Every finding on record at Grove of Elmhurst, The

Based on observation, interview, and record review, the facility failed to ensure residents who required assistance with Activities of Daily Living (ADLs) received the necessary care and services to maintain personal hygiene, including oral care, nail care, and grooming.This applies to 5 of 9 residents (R42, R73, R89, R102, and R115) reviewed for ADL care in the sample of 31. The findings include: 1. R102's face sheet showed he was admitted to the facility with diagnoses that included epilepsy, dysphagia, insomnia, history of falling, anemia, gastro-esophageal reflux disease and other symptoms and signs involving the musculoskeletal system. R102's Minimum Data Set, dated [DATE] showed he was severely cognitively impaired and required substantial maximal assistance for personal hygiene. On June 22, 2026 at 1:39 PM, R102 was sitting in the dining room with an accumulation of flacking white substance covering all areas of resident's short stubby beard and mustache and including his side burns and forehead. There was a white flaky substance on the front of his black shirt, and on both hands. R102 also had a thick bush of hair filling the openings of his ears and extending out of his ears. On June 23, 2026 at 11:36 AM, R102's was sitting in the dining room and he still had a thick bush of hair filling the openings of his ears and extending outside of the ears. On June 24, 2026 at 2:09 PM, R102 was again in the dining room with the same thick bushes of hair filling the opening of his ears and extending out of both of his ears. 2. Review of the Electronic Medical Record (EMR) showed that R115 was admitted to the facility on [DATE]. R115's diagnoses included depression, diabetes mellitus, dementia, history of falls, and chronic kidney disease. The Minimum Data Set (MDS) dated [DATE], showed that R115 was cognitively intact. The MDS further showed that R115 required substantial assistance from staff with hygiene and other ADL needs. The current care plan, initiated October 20, 2020, identified that R115 had an ADL self-care performance deficit and impaired mobility related to weakness and a history of falls. Interventions included providing assistance with ADLs, including personal hygiene. During the initial facility tour on June 22, 2026, at approximately 10:00 A.M., R115 was lying in bed. R115 was noted to have unkempt, long facial hair extending from the jawline, including the beard and moustache area. During interview, R115 stated that he would like assistance with washing and trimming his facial hair. On June 23, 2026, at approximