before touching multiple services including R3's clean brief, bedding, clothes, and the facility's communal mechanical lift. When asked about hand hygiene practices after performing incontinence care, V21 and V22 said that R3's brief was soiled and that they should have removed their gloves and performed hand hygiene. V21 and V22 stated they were aware that R3 has a history of urinary tract infections (UTIs). On 07/14/2026 9:34 AM, R3 stated, I've had a UTI forever now, I just can't shake it. R3's Lab Results Report provided by the facility showed R3 tested positive for two highly contagious bacterial infections: Klebsiella pneumoniae on 01/27/2026 and 06/10/2026, and Proteus Mirabilis on 04/01/2026, 05/11/2026, and 06/10/2026. R3's Physician order summary from 05/15/2026 through 07/31/2026 showed R3 has orders for Ertapenem Sodium (antibiotic) 1 gram, intravenous (IV) daily for seven days to treat UTI.

Based on interview and record review the facility failed to use two staff members when assisting a resident with bed mobility/daily care. This failure resulted in the resident falling off the side of the bed, elevated to high position, landing on the floor and sustaining a left hip fracture on 5/29/26. This applies to 1 of 3 residents (R4) reviewed for accidents/falls in the sample of 6. The findings include: R4's EMR (Electronic Medical Record) shows that she was last admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Obesity, Cerebral Ischemia and Major Depression. R4's Incident Report dated 5/29/26 states, On 5/29/26 at approximately 1:20PM, (R4) was receiving a bed bath from (V6-Hospice CNA-Certified Nursing Assistant). During care, the resident was rolled onto her right side with her left leg positioned over her right leg. At that time, the resident's lower body moved off the bed toward the floor. (V6) assisted the resident safely the rest of the way to the floor and immediately notified nursing staff, who immediately contacted emergency services. (R4's) [NAME] (Power of Attorney) met her at the hospital for evaluation. Imaging later showed an acute non-displaced fracture of the greater trochanter. Following discussion between the POA, Hospice and the ER physician regarding risks and benefits of treatment options, the decision was made to continue comfort-focused care without additional intervention. (R4) returned to the facility later that same day and resumed services with hospice. On 6/26/26 at 9:45AM V3 (CNA) stated, The hospice CNA is allowed to change the residents. (R4) passed away- she fell out of bed. When hospice was doing care on her- she passed away the next day. We were all pretty close to the hospice girl- she had been coming here a long time. (R4) loved her hospice girl. Her name was (V6). I heard (V6) was changing (R4) and she fell on the floor on the window side of the bed. (V6) yelled for help and the staff came to help and picked her up with the (mechanical lift). It was normal for her to change (R4). (R4's) death was very unexpected.On 6/26/26 at 9:50AM V4 (CNA) stated, I was coming out of the bathroom, and I heard that (R4) fell so I ran to (R4's) room. The bed was in a high position. (V6) is pretty tall. (R4) was lying on her left side and her legs were crossed, her right leg over her left and she was facing the door, and she was yelling Help me, Help me. Another CNA ran to get the nurse. The nurse (V16) came down, the NP (Nurse Practitioner) was here and (V2-RN came down too. The NP immediately said to send (R4) out so someone called 911. (V6) called hospice and told them what happened. We got (R4) back in bed with a (mechanical lift). (V2) took (V6) to talk to her so I don't know what (V6) said. There were no side rails up. (R4) was not a fall risk, her bed was normally at an average height. She loved being in bed. She went to the ER and came back later that night. She was here the next day and then she passed away that day. She was complaining of left hip pain after she fell. On 6/26/26 at 10:00AM V2 (RN- MDS) stated, I don't remember what (V6) said but I took a witness statement and I gave it to the Administrator at the time. I don't know who did the incident report at the time. I did education with (V6). (R4) had a low air loss mattress, and I told (V6) not to care for anyone on a low air loss mattress by herself. (R4) was a 2 assist for care in bed. (V6) said, I didn't even think of that. On 6/26/26 at 12:30 V16 (RN- Previous Employee) was called for interview. A message was left but no return call was received prior to survey exit.On 6/26/26 at 11:45AM Hospice was called. They stated (V6) in the field, and they would give her the message to return Surveyor's call.At 12:00PM the call was returned by a person claiming to be the Lead CNA from Hospice. She stated that (V6) was off this week and she could not return my call until Monday. Survey exited prior to the return call. V6's typed and signed statement dated 5/29/26 states, I was giving her, (R4) a bed bath. I had completed (R4's) top half and was going to change her, as in changing her brief, and clean her up. (R4) then assisted me to roll her onto her right side towards the window, and her left leg over her right and when I went to grab the brief, with my left hand, and angled away from the bed. I then looked fully back at her and seen her legs kept going out of the bed onto the floor, her torso was still in upward position due to her holding onto the bed rail. Then I moved the bed some and asked her if I could move her hands, she said yes, and then placed a pillow on the floor and lowered her torso down onto the floor. (R4) was not complaining about any specific pain until she rolled onto her back and then she started yelling out about pain in her left hip. R4's Care Plan dated 3/16/26 states, I have an ADL (Activities of Daily Living) self-care/mobility performance deficit that may fluctuate with activity throughout the day related to Activity Intolerance, right hemiplegia due to CVA, fatigue, limited mobility. 2 staff transfers and 2 staff for bed mobility, cognition and thought processes fluctuations due to cerebral ischemia. R4's Hospital Document dated 5/29/26 states, Since putting in the consult for orthopedics, patient's husband, DPOA (Durable Power of Attorney), had spoken with hospice. They have decided that they do not want patient going through any surgery or procedure for this hip fracture. Plan is to send patient back to the nursing home and she is on Norco (Analgesic), Tylenol and Dilaudid (Narcotic Analgesic) for pain control. Spoke with orthopedics, who also felt that is patient is non-ambulatory and is under hospice care, we will acknowledge patient and family's wishes to send patient back to nursing home under hospice care.

Based on observation, interview and record review the facility failed to identify a pressure injury on a resident's left heel until it was a stage 3. This failure resulted in R5 being found with an open area with devitalized tissue on her left heel on 4/18/26. The facility also failed to complete accurate weekly wound assessments for residents with pressure injuries. This applies to 2 of 2 residents (R5, R6) reviewed for pressure injuries in the sample of 14. The findings include: 1.R5's Face Sheet shows she was last admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure, Morbid Obesity, Type 2 Diabetes Mellitus and Chronic Kidney Disease. R5's Weekly Skin Assessments show an assessment dated [DATE] then no other skin assessments until 4/15/26. The Weekly Skin Assessment on 4/15/26 Shows- no foot concerns. R5's Wound Summary printed on 5/8/26 shows that R5 has an active, facility acquired, pressure ulcer on her left heel. The first wound assessment is dated 4/18/26 (3 days after the weekly skin assessment) and shows a Stage 3 to R5's Left Heel. The wound is described as Intact Skin 25%, Deep Maroon 40% and Necrotic, Soft Adherent 35%. Measuring 4 x 2 x 0cm with no exudate and no infection present. This identical assessment is document for 4/26/26 and 5/3/26. R5's Braden Scale (Pressure Ulcer Risk Assessment) dated 12/2/25 shows that R5 scored a 17 meaning R5 is At Risk for developing a pressure injury. (Compared to Moderate Risk, High Risk or Very High Risk)R5's EMR (Electronic Medical Record) shows no Progress Notes related to R5's wound. On 5/8/26 at 10:15AM (V6) removed the old dressing from R5's left heel. The area appeared macerated around the edges with some dark tissue in the middle. (About the size of 2 nickels placed lengthwise next to each other.) The heel was cleansed with wound cleanser, then covered with calcium alginate and a bordered foam dressing. The heal lift boot was placed back on R5's left heel.On 5/8/26 at 2:25PM V10 (Previous DON- Director of Nursing) stated, I have not been in the building since January. V2 is the new DON, and she is over the Wound Care now - I am not sure exactly when she took it over. Skin checks are done weekly by the nurse. If a CNA sees something new during a shower, then they will let the nurse know but the nurse is still doing weekly skin checks. (R5) is also seen by hospice and showers are often given by hospice staff. Something should have been seen prior to a Stage 3- absolutely.R5's care plan dated 4/17/26 states, I have an open area to my left heel s/t immobility, decrease in awareness r/t disease process, chronic respiratory failure, history of ulcers .The facility policy entitled Pressure Injury and Skin Condition assessment dated [DATE] states, Residents identified (at risk) will have a weekly skin assessment by a licensed nurse., Each resident will be observed for skin breakdown daily during cares and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment., Pressure injuries and other ulcers will be measured at least weekly and recorded in centimeters in the resident's clinical record. 2.R6's Face Sheet shows he was last admitted to the facility on [DATE] with diagnoses including Chronic Venous Hypertension with Ulcer of Left Lower Extremity, Chronic Pain Syndrome, Pressure Ulcer of the Right Upper Back and Spastic Hemiplegia affecting the Left Nondominant Side. A handwritten document provided on 5/8/26 by V6 (RN- Treatment Nurse) shows that R6 has a Left Ankle Stage 2 and a Right Back Pressure Injury.R6's Wound Summary Report Printed on 5/8/26 shows identical wound assessments on 3/6/26, 3/12/26, 3/26/26, 3/27/26, 4/2/26, 4/10/26, 4/18/26, 4/26/26 and 5/3/26. This assessment states, Active Pressure, Facility Acquired, Stage 4, Bright Pink or Red 75%, Slough white Fibrinous 25%, Scant Serosanguineous exudate, measuring 1.0 cm x 1.0 cm x 0.50cm.R6's Specialty Physician Wound Evaluation and Management Summary dated 5/5/26 (2 days after last facility assessment) describes R6's Right upper back wound as , Etiology: Pressure, Stage 4 Wound Size: 0.60 cm x 0.50 cm x 0.20cm, Exudate: Heavy Serous, Thick adherent devitalized necrotic tissue 5%, Slough 35%, Granulation Tissue 60%. On 5/8/26 at 5/8/26 at 10:30AM a dressing change was completed by V6 to R6's right upper back. R6's right back showed an open area with a yellow center about the size of a nickel adjacent to his right shoulder blade. The area appeared clean although yellow in color with some clear drainage but unable to determine the amount on the actual dressing. V6 stated, It was a huge hole. R6 then stated, It healed once then a week or two later it split open with a vengeance. On 5/8/26 at 11:40AM V6 stated, The wound assessments are in the other program- Wound Rounds. I do not have access to that. (V3-ADON- Assistant Director of Nursing) takes the pictures of the wounds and puts in the assessments. The (V2-DON- Director of Nursing and (V3) have access to those programs. (V2 and V3 were not present in the facility during this survey)On 5/8/26 2:25PM V10 (Previous DON) stated, I have not been in the building since January. (V2) is the new DON and she is over the Wound Care now - I am not sure exactly when she took it over. I know when I was in the building (R6's) wounds did not change very much from week to week.On 5/8/26 at 11:56AM (V9- Regional Nurse Consultant) stated, The Wound Care assessments are not part of the medical record. It is in a separate program. I can't give you access to that, but I can print out anything you want.The facility policy entitled Pressure Injury and Skin Condition assessment dated [DATE] states, Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least every seven days by a licensed nurse and documented in the resident's clinical record.

Based on interview and record review the facility failed to carry out treatment orders for an antibiotic ointment and failed to promptly notify a physician after the deterioration of a non pressure wound. These failures contributed to a delay in R1 missing 9 days of an antibiotic ointment and a delay in a physician assessing R1's left heel arterial ulcer. This applies to 1 of 3 residents reviewed for quality of care in the sample of 5. The findings include: R1's Face Sheet shows she was admitted to the facility on [DATE] and has diagnoses including: Type 2 diabetes with foot ulcer, displaced fracture of the 5th metatarsal bone of the left foot, hypertensive chronic kidney disease with end stage renal disease, renal dialysis, chronic pain, and anxiety disorder. R1's Care Plan shows she has a diabetic ulcer to her left foot and interventions include monitoring the area and notifying the physician of any changes including signs of infection, worsening of the wound based on size, appearance or odors and drainage. A Orders and Recommendations form signed by V5 ( Podiatrist and foot specialist) on 11/6/24 shows an order for R1 to apply Triple Antibiotic Ointment and a dry sterile dressing to her left heel ulcer daily. R1's 11/1/24-11/30/24 Treatment Administration Record (TAR) shows the Antibiotic Ointment was not administered for the first time until 11/15/24. (9 days after the treatment order was written) R1's Physician Order Summary (POS) shows the order was not entered into R1's Electronic Medical Record (EMR) until 11/14/24. R1's 11/8/24 Wound Assessment Report completed by V8 (Licensed Practical Nurse/LPN and covering wound nurse) shows R1 has a full thickness vascular diabetic ulcer measuring 1.50 centimeters (cm.) x 0.50 cm. there is no documented drainage to the wound. The wound bed is described as necrotic hard, firm. R1's 11/12, 11/19 and 11/25 wound assessments show the same descriptions to her wound bed with no changes. On 12/2/24 R1's wound assessment shows an increase in size to 2.00 cm. x 1.00 cm. On 12/10/24 R1's wound assessment shows the area measuring 1.50 cm. x 1.30 cm. with the overall surface size of 1.95 cm. The picture (in black and white) of the wound on the assessment form gives the appearance the wound is worsening and appears deeper. On 12/16/24 the wound assessment shows it is 2.00 cm. x 1.30 cm. with a surface area of 2.60 cm and the wound photo shows what appears to be slough beginning in the wound bed. On 12/30/24 the wound assessment shows there is now a moderate amount of serous drainage to the wound bed. On 1/13/25 the wound is now 3.0 cm x 3.0 cm and a total wound surface area of 9.0 cm. R1's 12/1-12/31/24 TAR shows a treatment order change for the wound that was given on 12/18/24 by V3 (Wound Care Physician). R1's Physician Progress notes show V14 (former facility Nurse Practitioner) documented R1's wound on 12/3/24 and described it as dry cracked skin to left heel and documents not healing. R1's 12/26/24 physician note refers to R1's wound and states she was provided with a diabetic shoe. Neither note shows that V14 saw R1 or that she was informed of the wound deterioration. R1's Progress note completed by V15 (R1's Physician and Medical Director) on 12/28/24 states, no issue is noted per nursing staff and does not mention R1's wound. The first wound care assessment documented by V3 was not until 1/14/25 and the wound was then described as 3 cm x 3 cm x 0.1 cm and has heavy serous drainage and 90% necrotic tissue and 10% slough. On 4/8/25 at 12:17 PM, V3 said he was not able to recall when he first saw R1 but said he should be contacted to see a resident if the wound shows heavy drainage, signs it is not healing, increased size or signs of necrosis. V3 said R1 would allow him to assess her wound and do treatments like debridement for the wound. V3 described her wound as a full thickness with soft necrosis. V3 reviewed his assessments with the survey and agreed his first assessment for R1's wound was on 1/14/25. On 4/9/25 at 9:25 AM, V8 said she was aware that the order for the Triple Antibiotic Ointment was not carried out on time. V8 said the nurse who got the order did not enter it into the EMR so it was missed until she caught it and added it to the treatments. V8 said in her opinion 12/10/24 was the start of the deterioration of R1's wound. V8 said she did not call to report this to anyone because R1 was supposed to have a podiatry appointment on 12/11/24 but R1 canceled that appointment and canceled again on 12/18/24. V8 said she called V3 to get an order to change the treatment for R1's wound care on 12/18/24. V8 said she would call a physician if a wound increases in size, is not healing, has heavy drainage or has signs of an infection. V8 did not call V5 or V14 to report the wound condition change. V8 said V3 first saw R1 on 1/14/25. V8 said initially R1 wanted to be seen by her own outside provider (V5) but there is nothing documented in R1 EMR's showing she refused the services or to be seen by V3. V8 also said R1 had been in the hospital from 12/22-12/25/24 and again from 1/6/25-1/12/25 for non related medical issues. On 4/9/25 at 11:17 AM, V5 said he did see R1 on 11/6/24 and gave orders for her to start the Triple Antibiotic Ointment daily to her wound. V5 said no one from the facility called to report that this was not started (until 9 days later) and this was a concern because this medicated ointment is an antibiotic to prevent infection, and by R1 not receiving it bacteria could build up in her wound bed. V5 also said no one contacted him to report the worsening wound. The facility provided Skin Condition Assessment & Monitoring- Pressure and Non-Pressure last revised 6/8/18 shows when there is changes to a wound physicians should be notified and that should be documented in the residents clinical record. Changes described that would require notification include onset of drainage, odor, cellulitis, increased pain, increase in wound measurements and onset of new ulcers. The facility provided Entering and Processing orders policy last revised on 1/31/18 shows after a physician visit the nurse should check for orders and the order will be completed and entered into the EMR.

Based on observation, interview, and record review, the facility failed to supervise a resident (R5) with a metastatic brain neoplasm and prevent an injury for one (R2) of two residents reviewed for accidents in a sample of five. This deficiency resulted in R2 going to the hospital, sustaining a fracture to his right knee, and ongoing pain requiring pain medication. Findings include. Facility's Residents' Rights for People in Long Term Care Facilities, Ombudsman Program revised 11/2018, documents: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide services to keep your physical and mental health, at their highest practical levels. Facility Abuse Investigation Report, dated 2/12/25, documents (R5) went into (R2's) room and threw a chair at (R2) while (R2) was in bed. (R2) complained of right knee pain and sent to the hospital for assessment. Pain medication was administered to (R2). R2's Medication Administration Record/MAR, dated 2/1-2/12/25, documents R2 was taking Tylenol 650mg/milligrams four times a day for pain. R2's MAR, dated 2/12-2/28/25 and 3/1-3/4/25, documents R2 was ordered Norco 5-325mg take one tablet every 24 hours taken 2/18/25 for pain 5/10 and 2/19/25 for pain 7/10. Norco 5-325mg 1 tablet every eight hours as needed for right knee pain taken 2/12 for pain 4/10; 2/13 for pain 6/10; 2/17 for pain 7/10; 2/20-2/22 for pain 8/10; 2/24 for pain 6/10; 2/28 for pain 7/10; 3/1 for pain 7/10; and 3/3 for pain 8/10. R2's medical record documents the following: (R2's) progress note by (V9 APRN/Advanced Practice Registered Nurse), dated 2/12/25, documents Patient seen today for follow up on uncontrolled right lower extremity pain. pain in right knee new onset status post injury where he was hit with a chair. R2's after visit summary from the hospital (2/13-2/17/25) progress note by V10 MD/Medical Doctor, dated 2/13/25, documents (R2) states he is having pain in his knee. R2's cat scan from the hospital, dated 2/14/25, documents Acute mildly displaced and mildly impacted fracture of the lateral femoral condyle posterior aspect with possible extension into the intercondylar notch. Prepatellar soft tissue swelling. (R2's prior x-ray from 2/11/25 documents R2 has no fracture.) R2's orthopedic consultation note by V11 MD, dated 2/15/25, documents Orthopedic consultation for a right distal femur fracture. (R2) was attacked by a roommate and began reporting knee pain. Recommendations: Non-operative management and pain control. R2's medical record documents the following: (R2's) progress note by V9 APRN, dated 2/19/25, documents Patient seen today in the facility and then again via telehealth this evening around 10:30PM for RLE/right lower extremity pain. Patient rates pain to RLE an 8/10. He is requesting a Norco; however, Norco is currently ordered q24 hours prn/as needed. Previous order was every 8 hours prn. Patient has new LE/lower extremity femur fx/fracture. Mild distress. Upset with inability to receive additional pain medication due to uncontrolled pain. I ordered Norco every eight hours as needed. Pain in right knee is a new onset s/p (status post) injury where he was hit with a chair. X-ray in ER/emergency room was negative, repeat x-ray negative, and then Femur fracture diagnosed in the hospital. On 3/4/25 at 11:30AM, R2 stated I have to rest my right knee due to (R5) throwing a chair at me. My knee is fractured, and I take pain medication for it, I can't do physical therapy or wear my prosthesis. I had an X-ray here (nursing home,) the hospital, and then another hospital. On 3/4/25 at 1:50PM, V2 DON/Director of Nursing stated (R5) threw a chair at (R2), and (R2) went to the hospital. On 3/4/25 at 2:15PM, V1 Administrator stated, I heard (R2) had a fracture.

Based on observation, interview and record review, facility staff failed to operate the facility van, with a resident aboard, in a safe manner to prevent an accident, for one of three residents (R1), reviewed for accidents. This failure resulted in R1 sustaining a nondisplaced fracture of the left patella, unspecified fracture. Findings include: The facility's Vehicle Safety Program policy, undated, documents that while driving will never be a risk-free activity, the goal of a vehicle safety program is to promote a heightened level. of safety awareness and responsible driving behaviors to protect employees, customers, and the general public from unsafe vehicle operations. For organizations that employ workers to operate a company vehicle or their personal vehicle while performing company-related duties, establishing a comprehensive vehicle safety policy will emphasize the organization ' s commitment to safe vehicle operations. On 2/25/25 at 9:30am, R1 stated that he was going to an appointment in the facility van, there was an accident. R1 stated that V4, Dietary Manager, was driving the van, not the regular driver. R1 stated that entering the parking garage and the top of the van hit the ceiling or something of the parking garage. R1 stated that he was jerked forward and hit the seat in front of him. R1 stated that he was having a lot of pain in his left knee area. R1 stated that the fire department and ambulance got him to a gurney and took him to the emergency room . R1 stated that he was told he had a fracture in his knee but has to go for further testing to determine the extent of the injury. V9, Registered Nurse, applied R1's left knee brace. R1's left knee was swollen, and slight bruising was observed. R1 complained of increase pain with movement. On 2/25/25 at 10:30am, V4 stated that she did receive a demonstration on to how to use and drive the van, but not a safety course. V4 stated she only transports only when she has too. V4 stated that there was a parking garage next to the building they were going. V4 stated that there was a slight incline to enter the garage, so she gave the van some gas to enter and hit something. V4 verified that she hit the sign indicating the height clearance of the parking garage. V4 verified that she did not even think about the height difference. V4 stated that she put the van in park and called 911. V4 stated that R1 slid forward in the wheelchair and hit his knees on the seat in front of him. V4 stated that R1 was complaining of increase pain in his left knee area. V4 stated that the ambulance assisted R1 out of the van, then onto a gurney. V4 verified that R1 was taken to the emergency room . V4 stated that R1 never fell out of his wheelchair and was seat belted in during the incident. R1's emergency room notes, dated 2/14/25, documents that the reason for visit is a motor vehicle accident. R1's left knee x-ray documents that R1 sustained a cortical disruption involving the cortex along the anterior margin a patellar spur at the patellar tendon. This form documents that R1 was treated for a nondisplaced fracture of the left patella, unspecified fracture morphology. R1's physician orders include instructions for the care of a patella fracture and to follow-up with an orthopedic physician. V14's, Police Officer, accident report, dated 2/14/25 at 1:26pm, documents that (V4) turned left into the parking garage and attempted to enter it. (V4) pulled into this parking garage, the front end of its roof collided with the clearance sign which is connected to the involved parking garage. When the collision happened (R1) rolled forward and bumped his left knee against the backside of the seat. It should be noted, this passenger was sat in a wheelchair at the time of the collision and occupants reported the seatbelt to be properly fastened. On 2/26/25 at 2:00pm, V2, Director of Nursing, stated that the facility has a check list to be completed for the facility van driver qualifications. On 2/27/25 at 10:40am, V14, Police Officer, stated that he did not see R1 on site, he was already being taken to the emergency room . V14 stated that the ambulance personnel told him that R1 slid down in the wheelchair with his butt half off the chair. V14 stated that V4 hit the actual height clearance sign of the parking garage. V14 stated that facility vans height clearance is located in front of the steering wheel, in clear view.

Based on observation, interview, and record review the facility failed to follow a physician order for change in resident condition for one (R2) of five residents reviewed for change in condition in the sample of six. These failures resulted in the delay of treatment for R2 resulting in continued decline for R2 and R2 being admitted to the local hospital's intensive care unit with multiple comorbidities. Findings include: These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 4/1/24 at 4:15 pm when the facility failed to follow a physician order to send R2 to the local hospital for an evaluation resulting in delay of R2 treatment and being admitted to the local hospital's intensive care unit with multiple comorbidities. V1 Administrator and V2 DON was notified of the Immediate Jeopardy on 5/1/24 at 9:00 am. While the immediacy was removed on 4/2/24, the facility remains out of compliance at Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of their removal plan and quality assurance monitoring. Findings include: The Contract between the facility and the in-house Dialysis Service, dated 3/1/2019, documents Dialysis Service Responsibilities include: Communication: (Dialysis) staff shall maintain timely communication with Facility's Nursing Director and immediately inform a Facility nursing staff member of any change in the Resident's condition, during Dialysis Services that requires immediate attention. Emergency Care: (Dialysis Service) will coordinate emergency care policies with Facility throughout the term of this Agreement, as they relate to Dialysis Services. (Dialysis service) shall supply such other data and reports as Facility reasonably requires. This same contract documents the Facility Responsibilities include: Communication: Facility staff shall inform (Dialysis) staff of any event occurring after a Resident's treatment that may affect future administration of Dialysis Services to that Resident. In addition, Facility shall immediately inform (Dialysis) of any changes in the Resident's medical condition relating to continued Dialysis Services. In-Service Training: Facility shall require staff members who are involved with Residents to attend in-service training to ensure that said staff members: (a) Have the knowledge necessary for managing an emergency or complication (including bleeding/hemorrhaging, hypovolemia, hypoglycemia, and infection/bacteremia shock); and (b) Have the knowledge necessary for providing care of lines and access, medical management, nutrition, hydration, recognizing and managing infection, handling waste, and managing end-stage renal disease. Coordination of Dialysis Services Purpose: It is critical that both Parties work cooperatively with Residents, their families, their physicians, and each other in order to achieve quality results of the Dialysis Services provided under this Agreement. Therefore, (Dialysis Service) and Facility agree to coordinate their respective services, as set forth herein. Duties of (Dialysis Service): Shall (a) Provide facility staff with general information about Dialysis Services, including Resident treatment options; (b) Conduct periodic dialysis education programs for Facility staff and physicians; (d) Review Residents' information to determine their suitability for Dialysis Services at Facility, before providing the Dialysis Services; (j) Consult with nephrologists and Facility staff on treatment plans for Resident Dialysis Services; (q) Report post-treatment status of Residents to Facility staff and for any adverse event, the Resident's nephrologist and the resident and/or the resident's responsible party; and (z) Arrange for the provision of dialysis-related emergency services at a hospital. Duties of the Facility: Facility shall: (l) Respond to emergencies involving Residents, including but not limited to: (i) medical emergencies, (ii) disruptive behavior of a Resident, or (iii) a request of a Resident to immediately stop treatment; and (m) Work with (Dialysis Service) to discharge a Resident for whom (Dialysis Service) cannot safely or consistently provide Dialysis Services for any reason, including but not limited to: erratic behavior, refusal to cooperate with (Dialysis) staff, or ancillary medical issues. The Physician Orders policy and procedures, revised 1/31/18, documents Purpose: To provide general guidelines when receiving, entering, and confirming physician or prescriber's orders. 1. When receiving physician's orders by telephone: Enter the order into the resident's chart under order tab and according to the instructions for the type of order that is received. 3. Notify the resident's physician (if not the prescribing physician), for verification if applicable. 6. Verbal and Telephone orders will be documented as such in the Electronic Medical Record. The facility's Physician-Family Notification-Change in Condition policy and procedures, revised 11/13/18, document Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner. The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: (B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (D) A decision to transfer or discharge the resident from the facility. The facility Licensed Practical Nurse (LPN) and Registered Nurse (RN) job descriptions, dated 5/2/17, document Essential Duties and Responsibilities include: Admit, transfer and discharge residents as required. Receive & transcribe telephone orders from physicians & record on the Physician's Order Form. Chart nurse's notes in an informative & descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. Perform routine charting duties as required & in accordance with established charting & documentation policies & procedures. Qualifications include: Must be knowledgeable of nursing & medical practices & procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities. The Face Sheet for R2, documents R2 admitted to the facility with the following diagnoses: Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease, End Stage Renal Disease, Type 2 Diabetes with polyneuropathy and retinopathy, Renal Osteodystrophy, Non-ST Elevation Myocardial Infarction, Dementia, Legally Blind, Hypertension, Atherosclerotic Heart Disease and Congestive Heart Failure. The current Medication Review Report, MAR'S (Medication Administration Records) and TARS (Treatment Administration Records) for R2, dated March 1 through April 16, 2024 do not include Physician orders for dialysis, the care of dialysis site, or monitoring related to dialysis for R2 as of 4/16/24. The current Care Plan for R2, documents Focus area: (R2) has renal insufficiency r/t (related to) CKD (Chronic Kidney Disease) stage 5, hypertensive heart and chronic kidney disease with heart failure. Interventions include: Monitor and report changes in mental status: lethargy; tiredness; fatigue; tremors; seizures. Monitor for s/sx of hypovolemia (increased pulse, increased respirations, decreased systolic, sweating, anxiousness) or hypervolemia (JVD (jugular vein distention), increased BP (blood pressure), lung crackles, headache, SOB (shortness of breath), dependent edema). Monitor/document/report PRN (as needed) the following s/sx (signs and symptoms): Edema; weight gain of over 2 lbs (pounds) a day; neck vein distention; difficulty breathing (Dyspnea); increased heart rate (Tachycardia); elevated blood pressure (Hypertension); skin temperature; peripheral pulses; level of consciousness; Monitor breath sounds for crackles. The current Care Plan for R2 documents Focus area: I have Congestive Heart Failure. Interventions include: Check breath sounds and monitor/document for labored breathing, Monitor Vital Signs, and Monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of Congestive Heart Failure: dependent edema of legs and feet, periorbital edema, SOB (shortness of breath) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, Orthopnea, weakness and/or fatigue, increased heart rate (Tachycardia), lethargy and disorientation. The current Care Plan for R2 documents Focus area: I have renal insufficiency r/t CKD stage 5, hypertensive heart and chronic kidney disease with heart failure. Interventions include: Monitor and report changes in mental status: lethargy, tiredness, fatigue, tremors, and seizures, Monitor for s/sx of hypovolemia (increased pulse, increased respirations, decreased systolic, sweating, anxiousness) or hypervolemia (JVD/jugular vein distention, increased BP (blood pressure), lung crackles, headache, SOB (shortness of breath), dependent edema, and Monitor/document/report PRN the following s/sx: Edema, weight gain of over 2 lbs (pounds) a day, neck vein distension, difficulty breathing (Dyspnea), increased heart rate (Tachycardia), elevated blood pressure (Hypertension), skin temperature, peripheral pulses, level of consciousness, Monitor breath sounds for crackles. The current Care Plan for R2 documents Focus area: I receive Hemodialysis 3 times per week. Interventions include: Check bruit and thrill every shift and record, Check capillary refill of extremity and notify MD (medical doctor) of significant changes, Check graft/fistula site for bleeding, Check vital signs every shift and record as ordered, Collaborate/communicate with dialysis center staff as needed. The current Care Plan for R2 documents Focus area: I have shortness of breath (SOB) r/t other asthma, morbid obesity, chf (congestive heart failure), anemia. Interventions include: Monitor/document changes in orientation, increased restlessness, anxiety, and air hunger, Monitor/document breathing patterns, and Monitor/document/Report breathing abnormalities to MD. On 4/16/24 12:00 pm through 4:30 pm and 4/17/24 8:00 am through 3:00 pm, R2 was not residing in the facility. On 4/17/24 the facility Dialysis Unit included V10 and V11 PCT's (Patient Care Technicians) and residents receiving dialysis treatment. The Dialysis Nursing Progress Notes Report for R2, dated 4/1/24 at 5:06 pm, documented by V8 Dialysis RN (Registered Nurse) prior to R2's dialysis treatment, documents CNA notified (V8 RN) and (V10 and V11) PCT's this patient has been ill since Saturday (3/30/24) and has been getting worse. (V8 RN) spoke with the nurse and she stated (R2's) VS (vital signs) were stable. (V8 RN) went to (R2's) room, (R2) has rales in upper lobes per auscultation, (R2) will respond when spoken to but immediately closes eyes and head leans to the side, eyes rolling back. (R2) has a temp (temperature) of 100.4, urine is very cloudy and brown in color with strong odor. O2 (oxygen) sat (saturations) at 81% on RA (room air). (V8 RN) notified floor nurse and (floor nurse) feels it's due to 'fluid overload' and patient 'just needs dialysis.' (R2) may be fluid overloaded, however, (R2) has other sx (symptoms) that do not correlate. (V8 RN) phoned V13 (R2's Nephrologist) and (V13) agreed (R2) should be evaluated in ER (emergency room ). (V8 RN) wrote the order and gave to floor nurse. (Floor Nurse) argued with (V8 RN) and basically refused to send the patient (R2) out. (V8 RN) and (V10 and V11) PCT's spoke with (V2) DON. (V2 DON) came back to the dialysis room and stated, 'my staff got different vitals than you did and (R2) seems ok.' (Facility) will not send (R2) out, feel it is not necessary. Staff brought patient (R2) to dialysis room, temp is 101.3, very slow to respond, O2 is now on and sats (saturations) are at 95%, 2L (liters) per n/c (nasal cannula). We will run patient as long as VS are stable. (V8 RN) also contacted (V15 Dialysis Regional Nurse) manager and informed (V15) of this situation. (V15) agrees that if (R2) becomes any worse, we are to stop treatment and reiterate to NH (nursing home) staff that (R2) needs to be evaluated in ER. The Other Orders report for R2, dated 4/1/24 at 4:15 pm, pre dialysis treatment, documents V8 Dialysis RN wrote a physician order as: Please have nursing home send patient (R2) to emergency room for evaluation of elevated temperature, decreased O2 (oxygen) saturation, MS (mental status) changes, rales upper lobes. This Physician Order was scanned into the miscellaneous tab of R2's EHR (electronic health record) and was not processed into the Physician Order tab in R2's EHR. The Dialysis Communication Report, dated 4/1/24, post dialysis treatment, documents R2 Moaning, confused, labored respirations with temperature of 99.5 and Blood Pressure of 131/99. The Dialysis Daily Notes for R2, dated 4/1/24 at 8:46 pm, documented by V8 Dialysis RN, post R2 dialysis treatment, documents (R2) remains confused, labored respirations, moaning, appears to be in pain but unable to verbalize. The facility Progress Notes for R2, dated 4/1/24 10:06 pm, Hematuria observed. Strong/foul odor noted to urine. Oxygen administered. Condition is stable, no distress noted; 4/2/24 5:58 pm, (R2) admitted to the hospital ICU with sepsis and very high troponin level. The Progress Notes, dated 4/4/24 through 4/16/24, document R2 remains at the local hospital. There are no Progress Notes documenting any other monitoring, vital signs, or resident condition between 3/29/24 (first dialysis treatment) through 4/2/24. The Medication Review Report for R2, dated 3/1/24 through 4/17/24 documents a Physician Order, dated 4/2/24 Send (R2) to (local hospital) for treatment and evaluation of elevated temp (temperature) and increased edema. The Medication Review Report for R2, does not include the Physician Order, dated 4/1/24, that ordered R2 to be sent to the hospital on 4/1/24 for elevated temperature, decrease in oxygen saturation, mental status changes or upper lobe rales. The local hospital discharge paperwork documents R2 was admitted on [DATE] through 4/17/24. The Reason for Admission documents: Dialysis access malfunction, Acute thrombus in right brachiocephalic vein extending to left brachiocephalic vein as well as superiorly to the junction of right subclavian and internal jugular veins, Acute on chronic anemia related to multifactorial etiology, Sepsis related to MRSA (methicillin resistant staph aureus) infection, Pneumonia, ESBL (extended-spectrum beta lactamase) UTI (urinary tract infection), MRSA bacteremia leading to acute endocarditis suspected related to catheter associated infection where right IJ (internal jugular) tunneled catheter, ESRD on hemodialysis with volume (fluid) overload, Acute on chronic systolic heart failure with pulmonary edema, Elevated troponin the setting of type 2 MI (myocardial infarction) demand mediated ischemia, Suspected pneumonia from Gram-negative etiology, and Acute metabolic encephalopathy exacerbating underlying dementia. On 4/16/24 at 12:23 pm, V3 LPN/Licensed Practical Nurse stated V13 (R2's) Nephrologist wanted R2 sent to the hospital on 4/1/24 due to altered mental status and V2 DON (Director of Nursing) said No and that R2 didn't need to go. R2 was admitted to the hospital with sepsis and an increased troponin (proteins that help regulate the heart) level. V4 RN (Registered Nurse) was R2's Nurse. V8 was the Dialysis RN that day. V3 LPN stated on Monday (4/1/24) R2 was not looking so hot, not communicating with us, not like her self as she is usually loud. Dialysis team was made to take R2 and on Tuesday (4/2/24) R2 was finally sent out. On 4/17/24 at 1:00 pm, V4 RN stated during shift report she was told that R2 had been running a temperature, vomiting, diarrhea, was having difficulty breathing, and not acting her self over the weekend and the physician wanted R2 sent to the hospital but V2 DON said Absolutely not. V4 RN stated towards the end of the shift R2 spiked a temperature and she was so hot, you could feel the heat coming off of her and V4 RN sent R2 out to the hospital on 4/2/24 during her shift. On 4/17/24 at 1:45 pm, V7 RN stated R2 was just not her normal self. She was answering questions. We checked her temperature and it was normal. Dialysis said it was 101.0 but ours was normal. We didn't know if it was just that she needed dialyzed. The Dialysis staff didn't want to take her. V7 RN stated herself and V6 LPN checked R2 and she didn't have a temperature. V7 RN stated the Dialysis staff didn't know R2 and just ordered to send R2 out to the hospital but V2 DON and R2's Family Member said to keep R2 at the facility. V7 RN confirmed R2 was not sent to the hospital until 4/2/24. On 4/17/24 at 2:00 pm, V6 LPN stated she was R2's Nurse and R2 went to dialysis (on 4/1/24) but not for long. R2 had been messing with her dialysis port and Dialysis staff cleaned it for her. V6 LPN stated she does not remember anything about sending R2 to the hospital and she did not send R2 to the hospital on 4/1/24. On 4/17/24 at 2:09 pm, V2 DON stated the Dialysis team would not take R2 due to blood pressure issues. R2 had a slight temperature but her vital signs were stable. V8 Dialysis RN said that R2 had diminished respirations, but she (R2) always does due to her condition. R2 was not sweating, not diaphoretic and her vital signs were ok. V2 DON also stated R2 had a UTI (urinary tract infection) and V6 LPN felt that when R2 got the new antibiotic in her for 24 hours R2 would be ok. V2 DON stated all she was told was that R2 couldn't get dialysis. V2 DON stated R2 was monitored and she (V2) is unaware of a physician order to send R2 to the hospital on 4/1/24. V2 DON stated If there was an order for her (R2) to be sent to the hospital (V2) would not have, not sent her. R2 ended up going out to the hospital due to her vitals signs being unstable and an increase in her temperature the next day (4/2/24). V2 DON stated the Dialysis Nurse communicates to the facility Nurses and the facility Nurses report to V2 DON. On 4/17/24 at 3:00 pm, V10 and V11 PCT's stated R2 had her first dialysis treatment on Friday (3/29/24) and on that following Monday (4/1/24) R2 had a change in mental status, had a temperature and there was concern with possible infection. V10 PCT stated what the facility staff do not understand is that if there is infection in the resident's blood stream the infection could be spread throughout the body during dialysis and make it worse for the resident, which is why dialysis team was concerned. The Nephrologist gave an order for R2 to go to the hospital emergency room to be evaluated on 4/1/24 but facility refused to send her. V10 and V11 PCT's stated a delay in R2's dialysis or delay in the treatment of an infection could definitely cause more problems for R2 which is why the doctor wanted R2 sent to the emergency room . On 4/17/24 at 3:30 pm, V1 Administrator stated she was unaware of there being a Physician order for R2 to be sent to the emergency roiagnom on [DATE] and confirmed if there was an order R2 should have been sent out to the hospital. On 4/23/24 at 1:59 pm, Call placed to V13 (R2's) Nephrologist office. V14 (V13's) Medical Assistant stated V13 Nephrologist is unavailable for interview, no longer sees R2 at the office due to R2 receiving dialysis at the facility, and all medical information for R2 would be in R2's Dialysis medical record. On 4/23/24 at 9:31 am, V1 Administrator stated CNA's reported to V8 Dialysis RN that R2 was not her normal self, V8 called V13 (R2's) Nephrologist and wrote the order for R2 to be sent to the local hospital around 4:00 pm even though R2 was not due to be dialyzed until around 5:00 pm. V1 Administrator stated she does not know why the order was not processed, not in R2's Physician Orders and unsure why it was scanned into miscellaneous tab. On 4/24/24 at 11:30 am, V15 Dialysis Regional Nurse stated V8 Dialysis RN called her in the afternoon regarding R2's declining condition and was looking for guidance as to what to do. V15 Dialysis Regional Nurse stated she told V8 Dialysis RN to call the Physician and communicate with the nursing home staff. V15 stated if we call the Nephrologist and are told to send a patient to the hospital, we would write the order and then give it to the facility nurse to follow through with. The Immediate Jeopardy began on 4/1/24 at 4:15 pm when the facility failed to follow a physician order to send R2 to the local hospital for an evaluation resulting in delay of R2 treatment and being admitted to the local hospital's intensive care unit with multiple comorbidities. V1 Administrator and V2 DON was notified of the Immediate Jeopardy on 5/1/24 at 9:00 am. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. All licensed staff were educated, by V2 DON, V9 RNC (Regional Nurse Consultant) and V16 QA (Quality Assurance) Nurse Manger, on Notification - Physician Notification on Change of Condition on 4/19/24. 2. All licensed staff were educated, by V2 DON, on Physician Orders including entering, processing, following and implementation of physician orders on 4/26/24. 3. All licensed staff were educated, by V2 DON and V9 RNC, on utilizing the back-up medication system and list of medications was posted by back-up medication system on 4/19/24. 4. V2 DON was educated, by V9 RNC on Change in Condition Assessment, Interventions and Documentation on 4/18/24. 5. All licensed staff have been re-educated, by V2 DON, V9 RNC, and V16 QA Nurse Manager, on the process to utilize the Dialysis Communication Report including the completion of the facility required information on the communication report on 4/19/24. 6. All licensed staff have been educated, by V2 DON, V9 RNC, and V16 QA Nurse Manger, on Change in Condition Assessment, Interventions and Documentation on 4/19/24. 7. V8 Dialysis RN was educated, by V2 DON, that when a physician order is received for a dialysis resident to communicate the order directly to the DON, and if unavailable, report to QA (Quality Assurance) Nurse Manager/ADON (Assistant Director of Nursing) on 4/19/24. 8. The facility Physician-Family Notification-Change in Condition, Emergency Pharmacy and Emergency Kits, and Dialysis monitoring and Observation were reviewed, by V1 Administrator and V9 RNC, on 4/19/24 with no changes being made to the policies. 9. In addition to the above the facility held an immediate QA meeting to address identified concerns on 4/19/24, completed chart audits for review of physician orders, dialysis monitoring documentation, wrote physician orders as needed between 4/26/24 through 4/29/24 and updated MARS and TARS to reflect Dialysis monitoring. The facility also has Dialysis company scheduled to do directed inservice to nursing staff on afternoon of 5/2/24.

Based on observation, interview, and record review, the facility failed to provide supervision and assistance for two of six residents (R68 and R23) reviewed for falls in a sample of 29. This failure resulted in R68 being sent to the hospital for pain and a fractured femur requiring surgery. Findings include: The facility's Fall Prevention Program policy, revised 11-21-17, documents Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls an implementation of appropriate interventions to provide necessary supervision and assistive devices are utilize as necessary .Fall/safety interventions may include but are not limited to: Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet .Residents at risk of falling will be assisted with toileting needs as identified during the assessment process and as addressed on the plan of care. 1. R68's Minimum Data Set/MDS assessment, dated 12-26-22, documents R68 is severely cognitively impaired; requires limited assist with one person physical assist for bed mobility and toilet use; requires supervision with one person physical assist for transfers; and is occasionally incontinent of bladder. R68's Fall Risk Assessment, dated 3-3-23, documents R68 is at risk for falls. R68's Progress Note, date 3-3-23, documents: Resident's roommate (R54) called for help down the hall. CNAs and this nurse entered room and found resident sitting on the floor in front of the toilet, facing the door. Observed resident's left leg pointing outwards in an unusual angle and resident c/o (complained of) severe pain in that leg. Resident denies hitting her head. 911 was called and resident was put on a stretcher to be sent to (local hospital) ER (emergency room ) for evaluation. R68's Progress Note, dated 3-3-23, documents facility received call from local hospital. States resident does have a fracture in femur of left leg. R68's Fall IDT (Interdisciplinary Team) note, dated 3-6-23, documents: Late Entry: Summary of the fall: Resident's roommate called down the hallway for help, stating resident was on the floor in the bathroom. Resident stated 'I was trying to go back to bed after going to the bathroom and fell ' .Root cause of fall: Abnormal gait and lost balance while ambulating without assistance. R68's Hospitalist Note, dated 3-7-23, documents Left Proximal Femur Fracture status post IM (Intramedullary) nailing 3-4-23. On 6-23-23, at 12:20pm, V12 Certified Nursing Assisant/CNA stated the following: It (R68's 3-3-23 fall) happened in the middle of the nightshift. Before this fall with a fracture (R68) had been going independent to the bathroom. (R68) walked herself in there. Not sure if (R68) was supposed to or not .Not sure what (R68's) care plan says. (R68) took herself. I didn't know (R68) was in the bathroom until the roommate (R54) called for help. (V13 CNA) and I went in the room together and (R68) was on the floor in an awkward position. (R68) did not say what happened. (R68) was in so much pain and literally going into shock. On 6-23-23, at 2:37pm, V13 CNA stated the following: (R68) was pretty independent and would ask for help if needed .We heard yelling and the call light had been turned on by the roommate (R54). At that point (R68) had fell in the bathroom. We didn't know (R68) was in the bathroom. Normally (R68) did take herself to the bathroom and if needed help would call .I can't remember what (R68's) chart said or the care plan. It was five months ago. But I would have known if (R68) needed supervision. I can't recall (R68) needing supervision. On 6-23-23, at 10:58am, R54 (R68's roommate) stated: They do leave (R68) in the bathroom then go do something else. They did that this morning. They'll come back in maybe 10 minutes. (R68) is confused. They should probably stay with her. On 6-23-23, at 11:14am, V14 Certified Nursing Assistant/CNA and V15 Physical Therapy Assistant/PTA assisted R68 to walk from a wheelchair to the bathroom toilet. A healed incision line noted to R68's left hip. R68's Progress Note, dated 4-29-23, documents: Description of fall: resident was transferring from toilet to wheelchair and fell .Investigation of 4/29 fall: resident states was transferring from toilet to wheelchair and fell ; forgets to use call light. R68's Interdisciplinary Team/IDT Fall note, dated 5-1-23, documents: Late Entry: .Summary of the fall: Resident found on the floor of her bathroom sitting on her butt. Resident states she was transferring from the toilet to her wheelchair and fell .Root cause of fall: Transferring unassisted. On 6-23-23, at 11:41am, V14 CNA stated the following: In the mornings (R68) will sit on the toilet for a little bit for a bowel movement then will pull the call light cord when she is finished. This morning (V16 CNA) went to check on (R68) then came to get me to help get (R68) off the toilet. (R68) could walk before the fracture. (R68) is a fall risk. Everyone is really considered to be a fall risk. On 6-23-23, at 12:07pm, V16 CNA stated the following: (V9 CNA) and I put (R68) on the toilet . I told (R68) when (R68) was finished to put her light on and (R68) did. (V14) CNA helped me get (R68) off the toilet. On 6-23-23, at 1:42pm V2 Director of Nursing/DON stated that as per policy residents who are a fall risk or require assistance to shower or toilet should not be left alone in the shower or while on the toilet. R68 required assistance to toilet. 2. On 6-20-23, at 10:13am, R23 was in bed with a sling to R23's right arm. R23 stated that the other day R23 fell in the shower. R23 slipped when turning to put the faucet in a different direction and fell on to the wet floor. R23 hurt the back of R23's shoulder and got all bruised up. R23 stated R23 also went to the hospital for a fall. R23's clinical record documents R23 was admitted on [DATE] with a right humerus fracture and sling to right arm after multiple falls at home. R23's Fall Risk Assessment, dated 5-5-23, documents R23 is at risk for falls. R23's Minimum Data Set/MDS assessment, dated 4-24-23, documents the following: R23 is moderately cognitively impaired; requires extensive assist with two person physical assist for transfers, dressing, toilet use, and personal hygiene; requires limited assist with one person physical assist for walking in corridor; requires total dependence with one person physical assist for bathing/showers; R23's balance is not steady, only able to stabilize with staff assistance; and R23 has upper extremity impairment on one side. R23's Progress Note, dated 6-10-23 at 1:00pm, documents: Resident was heard yelling help from the shower room. CNA (Certified Nursing Assistant) checked and resident was sitting on the floor wrapped in towels. (R23) stated (R23) slipped on the wet floor. (R23) also stated (R23) hit her head on the wall when (R23) fell . On inspection redness and hematoma noted to upper part of right side of head. ROM (Range of Motion) WNL (within normal limits), denies any discomfort. R23's Progress Note, dated 6-10-23 at 1:50pm documents: Out of facility with ambulance crew to ER (emergency room ) for evaluation and treatment d/t (due to)nausea and vomiting after hitting head during fall. R23's Fall IDT note, dated 6-16-23 by V2 Director of Nursing/DON, documents Summary of the fall: Resident slipped on shower floor and hit her head. Root cause of fall: Resident was let into the shower room by housekeeping and nursing was not aware of her showering. Intervention and care plan updated: Education provided to housekeeping to not let residents into shower rooms or any other locked area without getting approval from nursing. On 6-23-23, at 3:08pm, V2 Director of Nursing/DON stated that housekeeping should not have let (R68) in the shower. (R68) needs someone to stay with her.

Based on observation, interview, and record review, the facility failed to notify the doctor, implement/develop non-pharmacological pain techniques, and administer prescribed pain medication per order for one (R10) of one reviewed for pain in a sample of 29. These failures resulted in R10 having an increase in pain to where he was unable to get out of bed, and was transferred to the hospital for pain control. Findings include: Facility Pain Management Program, revised 7/6/18, documents To establish a program which can effectively manage pain in order to remove adverse physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. It is the goal of the facility to facilitate resident independence, promote resident comfort, preserve and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish that goal through an effective pain management program. R10's electronic medical record documents an actual admitted [DATE] with the following diagnoses: Cellulitis of left lower limb; Multiple Sclerosis; Spastic hemiplegia (affecting one side); chronic pain syndrome; disease of spinal cord; and foot drop. R10's medical record dated 5/15/23 documents R10 is cognitively intact and requires extensive assistance of two plus persons for activities of daily living. R10's current careplan documents R10's admitted as 5/11/23 and has a focus of I have an ADL/Activities of daily living self-care performance deficit related to multiple sclerosis, spastic hemiplegia, left foot drop, cervical myelpathy, and trigger finger right ring finger pain. I am on pain medication therapy related to muliple sclerosis and cellulitis with an intervention of Administer analgesic (pain reliever) medications as ordered by physician. Monitor/document side effects and effectiveness every shift. I have Multiple Sclerosis and spastic hemiplegia with an intervention of give medications as ordered; pain management as needed; see physician orders; and provide alternative comfort measures PRN/as needed. I have chronic pain related to Multiple Sclerosis and Cellulitis with an intervention of anticipate the residents need for pain relief and respond immediately to any complaint of pain. R10's Medication Administration Record (MAR), dated 5/1-5/31/23, documents the following: dated 5/11/23 Pain assessment every shift every day and night where night pain was a 7/10 on a pain scale with 10 being the worst pain; at 6:40pm on 5/11/23 R10 was assessed for pain as pain as 10/10 and was given PRN/as needed Tylenol 650mg by mouth as needed every 4 hours for mild to moderate pain. R10's ordered Hydrocodone/Acetaminophen 7.5-325mg 1 tablet every 8 hours as needed for severe pain; Cyclobenzaprine 10mg as needed for muscle spasms three times a day; or Diazepam 5mg every 12 hours as needed for muscle spasms with a start date of 5/11/23 was not given. R10's MAR, dated 6/1-6/30/23, documents the following: dated 6/5/23 pain was assessed as a 4/10, and on 6/18/23 pain was assessed as a 3/10; and was given PRN/as needed Tylenol 650mg by mouth as needed every 4 hours for mild to moderate pain. R10's ordered Hydrocodone/Acetaminophen 7.5-325mg 1 tablet every 8 hours as needed for severe pain; Cyclobenzaprine 10mg as needed for muscle spasms three times a day; or Diazepam 5mg every 12 hours as needed for muscle spasms with a start date of 5/11/23 was not given. R10's MAR further documents no PRN Hydrocodone was given on 6/5-6/7/23 and 6/18/23. On 6/6/23 Cyclobenzaprine was given twice and Diazepam was given once. On 6/18/23 Cyclobenzaprine was given once and Diazepam was not given. R10's nurses note, dated 6/7/23 at 3:04am by V7 RN/Registered Nurse, documents Shortly after the writer arrived on duty, resident verbalized he was having pain. PRN (as needed) Norco 7.5/325mg (milligrams) not yet available from pharmacy. At 7:17 PM, I gave resident prn Valium 5 mg. and prn Flexeril 10 mg. When I later gave room mate his scheduled meds, (R10) became upset wanting to know when his Norco would be coming. He was slamming things around in his room and cussing. He then called his son who called me about the Norco. I informed his son what meds I had given him while we wait for the Norco to arrive. Ordered med is NOT available in facility PIXUS system. I phoned pharmacy and was informed the script had been filled and would be in the next delivery we receive. I informed resident. He then came to the south dining room and watched a movie with another resident till about midnight. He returned to his room. A short time ago I heard resident cussing and slamming things at his bedside. He then came to the dining room as facility phone rang at 2:40 AM. Resident had called 9-1-1 to go to hospital. I printed appropriate paperwork. A police officer came to facility prior to ambulance and spoke with the resident until ambulance arrived. Resident stated you're a Liar to me. Left via ambulance at 2:49 AM. I phoned (local hospital) ER and let the nurse know (R10) was enroute and what prn meds I had given. (R10) took his phone with him and informed me his son knew he was [NAME] to the hospital. Local Pharmacy Patient Dispense History documents Hydrocodone 7.5-325mg tablet 7 day supply was delivered on 5/11/23, 6/6/23, and 6/19/23. On 6/20/23 at 10:30am, R10 was in his room in an electric wheelchair, alert and oriented, left foot red and swollen, and two 1/4 siderails on his bed to assist with mobility. R10 stated he is not getting his pain medications and over the last month he has had multiple days no pain medication available; He had three consecutive days no pain medications (6/5-6/7/23), went into withdrawals, and was sent out to the hospital for pain control. On 6/18/23 stated he did not get pain meds (vicodin but got them today 6/20/23) because they had to wait for them to come in. R10 stated his pain is a 7 but when he did not get his pain meds it was a 10/10, and he did not get out of bed those days. I have been taking Vicodin (norco) for a long time and I see a pain doctor in [NAME]. The staff are aware my pain medication was not here and they did not do anything about it. On 6/23/23 at 10:58 AM V2 Director of Nursing/DON stated We did not stock Norco in our Cubex/pixis or in our emergency medications prior to the incident with (R10) on 6/7/23 so there was none on hand to give to him; I am aware (R10) went to the hospital due to pain on 6/7/23 ; I am not sure why we never had it here and why he went three days without it. If a person admits in the afternoon it can be the next day about 6pm before we get their medications; I am not sure why they deliver at 6pm every day; yes pharmacy can come multiple times a day and have before; and if we order/call for stat (immediate) medications they can get it to us in an hour. Quite frankly I am looking for a new pharmacy; ours comes from Burr Ridge about an hour away; I do not know if we utilize a local pharmacy for medications that aren't here, we never have since I have been here (March 2023). V2 verified R10 did not get any Norco on 5/11/23, 6/5-6/7/23, and 6/18/23 due to no 7.5-325 Norco available in the facility but verified there was 5-325mg Norco available in their Cubex/pixis during those dates. On 6/23/23 at 11:19am V2 stated What we had in stock was the Norco 5/325mg and (V10) is taking the 7.5/325mg tablets. I have a call to our pharmacy rep to see about a stat pharmacy to utilize, and none of the staff was aware of a local pharmacy to deliver medications. At that same time, V2 verified no nurse called R10's physician to obtain a different pain medication order, or to implement any nonpharmacological pain interventions.

Based on interview and record review, the facility failed to ensure a residents dignity in a public place, while providing transpiration assistance to an out-of-facility appointment. This failure resulted in R1 experiencing ongoing embarrassment and humiliation. FINDINGS INCLUDE: The facility policy, Dignity, dated (revised) 4/23/2018 directs staff, The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his or her self-esteem and self-worth. The facility Transportation Log, dated February 2023 includes the following information, Thursday, February 23, 2023 (R1) Eye appointment at 2:15 P.M. On 2/28/23 at 9:02 A.M., R4 (R1's roommate) stated, (R1's) not here. (R1's) in the hospital. (R1) had been complaining of her leg hurting and they (facility staff) finally sent her to the hospital. I have never ridden in the facility van, but (R1) has. You need to talk to (R1) about it. It was bad. (R1) talked about it, constantly, for days. (R1) said it was a horrible, embarrassing situation. (R1) told me they took her to an appointment, and all she had on was a gown and socks. They didn't put foot pedals on her wheel chair and her socks got caught and she almost fell out of the wheelchair. She was so upset and embarrassed because bystanders had to help put her back in her chair, hold her legs up so the girl (V3/Transpiration Aid) could move her chair and her gown kept blowing up because of the wind. (R1) was still crying everytime she talked about it. On 2/28/23 at 10:13 A.M., V4/R1's Power of Attorney stated, Yes, I am aware of the situation that occurred on 2/23/23 when facility staff transported (R1) to an eye doctor appointment without sufficient staff to assist and with (R1) dressed inappropriately for the weather. (R1) called me immediately when she returned from the appointment. (R1) was crying and very distraught. (R1) kept saying it was the most embarrassing and horrible thing that had ever happened to her. (R1) said they were unable to use her regular wheelchair to transport her and had placed her in a smaller wheelchair and didn't put the footrests on the chair for her feet to rest on. They took (R1) out of the building in only a house dress and socks. (R1) wasn't wearing a jacket and (R1's) legs were exposed. (R1) said (V3/Transportation Aid) had taken her to other appointments, but that another person always went with to assist. For this appointment, they sent (V3/TA) by herself without assistance. (R1) is unable to hold her legs up and (R1) weighs almost 370 pounds. (R1) told me once (V3/TA) got her out of the van, she was unable to push (R1), because (R1's) feet kept dragging on the pavement. (R1) told me she almost fell completely out of the wheelchair two different times, and it took the assistance of bystanders to lift (R1's) legs up and assist in pushing (R1's) wheelchair into the eye doctor's office. (R1) says it was very windy outside and her dress kept flying up and (R1) was exposed. After the appointment, it took assistance from staff at the eye doctor's office and even a couple of managers form the next-door jeweler's office to get (R1) back in the van. Besides being so humiliated and cold due to the outside weather temperatures, (R1's) lucky (R1) wasn't seriously hurt. On 2/28/23 at 10:27 A.M., V3/Transpiration Aid (TA) stated, When I was told to take (R1) to this appointment (2/23/23), I went to (V1/Administrator) and I told (V1) I needed help with R1 as (R1) is too heavy. V1 told me, You'll be fine. Figure it out. I told (V1) again I wasn't comfortable, but (V1) wouldn't get me any assistance. When I went to get (R1), it took three other cnas to help get (R1) from (R1's) regular wheelchair into this smaller chair. I believe, it was V5 and V6/CNAs and I can't remember who else. I asked for some foot pedals for (R1's) chair, and they told me there wasn't any. I got (R1) loaded into the van and drove (R1) to the appointment. I unloaded (R1) from the van and then I had an incline to push (R1) up to get to the sidewalk. (R1) can't hold (R1's) legs up and they kept dragging on the ground. (R1's) socks would catch the cement. (R1) almost came out of her wheelchair totally, a couple of times. Every time I tried; (R1) would slip further down in her chair. Some bystanders came to help me. I know (R1) was crying, (R1) said she was so embarrassed. It was very windy and chilly out that day. At one point, (R1's) dress flew up and exposed (R1). I took my jacket off and wrapped it around (R1's) legs. I was very frustrated and angry that I hadn't gotten any help. It was embarrassing for (R1) and for me. When we left the appointment, some of the staff from the eye doctor's (office) and even a manager from the jewelry store came and held (R1's) legs up so I could push (R1) to the van. When we got back, I immediately went to (V1/Administrator) and (V8/Human Resources) and they told me all of it was my fault. On 2/28/23 at 10:59 A.M., R1 stated, (V3/Transportation Aid)) took me to my appointment, this past Thursday (2/23/23). (V3/TA) has taken me before, but she had help. I don't know why (V3/TA) didn't have any help this time. They put me in a different chair, because my regular chair won't fit on the facility van. They told me they didn't have any footrests that would fit this chair, so we left without them. It was so humiliating. My socks would snag on the concrete, and it would pull me almost completely out of the chair. I kept trying to push myself back into the chair, but I couldn't get myself all the way back. I can't hold my legs up off the ground and they kept dragging. My dress kept coming up because of the wind. (V3/TA) gave me her coat to cover my legs. People kept coming by to help. Finally, a nurse from somewhere and the manager of a jewelry store came and kept my legs lifted up and (V3/TA) could push my chair into the doctor's office. It was very cold and windy. I was really upset, and my legs were freezing cold. None of this is (V3's) fault. She needed help. I've been so upset about all of this, since it happened. I haven't been able to stop crying. I was so humiliated and embarrassed. At that same time, R1 stated she was not going to return to the facility upon discharge from the hospital. I'm never going back there. On 3/1/23 at 8:49 A.M., V2/Interim Director of Nurses (DON) stated, When a resident leaves the facility for an outside appointment, the expectation is that the resident is fully clothed, preferably in their own clothing, with the appropriate outside garments on, depending on the weather. Including shoes and socks. If a resident prefers to leave the facility in a dress or a skirt, their legs should be completely covered with a blanket or lap robe to ensure their dignity. A resident should never leave the facility in only a gown and socks. If a resident requires footrests on their wheelchair, then they should always have those footrests in place to prevent accidental ejection from their wheelchair or injuries to their feet, ankles, knees or legs. On 3/2/23 at 8:45 A.M., R1's personal belongings were packed in boxes on top of her bed. No clothing or personal items were present in R1's closet or dresser drawers. At 9:40 A.M., V1/Administrator confirmed R1 was not returning from the hospital to the facility. V1 also confirmed that (R1) was going to another facility.

Based on interview and record review the facility failed to implement pressure relieving interventions to prevent pressure ulcers for one resident (R1) of three reviewed for pressure ulcers in a sample of three. This failure resulting in R1's pressure ulcer worsening and being sent out to hospital. Findings include: The facility Pressure and Skin Condition Assessment, revised 1/17/18, documents to establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. The residents care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care. R1's Braden score, dated 6/8/22, documents a score of 17, indicating that R1 is at risk for pressure ulcers. Facility wound tracking report documents on July 30, 2022 for R1 documents coccyx IAD (incontinence associated [CONDITION(S)]) measuring 1.6 cm in length and 1.1 cm width. Facility wound tracking report docuements on August 6, 2022 for R1 documents coccyx IAD measuring 6.5 cm length and 4.3 cm width. R1's Progress Notes, dated 8/15/22, documents that during wound care and extreme odor and copious amounts of green pus was draining from the wounds on R1's coccyx. V4, R1's Primary Care Physician, was notified and orders were received to sent to the emergency room for an evaluation. This form documents that R1 was admitted to the hospital for a wound infection. V5's (Wound Doctor) Wound Care Notes, dated 8/2/22, documents that R1's has a stage 3 full thickness pressure ulcer to the right buttocks, measuring 2.5cm (Centimeters) by 15cm by 0.1cm. The wound has moderate serous drainage with 15 percent slough. R1's right buttock wound required surgical debridement at the bedside. Wound care orders were given for Leptospermum honey-apply and alginate calcium three time weekly for 30 days. V5's wound care notes, dated 8/9/22, documents that R1's right buttocks wound is unstageable due to necrosis. The wound measures 3. 5cm by 2.0cm by 0.1cm, with 30 percent slough. R1's stage four coccyx wound measures 8.0cm by 7.0cm by 0.3cm with 2cm of undermining at 6:00 O'clock. A strong odor and a moderate amount of purulent exudates (draining) noted. This wound has a surface area of 56.0cm and 80 percent of thick adherent devitalized necrotic tissue. Sodium hydrochlorite solution one quarter strength, pack wound daily and apply zinc ointment daily for 30 days. On 8/22/22 at 1:00pm, V3, RN Hospital Registered Nurse, stated that R1 was admitted to the Intensive Care Unit for [CONDITION(S)] ([CONDITION(S)]-resistant Staphylococcus Aureus) of her coccyx wound requiring intravenous antibiotics. V3 stated that the wound on her coccyx is tunneling and is almost into the spinal column. On 8/23/22 at 12:30pm, V5, Wound Doctor, stated that R1 would require repositioning every two to three hours to prevent the pressure ulcers and a pressure relieving mattress. On 8/23/22 at 12:45pm, R1 stated that she was not turned or repositioned for hours at a time. R1 verified that she did not get out of bed while at the facility. R1 stated that on weekends her dressings were not changed every day. On 8/23/22 at 11:40am, V2, Director of Nursing, stated that she did venous wounds of bilateral lower extremities, but did not have any pressure ulcers on her bottom. V2 verified that R1's bed mobility is not signed out every two hours as required. V2 also verified that R1's care plan does not have pressure ulcer preventative interventions in place, should have had them in place on admission.

Noncompliance resulted in two deficient practice statements: A. Based on observation, interview, and record review, the facility failed to monitor the placement and function of personal alarm bracelets for four of five residents (R33, R57, R69, R176) and failed to ensure appropriate interventions were implemented for a resident assessed as high risk for wandering, provide supervision when a daily wandering, cognitively impaired resident exited the building, failed to ensure that the South East exit door's alarm was enabled and in working condition, failed to recognize the incident of elopement as an elopement and failed to report the elopement occurrence to State Agency, for one of five residents (R43), reviewed for elopement, in a sample of 36. These failures resulted in R43 not being adequately supervised and exiting from the facility on 2/17/22 around 2:00 P.M. Facility staff did not observe R43 exiting the building and were unaware that R43 left the building in winter conditions, for approximately 11 minutes, before another resident alerted staff to the missing resident. Post-incident, R43 was observed via the facility video camera slipping off the sidewalk, falling to her knees and falling against the facility garage, hitting her head, and found laying in the snow within one to two feet of a major river bank, which is located just behind the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 4-29-22, the facility remains out of compliance at Severity level II, as the facility continues to educate staff on elopement precautions and the facility's policy and procedure for monitoring residents at risk for elopement , Code Pink (Elopement-missing person) drills continue to be performed weekly for one month and monthly thereafter for 6 months, Exit doors secured with an alarm are tested daily for 30 days then weekly, and continues to implement their Quality Improvement auditing tool regarding compliance with the elopement incident and their plan of action. FINDINGS INCLUDE: 1. The (undated) facility policy, Elopement Risk Assessment, directs staff, To identify residents who may be potentially at risk for elopement and at risk for harm. To use as a baseline to maintain a secure resident environment. An elopement risk assessment will be performed during the admission process; reviewed/updated quarterly and when there are documented changes in mood or behavior which indicate the potential for elopement. A Social Service Department will conduct the elopement assessment during the admission process, when there is a significant change in mood or behaviors and quarterly. Risk factors will be assessed including the following: Independent ambulation with or without assistance; Pre-admission or history of elopement; Purposeful exit seeking; Restless, aimless pacing; Verbalization of wanting to leave the facility and/or go home; Grabbing doorknob or pushing on exit door; A cognitive impaired individual who is a follower; Inability to differentiate safe from unsafe situations; Diagnosis of Alzheimer's, Dementia, [CONDITION(S)], Brain Injury; Inability or refusal to follow instructions; Should an elopement risk be determined, interventions will be immediately initiated to protect the resident in a reasonable manner and as approved by the physician. The Social Service Department will notify Facility Staff and initiate interventions necessary to protect the resident. Interventions include, however, are not limited to the following: Relocation to Secure Unit, Bed Alarm and/ or Chair Alarm, Use sign in/sign out, Psychological Consultation, Personal Alarm Arm or Ankle Bracelet, 15 minute to 1 Hour observations, One - to- 0ne observation, Behavior Management Programs. In the event the assessment was initiated because of an elopement (where the resident's whereabouts are unknown), the elopement will be reported in accordance with the facility's Accident/Incident Unusual Occurrence Policy. The facility policy, Incident/Accidents, dated (reviewed) 1/5/22 directs staff, The Incident/Accident Report is completed for all unexplained bruise or abrasions, all accidents or incidents where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors or other, and resident -to-resident altercations. An accident is defined as any happening, not consistent with the routine operation of the facility, that results in bodily injury other than abuse. An incident/accident report will be completed for: All serious accidents or incidents of residents; All unusual occurrences; All unexpected events that occur that cause actual or potential harm to a resident or employee; Leaving premises without authorization. The Director of Nurses, Assistant Director of Nurses, or Nursing Supervisor must notify the following if an actual injury occurs: (State Agency), by phone, within twenty-four hours of the occurrence. The (State Agency) is to be notified of the following: any incident or accident which has, or is likely to have, a significant effect on health, safety or welfare of a resident. The facility's Elopement Device policy, revised 1-5-22, documents Purpose: To establish procedures for ensuring personal elopement devices are used in accordance with identified risk, physician orders and to ensure the security system is inspected to identify malfunctions should they occur. This policy also states Procedure: 7. The anklet or bracelet device will be inspected by nursing personnel once each day by: a. Inspecting the location of the device on the arm or leg. B. Placing the transmitter tester near the anklet or bracelet to test the battery for proper working order. R43's facility Admission Record documents that R43 was admitted to the facility on [DATE] from another facility with the following diagnoses: Alzheimer's Disease, Anxiety, Abnormalities of Gait and Mobility, Unsteadiness on feet. R43's Admission Elopement/Unauthorized Leave Risk Assessment, dated 12/10/21 and signed by V9/Social Services Director documents, (R43) has a a diagnosis of Dementia, Has reported/documented episodes of elopement, Has signs of compromised decisional capacity and substantially impaired judgement and/or physical status limitations that would place the resident at risk in the community. This form also documents, Elopement Risk decision: (R43) appears to be: At risk to elope and should be placed on the Elopement Risk Protocol. A care plan for Elopement is indicated. R43's Admission Care Plan, dated 12/10/21 includes a care plan for R43's elopement. No intervention to show that a Personal Alarm Bracelet was placed on R43, is included. R43's Minimum Data Set Assessment, dated 12/17/2021 documents under Section C: Cognitive Patterns- BIMS (Brief Interview for Mental Status) 03:15 (cognitively impaired). This same form documents Section G: Functional Status- able to walk, not steady but able to stabilize without staff assistance. R43's Treatment Administration Records for December 2021, January 2022 and February 2022 show that a Personal Alarm Bracelet wasn't placed on R43 until 2/18/22. R43's Nursing Progress Notes, dated 12/11/2021 at 6:50 P.M. document, (R43) having increased anxiety, exit seeking, requested (as needed medication) to be increased to (twice daily). R43's Nursing Progress Notes, dated 12/26/2021 at 12:28 A.M. document, After supper, (R43) became very fretful and worried about how she was going to get home. (As needed antianxiety medication) given at 6:30 P.M. (R43) wandered hall, crying and worried. Emotional support and reassurance given. (R43) walked with another resident for awhile. (R43) directed to room multiple times. (R43) would only stay a few minutes before wandering into hall again. R43's Nursing Progress Notes, dated 2/10/2022 at 1:55 P.M. document, Wandering a lot today. Easily redirectable for very short periods. R43's facility CNA (Certified Nursing Assistant) documentation, dated 12/25/2021 through 4/28/2022 document that R43 wanders the facility daily. R43's Nursing Progress Notes, dated 2/17/2022 at 2:20 P.M. and signed by V6/Registered Nurse document, At (2:00 P.M.) Southeast alarm door went off, a resident (R16) came to the dining room and said (R43) was outside. Staff ran outside and brought (R43) back inside. Full body check done, no bumps, bruises or redness noted. (R43) denies any discomfort anywhere. R43's facility Resident Monitoring form, dated 2/17/22 documents, February 17, 2022 at 1430 (2:30 P.M.) Sitting in chair, in dining room, smiling. Documentation by facility staff, every 15 minutes from 2:30 P.M. until 5:30 P.M. documents, Sitting in dining room. Documentation at 1745 (5:45 P.M.) and 1800 (6:00 P.M.) is blank. No further documentation after 6:00 P.M. is present. R43's Nursing Progress Notes, dated 2/18/2022 at 8:09 A.M. and signed by V2/Director of Nurses document, Summary of Inter Disciplinary Team: (R43) was outside the facility. (R43) was confused and unable to get back into the facility. Upon return inside, vitals (vital signs) were taken and all WNL (within normal limits). Put on 1 to 1 monitoring for the rest of the day and then put on 15 minute checks. Will discuss with family potentially finding a secured dementia unit, for placement. R43's Physician Order Sheet, dated February 2022 document on 2/18/22 at 8:54 A.M., Placement of code alert (personal alarm) bracelet. Monitor placement and function every shift. R43's Nursing Progress Notes, dated 2/18/2022 at 4:48 P.M. document, Late appearing bruise from incident of 2/17/22 observed to (R43's) left forehead/temporal area. POA (Power of Attorney) notified and would like a CT (Computerized Tomography) Scan. (R43) going to (local emergency room ), R43's Hospital emergency room Report, dated 2/18/22 documents, (R43) presents for a fall that happened approximately 24 hours prior to arrival. Physical Exam: Head- hematoma noted to the left forehead, unable to discern if that is from this recent fall. CT Scan of head and cervical spine negative. Disposition: Return to facility. Follow Head Injury instructions. Return for any worsening of condition. On 4/25/22 at 10:05 A.M., R43 was up ambulating, slowly and independently, throughout the facility SouthEast hallway, mumbling to herself. A personal alarm bracelet was present on R43's left ankle. Facility staff that were assisting other residents repeatedly instructed R43 to have a seat in the South dining room/day room. R43 ignored the instructions and continued to wander. Visualization of the facility South East exit door at that time showed a white piece of standard sized printing paper with the words, Please remember to reset alarms taped to the exit door. At that time, V3/Licensed Practical Nurse (LPN) stated, That's up there to remind staff to turn the door alarms back on, if they go out the door. V3/LPN also stated, (R43) got out that door sometime in February (2022). I wasn't working that night. (R43) has always been at risk for wandering. (R43) didn't have a code alert (personal alarm bracelet) on at the time. I don't know why she didn't. On 4/26/22 at 10:23 A.M., R43 was lying in bed, attempting to stand by herself. R43 was unable to answer questions and would repeat anything spoken to her. On 4/26/22 at 11:02 A.M., V4/(R43's) spouse stated, Someone called me from the facility the night she got out (2/17/22). They told me she had gotten outside and fell and hit her head and knees. They told me they found her in the snow. Thank God (R43) didn't fall in that river. (R43) would have been dead. I don't know why they didn't take (R43) to the E.R. then. She should have been seen by the doctor and tests taken. I finally had to insist, when they called me again, to take her to the E.R. to get a cat scan (CT Scan). No one ever told me about these bracelets (personal alarm bracelet) until after she had gotten out. Seems like (R43) should of had one on, from the start. I know (R43) has tried to get out that door a few times. On 4/26/22 at 11:10 A.M., V5/(R43's) Family Member stated, They (facility) called me the night (2/17/22) she fell . It was the nurse (V6/Registered Nurse). She told me (R43) had gotten out the door and they (facility) didn't know (R43) was outside. They told me (R43) didn't have a coat on and it was very cold and snowy that day. When they did find (R43) she had fallen and hit her head. They told me (R43) was laying by the side of the building. On 4/26/2022 at 1:12 P.M., V6/Registered Nurse (RN) stated, I was the nurse that was working the day that (R43) got out of the building. (R43) had been agitated that day, wandering and going to the doors. (R43) has a history of this. On that day, (R43) got out (of the building) without anyone seeing her. The (South East) door didn't alarm and (R43) didn't have an alarm on. I don't know why. I was down the hallway and I heard another resident (R16) say from the dining room, 'She (R43)'s outside.' (V8/Certified Nursing Assistant) ran outside and got her. It was cold outside and there was snow on the ground. (R43) only had pants and a sweatshirt on. She didn't have a coat on. (V8/CNA) said (R43) had fallen and she found her on the ground. We changed her clothes and covered her up with blankets. I checked (R43) out and didn't see any injuries. (V2/Director of Nurses) wasn't in the building, so I went to (V1/Administrator)'s office and told her what had happened. I sat with (V1/Administrator) and watched the video recording of it. The time lapse on the video showed (R43) had been outside for 10 to 11 minutes. It showed (R43) sliding off the sidewalk and hitting the building with her head. It showed (R43) back behind the building, within a foot of the river bank. Thank goodness she turned around or (R43) would have slid into the river. R176 is a wanderer and at high risk for eloping and he has a personal alarm bracelet on. I don't know why (R43) didn't have one on, until after she eloped. On 4/26/22 at 1:36 P.M., V8/Certified Nursing Assistant (CNA) stated, I've been a CNA for three years now and have worked at (the facility) since November 2021. I work day shift and I am usually assigned to the south halls. I've known (R43) since she was admitted . (R43) is a wanderer. (R43) is very confused. (R43) is usually up walking around and goes to the doors, often. Me and another CNA, I can't remember which one, went to change a resident. All of a sudden we heard (R54) yelling and saying, '(R43) is outside'. (R54) said she saw (R43) back behind the building, facing the river. I ran out the (South East hallway) door. We never heard an alarm go off when (R43) went outside and it didn't go off when I went outside. Somebody said later it had been turned off. It was cold outside and there was snow on the ground. When I saw (R43) she ran from me, towards the river. I was yelling at her to stop and then I slipped and almost fell down the bank. I was so scared. I don't know how to swim and I thought we were both going to drown. I saw (R43) fall when she turned back towards me and land on her knees. (R43) got up by herself and then slipped again and hit her head on the garage. When I finally got to (R43), I pulled her back inside. (R43) had jogging pants on and a black sweater. (R43) had shoes on, but not a coat. (R54) was cold and wet when I brought her back in. I changed her clothes and covered her up with blankets. On 4/27/22 at 10:10 A.M., V6/Registered Nurse stated, I don't know why I charted in (R43)'s chart that the alarm was going off when (R43) left the building. The alarm didn't go off, that's why we didn't know (R43) was outside. (R54) was in the dining room and saw (R43) out behind the building and alerted us. On 4/27/22 at 10:22 A.M., V9/Social Services Director (SD) stated, I've been doing this job for five to six months. I don't have a degree in social work. I don't have any college degree. I'm learning as I go. I am responsible for doing the elopement risk assessment when a new resident is admitted . If a resident is high risk (for elopement) they get a (personal alarm bracelet) put on. The doors have a sensor on them and when a resident with a (personal alarm bracelet) goes toward the doors, they lock down. (V15/Business Office Manager) keeps the alarms locked up in her office. I'm not sure what the nurse's do if they need one (alarm) when (V15/BOM) isn't here. I was here the day when (R43) went out the door. We didn't hear an alarm go off. We couldn't put an alarm on (R43) that day, after (R43) went outside. (V15/BOM) wasn't here to give us one. On 4/27/22 at 11:37 A.M., V1/Administrator stated, I was in my office on a telephone call when (R43) went out the door. We did not hear an alarm go off. (R43) exited the facility out the South East door. One of the CNAs saw (R43) and went and got her. I did not notify the state (State Agency) of the incident. (R43) didn't leave the grounds, so I didn't consider it (the incident) an elopement. I wasn't aware the alarm on the South East door wasn't working. On 4/27/22 at 11:48 A.M., V2/Director of Nurses (DON) verified that the facility Elopement Risk Assessment defined an elopement as, where the resident's whereabouts are unknown. V2/DON also verified that (R43)'s exit out the facility South East door would be called an elopement, as the facility staff did not know that (R43) had left the building and another resident (R54) alerted staff to her whereabouts. V2/DON verified that R43 was assessed on admission and was at high risk for eloping and a personal alarm bracelet should have been placed at that time. V2/DON stated, A (personal alarm bracelet) was placed on (R43) on 2/18/22. 2. On 4-25-22, at 9:55 A.M., R33 was ambulating near an exit door with a personal alarm bracelet noted to R33's left ankle. R33's current Care Plan documents R33 is an elopement risk/wanderer and includes an intervention of wearing a (personal alarm) to left ankle, dated 2-7-22. R33's Medication Administration Records/MARs and Treatment Administration Records/TARs, dated February - April 2022, do not include any monitoring of the placement or function of R33's personal ankle alarm. 3. On 4-25-22, at 11:35 A.M., R57 was seated in a wheel chair near the South Hall nurse's station with a personal alarm bracelet noted to R57's ankle. R57's current Care Plan documents R57 is an elopement risk/wanderer and includes an intervention of wearing a (personal alarm) to the ankle. R57's Medication Administration Records/MARs and Treatment Administration Records/TARs, dated February - April 2022, do not include any monitoring of the placement or function of R57's personal ankle alarm. 4. On 4/28/22 at 9:10 A.M., V69 was laying in bed. A personal alarm bracelet was present of R69's ankle. R69's current Care Plan documents that R69 wanders aimlessly and has a diagnosis of Alzheimer's Disease. This same care plan includes an intervention of a personal alarm bracelet to the ankle. R69's Medication Administration Records, dated February 2022, March 2022 and April 2022 document staff as only checking R69's personal alarm bracelet daily, instead of the facility required twice daily. 5. On 4/28/22 at 9:48 A.M., R176 was ambulating near the North Hall nurse's station. A personal alarm bracelet was present on R176's ankle. R176's current Care Plan documents that R176 is an elopement risk/ wanderer and includes an intervention for a personal alarm bracelet, which was initiated on 4/19/22. R176's Medication Administration Record, dated April 2022 does not include monitoring for the placement or function of R176's personal alarm bracelet until April 27, 2022. On 4-27-22, at 12:25 P.M., V2 Director of Nursing/DON stated the following: There are no TARs for (R33). There is no order for monitoring of (R33's) personal alarm for placement and function (which would trigger it on the TAR) and there should be. It should be documented somewhere, but it isn't. At that time, V2/DON also verified that R57, R69 and R176's personal alarm bracelets were not being monitored for place or function, as recommended. An Immediate Jeopardy was identified on 4-27-22 at 3:30 P.M. The Immediate Jeopardy began on 2-17-22 when R43 exited the building unattended, through an unalarmed door and without facility knowledge. On 4-28-22 at 8:30 A.M. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Staff were in-services/trained on elopement precautions and facility's policy and procedure for monitoring residents at risk for elopement on 4/28/22 by facility Management . Education will be ongoing. Staff on vacation or FMLA (Family Medical Leave Act) will be in serviced before returning to work by Administrator/Director of Nurses, nurse Management and HR (Human Relations). Administrator will monitor for compliance. End of the day 4/29/22 2. New hires will be trained on elopement precautions, Code Pink and Wanderguard System, as part of their General Orientation before starting by HR, Nurse Management or Social Services. At employee orientation prior to working the floor. 3. Social Services in-serviced by Administrator on proper elopement assessment and care plan initiation and interventions. 4/28/22 and ongoing 4. Resident Elopement Assessments for all residents reviewed and updated accordingly by the IDT (Interdisciplinary Team) team. Elopement Care Plans reviewed and updated by the IDT team. Resident Elopement Assessments and Care Plans will be reviewed by IDT at least quarterly and after any incident or resident change in behavior. 4/28/22 and ongoing 5. All staff educated by DON on identifying residents at risk for elopement and Policy and Procedure for reporting to leadership to ensure proper interventions/Care Plans are initiated timely. Residents at risk are/will be placed in red binders, at each nurse's station and the reception desk. 4/28/22 and ongoing 6. MD'S (Minimum Data Set) (Assessor) and DON assessed all current residents for elopement precautions and ensured all at risk residents have updated Care Plan and interventions, in place. If ankle monitoring device is being used the MAR (Medication Administration Record)/TAR (Treatment Administration Record) has been updated for functionality and placement pf code alert bracelet. 4/28/22 and ongoing 7. Code Pink (Elopement/Missing Person) drill was performed on 4/28/22 by Administration and will be performed weekly for one month and monthly thereafter for 6 months by Social Services, Nurse Management and Administration. Staff will be re-inserviced on Code Pink if/when revisions are made and upon annual review of annual policy by Social Services, Nurse Management and Administration. New hires will be inserviced on Code Pink during their general orientation. 4/28/22 and ongoing 8. Exit doors secured with an alarm will be tested daily by Maintenance and Manager-On-Duty, by opening door without the code to ensure that alarm sounds. Staff response time will be recorded daily to ensure proper response time by Maintenance and/or Manager-On-Duty. This will be tested daily for 30 days, then weekly. QA (Quality Assurance) Tool in place and will be completed by Maintenance and Manager-On-Duty. 4/28/22 and ongoing 9. A Wander Guard bracelet will be placed in a blue, plastic envelope, marked with Code Alert, in the North (Hall) Med (Medication) room, so that the nursing staff always has access to a Code Alert bracelet. DON or designee will check daily to ensure that the Code Alert bracelet is available to staff at all times in the North (Hall) Medication room. 4/28/22 10. QAPI (Quality Assurance and Performance Improvement) review with Medical Director to review elopement incident and plan of action. Action plan will be reviewed monthly at QAPI meeting. Medical Director approved plan with no further recommendations. 4/28/22 and ongoing 11. Medical Director notified of Incident on 4/28/22 in the facility by the Administrator and reviewed the facility's immediate action plan. He agreed with immediate action plan. 4/28/22 12. Emergency Care Plan initiated, R43 placed on frequent checks. R43 engaged with activities and other staff. Wander Guard placed on resident ankle to ensure safety of resident. 4/28/22 Completion Date: 4/29/22 B. Based on observation, interview and record review, the facility failed to implement appropriate fall interventions to prevent a fall for one of eight residents (R57), reviewed for falls, in a sample of 36. FINDINGS INCLUDE: The facility's Fall Prevention Program, revised 1/5/22, documents to assure the safety of all residents in the facility. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. R57's Fall Risk Assessment, dated 4/15/22, documents that R57 is at risk for falls. R57's Progress Notes, dated 4/15/22 at 10:45pm, documents that R57 was in southwest hallway in wheelchair and she bent forward attempting to pick something off floor when she fell out of her wheelchair hitting her head, staff was nearby at linen cart, resident noted to have hematoma forming on left forehead above eye, ice applied, neuro checks initiated and within normal limits for resident (R57). Resident (R57) assisted off floor and toilet and assisted back to bed. R57's Current Physician Order Sheet, documents that R57 take [MEDICATION(S)] 75mg daily for [CONDITION(S)] Heart Disease. R57 also has a diagnosis of an Aortic Aneurysm of unspecified site without rupture. On 04/25/22 11:35am, R57 has purple, blue, back eyes. R57's forehead is also purplish black and stated that it hurts above her left eye. R57 was unable to give specific details about how she received the bruising to her face. On 4/26/22 at V3, Licensed Practical Nurse, stated that R57 has leaned forward to pick up items that are on the floor for years. V3 verified that R57's current care plan does not have safety interventions in place for R57 leaning forward in her wheel chair to pick items off the floor that are not there. V3 also stated that R57 should have been sent to the emergency room for an evaluation, due to the head injury. On 4/29/22 at 11:00am, V14, RN, stated that any resident that is on an anticoagulant (blood thinner) should automatically be sent to the emergency room for an evaluation, with any type of head injury.

Based on interview and record review, the facility failed to complete a fall investigation and fall risk assessment and review and revise fall interventions following an unwitnessed fall for one (R1) of three residents reviewed for falls. These failures resulted in R1 experiencing a subsequent fall resulting in a right [CONDITION(S)]. Findings include: The facility Fall Prevention Program, Revised 12/20/20, documents the following: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. This same policy documents, The Fall Prevention Program includes the following components: Methods to identify risk factors. Methods to identify residents at risk. Assessment time frames. Use and implementation of professional standards of practice. Notification of physician, family/legal representative. Communication with direct care staff members. Documentation requirements. Care plan incorporates: Addresses each fall. Interventions are changed with each fall, as appropriate. Preventative measures. This policy also documents, A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. R1's quarterly MDS (Minimum Data Set) Assessment, dated 4/7/21, documents R1 is severely cognitively impaired and requires extensive assistance of staff for dressing, toileting, personal hygiene, bathing, and walking. This assessment documents that R1 requires limited assistance of staff for bed mobility, locomotion on and off unit, and with eating. This assessment also documents R1 is frequently incontinent of bladder and occasionally incontinent of bowels and has a history of falls. R1's Current Care Plan, documents R1 has had falls with minor injury related to rolling out of bed while attempting to change her clothing on 5/17/20, 5/26/20, and 5/26/20. This same Care Plan documents R1 had a fall on 4/11/21, 4/14/21, 5/11/21, 5/12/21, and 5/15/21. The Fall Risk Assessments for R1, dated 4/9/21, 4/11/21, 4/14/21, 5/11/21, 5/12/21, and 5/15/21 documented scores between 15 through 24, all indicating and documenting R1 is At risk for falls. On 6/10/21 at 2:40 pm, V2 DON (Director of Nursing) stated she does all the fall investigations at the facility. V2 stated if a resident falls, the Nurse is to assess the resident, start the initial fall report, document it in the resident's Progress Notes, make the notifications and send the initial report to State Agency if there is an injury. V2 stated the Nurses are to call her if a resident has a fall and if there is an injury, she will notify V1, Administrator. V2 also stated all resident falls are discussed in the morning meeting and interventions are put into place and placed on the residents care plan by herself or the Care Plan Coordinator. 1. The Progress Notes for R1, dated 5/24/21 at 4:00 am, documents Resident (R1) observed laying on the floor with a pillow on her head. This nurse asked resident if she put herself on the floor. She responded by saying, 'I don't know.' Resident was put back to bed with 2 persons assist. Will continue to monitor resident on this shift. R1's Progress Notes do not contain any further documentation, body assessment, fall assessment, or follow up documentation for R1's fall. R1's EHR (Electronic Health Record) does not include a follow up assessment, new Fall Risk Assessment, Care Plan review or revision, Neurological assessments post fall, required notifications, or Un-Witnessed Fall Report. On 6/10/21 at 1:25 pm, R6 stated (R1) was her roommate and fell quiet a few times. R6 stated, The last time she (R1) fell in our room, I was sleeping, it was dark out. I heard her hit the floor and woke up. I saw her near the end of the bed and she was trying to crawl back towards her bed. I hollered for the staff. They came real quick and put her back to bed. (R1) fell again later that morning and broke her hip but I didn't see that one. On 6/11/21 at 1:55 pm, V2, DON, stated she did not know that R1 had fallen on 5/24/21 at 4:00 am until now. V2 confirmed the night Nurse who discovered R1 had fallen at 4:00 am should have followed the fall protocol, initiated the fall investigation report and made the necessary notifications. V2 also stated she did not do an investigation for this fall because it wasn't reported to her and she was unaware. 2. The facility's Un-Witnessed fall Report #943 for R1's 5/24/21 fall at 7:20 am was initiated by V3, RN. V3 documented, I was called to residents room due to resident was sitting on her left buttock with her back against the side of the bed. No complaints to me regarding any pain at the time. Upon doing range of motion, she complained about right sided pain. This is being considered an un-witnessed fall but due to her position. She did not hit her head. Resident unable to give description. ROM (range of motion) appeared adequate except some pain when raising right leg. Placed in bed. No injuries observed at time of incident. A Late Entry Progress Note for R1 (dated 5/24/21) documented by V3 RN, documents, Resident (R1) had an un-witnessed fall 5/24/21 7:20 am. (R1) unable to say what happened. Assessment: Un-witnessed fall, neurological checks initiated. Alert and disoriented per usual baseline. No changes in range of motion from normal baseline. No injuries observed. Actions Taken: assisted into chair, after consultation with Hospice and family it was decided to send her to ER (emergency room ) for evaluation. The Progress Note for R1, dated 5/24/21 at 1:39 pm (in reference to R1's 7:20am fall) by V3 RN, documents, Was called to resident room by CNA to observe resident sitting on her left buttock on the floor in front of bed with her back resting against the side of bed. There was nothing she could have hit her head on. It appears she slid out of bed onto her buttock. Neuro (neurological) checks was within normal limits. No complaints of pain at this time. ROM was within normal limits for this resident. Placed resident in bed. The Progress Note for R1, dated 5/24/21 at 1:54 pm by V3 RN, documents, Hospice nurse arrived at 11:00 am. Spoke to Hospice, MD (Medical Doctor) and family about sending resident to (local hospital) for X-ray of right hip and pelvis. EMS (Emergency Medical Service) notified and took resident to Hospital. Resident left building at 12:05 pm. The Progress Note for R1, dated 5/24/21 at 2:07 pm by V2 DON, documents, Received call from Hospice nurse stating that resident will be revoking Hospice at this time and will be admitted to the hospital due to right [CONDITION(S)]. On 6/10/21 at 3:00pm, V3 RN (Registered Nurse) stated V6,CNA (Certified Nursing Assistant), called her to R1's room early in the morning on 5/24/21 because R1 was on the floor. V3 stated R1 was sitting on the floor with her back to the bed and was leaning to her left side. V3 stated she did a body assessment and there was no left leg swelling, no left leg bruising or left leg rotation and R1 did not complain of any pain at the time and her vital signs were good. V3 stated she, V5, CNA and V6, CNA got R1 up off the floor and put her into bed Later in morning, V5 and V6 got her up into a reclining wheelchair and took her to the dining room. V3 stated when the Hospice Nurse came to the facility around 11:00 am, she (V3) went with her to the dining room to check on R1. V3 stated at that time noticed R1's right leg rotating outward and R1 was complaining of right hip pain. V3 stated Hospice called R1's family and the decision was made to send R1 to the local hospital for an X-ray. V3 stated she received a call from Hospice later in the day that R1's right hip was fractured. V3 also stated there were no other incidents for R1 that day that were reported to her. On 6/11/21 at 11:11 am, V6, CNA stated she was working on the [CONDITION(S)] hall that day and was not involved with R1's fall, did not see R1 on the floor, and does not know anything about R1's fall. On 6/11/21 at 1:09 pm, V4 CNA stated she saw R1 in bed during her 6:00 am rounds when she first got to work but didn't see her again until after she fell . V4 stated she was in another resident room providing am cares at the time of R1's fall. She stated V6, CNA found R1 on the floor and notified V3, V5 , CNA helped get R1 off the floor into bed. The facility's Final Investigation report for R1, dated 5/28/21, documents on 5/24/21 at 7:20 am (R1) was observed on the floor beside her bed. No initial complaint of pain. Assessed by nurse and assisted into chair. About 30 minutes later she began to complain of right hip pain. Examination in ER (emergency room ) revealed a nondisplaced fracture of right hip. Surgery was performed. Care plan was reviewed and interventions added to increase monitoring while in bed at night. On 6/11/21 at 1:55 pm, When V2, DON, was asked about how she investigated this fall she stated, I talked with all the staff that work the unit, the roommate, and other residents or staff. I don't write up the interviews of the people I talk to. V2 stated she puts the summary into the Fall Report and on the Final Reports that are sent to the State Agency. V2 stated R1 was found on the floor at 7:20 am and there were no other staff or resident interactions. V2 confirmed V3 RN, V4, V5, and V6, CNAs, worked the unit on 5/24/21. V2 stated she doesn't know why she did not list V4 and V5 CNAs on the Fall report and does not know why V6 is saying she doesn't know anything about R1's fall. V2 also stated she had added to increase monitoring while in bed at night because the nurses work 12 hour shifts, 7:00 am to 7:00 pm. V2 stated she was not aware of R1's previous fall at 4:00 am, does not know what happened, and does not know if something else may have occurred between R1's 7:20 am fall and 12:05 pm when Hospice arrived at the facility and right hip rotation was seen and R1 complained of right hip pain.

Based on observation, interview and record review, the facility failed to follow their COVID-19 policy and The Centers for Disease Control and Prevention (CDC) COVID-19 guidelines for cohorting/room placement of residents and failed to notify resident care staff of three residents testing positive for COVID-19. These failures have the potential to affect the 44 residents that reside in the facility that have not contracted COVID-19. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 12/16/20, the facility remains out of compliance at a Severity Level 2, as the facility continues to educate nursing staff on proper placement of COVID-19 residents as well as proper process for notification of COVID-19 positive residents to staff. The facility also continues to ensure that transmission based precautions will be implemented for COVID positive residents and relocation to COVID positive zones will occur. Findings include: The facility's Infection Control-Interim policy addressing healthcare crisis related to Human [MEDICAL CONDITION] revised 11/6/2020 documents, Screening: The facility shall use a checklist-based screening protocol, administered verbally and recorded in written or electronic format, for each person entering the facility, including all staff, visitors, and other persons including state authorized personnel. The facility must deny access if any findings are positive. The facility must retain screening records according to the facility's record retention policy, but not for less than 30 days. Visitors and Vendors: Visitors will be screened using the questionnaire for symptoms, temperature will be taken and if there are no concerns they will be allowed to visit and provided a mask and alcohol gel to perform hand hygiene before entering resident area. Staffing Assignments in COVID positive units: Every effort will be made to designate staff to be assigned to COVID unit (red zone) only. Cohorting/ Room Placement: It might not be possible to distinguish patients who have COVID-19 from patients with other respiratory viruses. As such, patients with different respiratory pathogens will likely be housed on the same unit. However, only patients with the same respiratory pathogen may be housed in the same room. For example, a patient with COVID-19 should not be housed in the same room as a patient with an undiagnosed respiratory infection. Confirmed positive Residents only in the Red Zone- No PUI's (Person Under Investigation) pending results-- Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). Employee Return to Work Guidelines: This facility has adopted the symptom- based method for employee return to work if considered a PUI or confirmed positive for COVID-19, meaning no testing or re-testing with negative results will be required before returning to work. HCP (Health Care Personnel) with mild to moderate illness who are NOT severely immunocompromised: At least 10 days have passed since symptoms first appeared and at least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms have improved. Note: HCP who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed since the date of their first positive [MEDICAL CONDITION] diagnostic test. On 12/5/2020 at 7:30 AM V5/Certified Nurses Assistant/CNA allowed surveyor into the facility. V5/CNA had (state agency) wait at main nursing station on North hall as she went to get V3/Registered Nurse/RN. V3/RN was informed the (state agency) was there on a complaint investigation and stated he would notify V1/Administrator. Neither V3/RN nor V5/CNA screened the (state agency staff) for COVID-19. V3/RN stated there is positive COVID-19 residents in the facility and are all located on the Southwest hall. There are no COVID-19 positive residents on the Northeast, Northwest or the Southeast halls. (State agency) went into the conference room located off of the main dining room and then to the Southeast and Southwest(COVID-19) hall where V6/CNA and V10/CNA were at the nurses station wearing N95 masks. On 12/5/2020 at 7:35 AM, V6/CNA stated, Southwest hall is our COVID-19 positive hall. We have one resident (R1) that keeps testing negative but she has all the symptoms so she is (located in a room on the Southwest hall). (R1's) roommate (R2) has tested positive for COVID-19. I am working that hall today. At this time V10/CNA confirmed what V6/CNA stated above. On 12/5/2020 at 8:15 AM, V2/Director of Nurses/DON stated, (R1) keeps testing negative for COVID-19 but has all the symptoms that's why she is on the COVID-19 hall(Southwest). (R2) is positive for COVID-19. At this time V2/DON confirmed 44 of the 67 residents in house have not contracted COVID-19. R1's medical record documents R1 resides in a room on Southwest(COVID-19) hall and does not contain a [DIAGNOSES REDACTED]. between 96.4 and 98.8 degrees Fahrenheit. No other symptoms were found documented in R1's medical record. R1's Lab report documents a specimen for COVID-19 was collected on 11/18/2020 and a negative results was reported. R1's Rapid Point of Care Testing Report dated 12/10/2020 documents R1 tested negative for COVID-19. On 12/12/2020 at 1:08 AM, R1's room was observed on the Southwest (COVID-19 positive/Red Zone) hall. R2's medical record documents R2 resides in a room on the Southwest(COVID-19) hall and documents a [DIAGNOSES REDACTED]. On 12/5/2020, the facility's Daily Census sheet documents the following: Northeast hall had eight empty beds; Northwest hall had seven empty beds; and Southeast hall had six empty beds. All listed halls are non COVID-19 halls. The facility's Daily Census sheet dated 12/5/2020 documents R1's room as Southwest(COVID-19) 46-2 and R2 as Southwest 46-1. R4's Lab report dated 12/12/20 documents V2/DON was notified of R4's positive COVID-19 result on 12/10/2020 at 9:15 PM. R5's Lab report dated 12/12/20 documents V2/DON was notified of R5's positive COVID-19 result on 12/10/2020 at 9:16 PM R6's Lab report dated 12/12/20 documents V2/DON was notified of R6's positive COVID-19 result on 12/10/2020 at 9:17 PM On 12/12/2020 at 1:30 AM V1/Administrator stated she was not notified until 12/11/2020 that R4, R5 and R6 were COVID positive. V1 also stated that V2 did not notify any direct care staff working on 12/10/20 of R4, R5 and R6's positive COVID-19 test results. V1 stated V2/DON notified her on 12/11/2020 around 9:00 PM that V16/CNA was positive but not about the residents. At this time V1 stated V2/DON rapid tested R1 on 12/10/2020 and R1 was negative for COVID-19 and was moved to another room on the Southwest (COVID-19 positive) hall. The facility's Daily Census Sheet dated 12/5/2020 documents there are 67 residents residing in the facility. The Immediate Jeopardy was identified on 12/6/2020. The Immediate Jeopardy began on 11/11/2020 when the facility allowed a COVID-19 positive resident (R2) to cohort with a COVID-19 negative resident (R1). V1/Administrator was notified of the Immediate Jeopardy on 12/10/20 at 9:30 AM. V1 (Administrator) was notified of the Immediate Jeopardy on 12/10/20 at 9:30 AM. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: Actions completed by V1/Administrator and V2/Director of Nurses/DON: 1. On 12/10/2020 at approximately at 11:00 AM, R1 was moved to the Northeast (non- COVID-19) hall. 2. On 12/10/2020 all staff were inserviced on the CDC's guidance for infection control and cohorting of residents. Any staff on vacation or Family Medical Leave will be inserviced prior to returning to work. 3. On 12/11/2020, the facility's Quality Assurance Performance Improvement (QAPI) committee reviewed the infection control concerns, root causes and plan of action with the facility's Medical Director. 4. On 12/16/2020 V1/Administrator and V2/DON were inserviced on notification of staff on any positive COVID resident results and either DON or designee will place information on facility communication board immediately for all staff to have access and be notified upon start of their next shift.

Noncompliance resulted in two deficient practices: A. Based on interview and record review, the facility failed to ensure a resident's gown was secured during transport for one of seven residents (R55) reviewed for falls in the sample of 21. This failure resulted in R55 falling forward out of a wheelchair, sustaining nasal fractures and lacerations requiring 13 sutures. B. Based on observation, interview, and record review the facility failed to maintain a resident bathroom wall heater and bathroom floor tile in safe condition for two residents (R8, R11) of 20 residents reviewed for environmental conditions in the sample of 21. R8 and R11 are not on the sample. Findings include: A. The facility's Fall Management Guidelines policy (10/2014), documents Fall reduction/injury prevention strategies that can be implemented upon admission may include, but are not limited to the following: removal of trip hazards, use of appropriate footwear. The facility's investigation dated 4/18/18 documents on 4/18/18 at 7:05pm, R55 was transported from the shower room by V8, Certified Nursing Assistant/CNA, when R55's gown engaged with the wheel of the wheelchair causing a change of plane in a forward motion. The investigation documents R55's injuries as lacerations to the right eyebrow, nose, and upper lip, and right wrist, and nasal fracture. R55's Emergency Department (ED) report dated 4/18/18 documents Open fracture of nasal bone and [MEDICAL CONDITION]. R55's head Computerized Tomography (CT) dated 4/18/18 documents Mildly displaced and angulated bilateral nasal bone fractures with overlying soft tissue swelling. Mildly displaced [MEDICAL CONDITION] nasal septum. Component opacification of the maxillary, ethmoid, sphenoid sinuses, new from previous and may indicate component hemorrhage from nasal fractures. R55's ED follow-up Progress Notes dated 4/20/18 document (R55) had 12 stitches on the forehead and 1 (one) stitch on the base of the nose laceration. R55's Minimum Data assessment dated [DATE] documents R55 is severely cognitively impaired and requires extensive assistance with transfers and activities of daily living. R55's fall risk assessment dated [DATE] documents R55 is at risk for falls. R55's fall risk assessment dated [DATE] documents R55 is not at risk for falls. On 5/16/18 at 10:15am, V8, CNA, stated (V8) was transporting R55 in a wheelchair from the shower room, when R55 began to lean forward and R55's gown caught in the wheelchair wheel and went under the wheel, causing R55 to fall forward onto (R55's) face. On 5/16/18 at 10:30am, V2, Director of Nursing, stated the root cause of R55's fall was (R55's) gown getting caught in the wheelchair wheel. V2 stated V8 was retrained on fall precautions and keeping residents' gowns tucked underneath them during transport. B. The facility's Maintenance Services Policy (04/2017) documents 1. Maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe manner at all times. 2. It is the job of all staff to identify areas of concern regarding maintenance of the building. On 05/16/18 at 2:30PM, R8 and R11's resident bathroom's wall heating unit was missing the front cover leaving sharp and jagged edges exposed, and the bathroom floor tile had a hole measuring 5.5 (five and one-half) inches in length, 1.75 (one and three-quarters) inches at the widest width, and 3/8 (three-eighths) inch deep. On 5/16/18 at 2:30pm, V7, Maintenance Director, confirmed the missing front cover of the heater exposing sharp and jagged edges and the missing chunk of floor tile. V7 stated these areas could be hazardous to residents using the bathroom. V7 stated (V7) was unaware of these conditions, and that work orders had not been completed for them. V7 provided the work orders and none were present for the heater or floor tile. On 5/16/18 at 2:35pm, V14, Certified Nursing Assistant, stated R8 and R11 use the resident bathroom.

Based on interview and record review, the facility failed to protect one resident from an episode of physical abuse. R49 was struck in the face with a support cushion by E16 causing R49 emotional distress and anger that still continues. R49 was one of four residents reviewed for allegations of abuse in the supplemental sample. Findings include: 1. R49's Investigation of Physical Abuse Report dated 5/24/16 documents that at approximately 6:40 PM on 5/24/16, it was witnessed by E15 (Dietary Aide) that E16 (former CNA/Certified Nursing Assistant) had hit R49 in the face with R49's support cushion from R49's chair. E15's (Dietary Aide) written statement dated 5/24/16 documents the following: I came out of the kitchen and walked towards south (hallway). I saw (E16, former CNA) pick up a pillow off of the floor and hit (R49) in the face with the pillow. (E16) told (R49) to stop it or (R49) was going to fall on the floor and (E16) was not going to pick (R49) up. (R49) said something and (E16) smashed the pillow in (R49's) face and hit (R49) a few times. (E16) then pushed (R49) to the North dining room and left (R49) there. I went and told (E17, Activity Director). E1's (Administrator) written statement dated 5/24/16 documents that E15 (Dietary Aide) reported witnessing E16 (former CNA) strike R49 in the face with a support cushion and state to R49 that if R49 fell , E16 would not pick R49 up. This same written statement also documents that E1 interviewed R49 on 5/24/16, and R49 confirmed that E16 struck R49 in the face with R49's support cushion. Local Police Report Incident Report # 70 dated 5/24/16 documents the following: Upon arrival, I (Z2, Local Police Officer) was met by (E1, Administrator), who stated that (E1) had received a report from (E15, Dietary Aide) that (E15) observed (E16, former CNA) pick a pillow up from the floor that fell off of (R49's) chair and strike (R49) in the face with it several times. (E1) told me that (E15) said that (E16) then told (R49) that if (R49) fell on the floor that (E16) would not pick (R49) up. R49's Minimum (MDS) data set [DATE] documents a Brief Interview for Mental Status score of 15, indicating that R49 is cognitively intact. On 3/30/17 at 1:33 PM, R49 stated that R49 recalls the incident with E16 that occurred on 5/24/16 and stated, (E16) threw it (support cushion) at me and hit me in the face. R49 also stated, (E16) was just being a b*tch. I (R49) never had to deal with (E16) after that. It made me feel like sh*t. It bothered me and it still bothers me when I think about it. It makes me angry. R49 also stated, I felt that (E16) was abusive toward me (R49). I (R49) never want to be around (E16) again. On 3/30/17 at 3:00 PM, E1 (Administrator) confirmed that E16 struck R49 in the face with a support cushion on 5/24/16.

Based on interview and record review, the facility failed to provide supervision and identified interventions to prevent a fall for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 sustaining a laceration to head obtaining two staples at local hospital. Findings include: A facility Incident Report dated 11/27/16 by E4, Registered Nurse (RN), documents that on 11/27/16 at 5:15p.m., E3, Certified Nursing Assistant (CNA), found R1 on the floor in R1's bathroom, sustained a laceration to her head and was sent by ambulance to the local hospital emergency room for treatment and two staples to close the laceration. The facility's Incident Investigation Worksheet, dated 11/27/16 by E4, RN at 5:30p.m., identifies R1's 11/27/16 incident as Unwitnessed and documents that R1 is cognitively impaired. The facility's State Report dated 12/02/16 by E1, Administrator, addresses R1's fall incident of 11/27/16 and includes the following documentation: On 11/27/16, (R1) was observed on the bathroom floor with an open contusion to the head. Incident was unwitnessed. (R1) was transported to (local hospital emergency room ) where she received two staples to the occipital area of the head. (R1) is an (elderly) resident with a history of CVA (Cerebral Vascular Accident, anemia and [DIAGNOSES REDACTED] . Upon investigation, (R1) was discovered taking herself to the bathroom. (E3) CNA assisted her immediately and resident was safely assisted to toilet. (E3) left resident for a few minutes .and resident had again tried to transfer herself independently. According to care plan intervention, resident was not to be left alone in bathroom due to poor memory, confusion and impulsive, unsafe transfers. R1's Fall Risk Evaluations, dated 11/11/16 and 11/27/16, state R1's Risk Scores of 50 and 48, respectively, indicate R1 is at High risk for falls. R1's current care plan addressing falls states (R1) is at risk for falls due to generalized weakness secondary to CVA and confusion related to dementia and the following fall intervention, dated 11/18/16 : Do not leave resident alone in bathroom. R1's Resident Status Sheet, kept on the inside of R1's closet, includes the following highlighted, hand-written statement in the Bladder portion of the care card: Do not leave resident alone in restroom. R1's Resident Status Sheets also identifies R1 as a High Fall Risk under Special Care Needs/Requests. On 12/13/16 at 12:10p.m., E2, Director of Nursing (DON) stated that R1 is confused and R1's fall care plan includes numerous interventions in place for prevention of falls. E2 also verified R1 had fallen in the bathroom on the evening of 11/27/16 and has had a history of [REDACTED]. E2 stated the majority of R1's past falls occurred due to R1's self-transferring herself. E2 also stated that Resident Status Sheets or cue cards are found on the inside of each residents closet and are used as references for staff members in order to identify each resident's specific needs, i.e., manner of transferring, incontinence needs, cognitive status, safety issues, fall risks and other risk factors and interventions for CNA's and Nursing staff. E2 verified that E3, CNA did not follow R1's care plan interventions and should not have left R1 unattended in the resident's bathroom. On 12/13/16 at 2:50p.m., E3, CNA verified that E3 left R1 unattended on the toilet in the bathroom while she went to the room door to find help in transferring R1 back to her wheelchair. E3 stated she heard R1 fall and found R1 on the floor in the bathroom with blood on her head and on the floor. E3 stated that, at the time of R1's fall on 11/27/16, E3 was unaware that R1 could not be left alone in the bathroom. E3 verified she was aware that Resident Status Sheets are posted on the inside of each resident's closet for reference regarding the residents needs and cares.

Based on interview and record review, the facility failed to provide supervision to one of three residents (R7) reviewed for mechanically altered diets, in a sample of nine. This failure resulted in R7 requiring transport to the hospital after R7 was found unresponsive, and R7 subsequently died from choking on a bolus of food. Findings include: R7's Minimum Data Set, dated dated [DATE], documents R7 is severely cognitively impaired. This same form documents that R7 is ambulatory, and displays coughing or choking episodes during meals or when swallowing medications. R7's Physician order [REDACTED]. This same form documents R7's current diet order as follows: general pureed diet. R7's Care Plan Report, dated [DATE], documents R7 is on a restorative eating program related to the risk of choking, needing cues to eat at a slow pace, and reminders to chew food adequately before swallowing. R7's Incident Report, dated [DATE], documents that R7 has a history of choking. This same form documents that on [DATE], R7 was sitting in the dining room when E16, Licensed Practical Nurse, heard R7 choking. E7 was assisted to a standing position and E16 began performing the Heimlich maneuver, which expelled the lodged food. This form also documents that R7 was given a peanut butter and jelly sandwich and a cookie by an unidentified Certified Nursing Assistant. The facility's investigation of R7's choking incident, dated [DATE], documents the following timeline for R7's location in the facility. At 7:15pm R7 was in R7's room At 7:45pm, R7 was in the patio room. At 8:00pm R7 was ambulating in the north hallway. At 8:20pm, R7 was sitting at a table in the facility's North Dining Table. On [DATE] at 8:26pm, R7's Nurses Notes document, "(R7) observed on floor in NDR, (north dining room), cyanotic, no respirations. Upon assessment, bread, peanut butter and jelly was coming out of (R7's) mouth. CPR (Cardiopulmonary Resuscitation) was initiated." Local hospital emergency room notes, dated [DATE], documents, "...On arrival, large amount of brownish material suctioned and on presentation intubated." This same form documents R7's time of death at 9:06 pm on [DATE]. On [DATE] at 3:15pm, Z6, Coroner, verified that R7's cause of death was aspiration of a food bolus. Z6 also stated, "...the food appeared to be peanut butter." On [DATE] at 2:10pm, Z4, Speech Therapist, stated that R7 had two previous incidents of choking in the facility prior to R7's choking incident on [DATE]. Z4 then stated, "(R7) was supposed to be supervised for all meals and the facility was not providing the supervision." Z4 also verified that after R7's choking episode on [DATE], Z4 changed R7's diet from a mechanical soft to pureed. On [DATE] at 1:00pm, Z5, Speech Therapist, verified that while R7 was at the facility, R7 required continuous staff supervision while eating. On [DATE] at 1:00pm, E13, Licensed Practical Nurse, (LPN), verified that R7 would wander independently into other residents rooms, and R7 would take objects from these rooms. E13 stated, "(R7) was provided food in individual bowls and needed supervision while (R7) was eating." E13 also stated that R7 would eat meals too fast, and cough. E13 then verified that on [DATE] at 8:20pm, E13 was sitting at the north nurse's station and E13 saw R7 wandering around the dining room. E13 stated that night time snacks were sitting on the north nurse's station desk, within reach of anyone walking by, and the night time snacks included the following: pudding, applesauce, graham crackers, and peanut butter and jelly sandwiches. On [DATE] at 8:25pm, E13 stated E13 heard a loud thud and observed R7 on the floor. On [DATE] at 1:40pm, E9, LPN, verified that R7 was ambulatory and would wander throughout the facility independently. E9 stated that night time snacks were left on top of the nurse's desk, and anyone walking by would have access to these snacks. E9 stated on [DATE] at 8:25pm, E9 heard E13, LPN, yell for help, so E9 ran to the north dining room. Upon entering the north dining room, E9 verified seeing R7 lying on the floor, with blue skin color and a faint pulse. E9 stated, "We started CPR (Cardiopulmonary Resuscitation) and called 911." R7's Nurse's Notes dated [DATE] document that R7 was observed on the North Dining Room floor, cyanotic with no respirations, and R7 had bread, peanut butter and jelly coming out of R7's mouth. On [DATE] at 2:10pm, E14, Dietary Manager, verified that R7 would eat too fast and needed reminders to slow down. E14 also verified that R7 would wander throughout the facility independently. E14 then stated, "(R7) would grab food, and (facility staff) would take it away from (R7)." E14 also stated that the facility's night time snacks consisted of pudding, applesauce, graham crackers, and peanut butter and jelly sandwiches. On [DATE] at 11:45am, E14 verified that a regular peanut butter and jelly sandwich is not an appropriate snack for R7.

Based on interview and record review, the facility failed to develop and implement new individualized fall interventions after falls for two of three residents (R1 and R2) reviewed for falls in a sample of three. This failure resulted in R2 sustaining a closed head injury with concussion after a fall. Findings include: 1. R2's Physician order [REDACTED]. The facility Incident/Accident Log documents R2 fell on [DATE] in R2's room. R2's Incident Investigation report, dated 10/26/2014, documents, "environmental factors: resident had a bowel movement." R2's Care Plan, dated, 9/23/2014, documents "fall without injury on 10/26/2014" and lists interventions for falls which include: "Keep areas free from obstructions to reduce the risk of falls or injury; Encourage participation in all aspects of care with verbal and physical hands on assist for follow through; With each encounter remind resident to call for assistance before moving from bed-to-chair and from chair-to-bed; Respond promptly to calls for assist; Use alarm to monitor attempts to rise; Footwear will fit properly and have non-skid soles." R2's Care Plan was lacked any new intervention(s) for fall on 10/26/2014. The facility Incident/Accident Log documents R2 fell on [DATE] in the North Dining Room. On 11/21/2014 at 11:45 a.m, E2 (Director of Nurses) verified that R2's Incident Investigation Report was started 11/17/2014 and is pending completion. R2's Nursing Note, dated 11/17/2014, states, "Resident noted on floor by staff members. Upon assessing, resident had no visible injuries. Resident is unconscious, lying on (R2's) left side with left side of head on floor...911 called for transport to (local area hospital Emergency Department)." The local area "Adult Hospitalist Admission Assessment" (dated 11/18/2014) states, "Principal Problem: Closed head injury with concussion." R2's "Computed Tomography (CT) Examination of the Head, without contrast" (dated 11/18/2014) states, "Foci of acute hemorrhage demonstrated at the frontal regions bilaterally, the subarachnoid versus peripheral parenchymal in location." On 11/21/2014 at 4:52 p.m., Z2 (R2's Physician) stated, "On 11/17/2014, (R2's) CT shows areas with bleeding on the brain. Looking back, (R2) also had a CT of the head complete on 9/4/2014, which at the time, (R2) had no signs of intercranial bleeding. The change in these radiology reports is due to the fall (R2) had on 11/17/2014." On 11/21/2014 at 3:35 p.m., E1 (Administrator) stated, "We just received witness accounts for (R2's) fall on 11/17/2014 that said that prior to the fall, (R2) had a incontinent bowel movement and was finger painting. They cleaned (R2) and brought (R2) out to the dining room to sit. So, since the Incident Report from 10/26/2014 states that (R2) had a bowel movement, both occurrences were related to a toileting issue. For residents with impaired cognition, I would expect a new intervention be developed and Care Planned to reduce the likelihood of future occurrences. For R2, I would expect an intervention of allowing more time for the resident to use the toilet to be on the Care Plan." 2. R1's POS, dated 10/20/2014, documents an admission date of [DATE]. R2's Care Plan, dated 10/9/2014, documents [DIAGNOSES REDACTED]. The facility Accident/Incident Log documents R1 fell on the following dates: 9/30/2014, 10/9/2014, 10/10/2014, 10/12/2014, 10/14/2014, again on 10/14/2014, 10/19/2014, 10/23/2014, 10/31/2014, 11/7/2014, again on 11/7/2014, 11/10/2014 and 11/11/2014. R1's Care Plan, dated, 10/9/2014, documents "fall without injury on 10/10/2014, 10/11/2014, 10/12/2014, 10/14/2014, 10/19/2014, 10/23/2014, 10/31/2014, 11/7/2014, and 11/10/2014" and lists interventions for falls which include: "Keep areas free from obstructions to reduce the risk of falls or injury; Place call bell/light within easy reach; Remind (R1) to call for assistance before moving from bed-to-chair and from chair-to-bed; Respond promptly to calls for assist; Use alarm to monitor attempts to rise; Footwear will fit properly and have non-skid soles; Provide Reminders to use ambulation and transfer assist devices." R2's Care Plan lacked any new interventions to prevent further fall for falls listed above. On 11/21/2014 at 11:52 a.m., E3 (Care Plan Coordinator) stated, "After a fall, we review the incident report to see what could've led to the fall to determine root cause. That allows us to make any necessary changes to the environment or plan of care to try to prevent further occurrences and/or injuries...The fall should be logged on the Care Plan and if there is a new intervention, it will be put on the Care Plan." On 11/21/2014 at 3:35 p.m., E1 (Administrator) stated, "For residents that have impaired cognitive abilities, I would expect my Director of Nurses and Care Plan Team to try to develop new fall interventions after each fall to try to prevent/reduce future occurrences. (R1's) fall interventions are very basic and not individualized to (R1's) needs. I would expect (R1) fall interventions to be more detailed, especially because some interventions aren't pertinent since (R1) doesn't have the ability to use a call light."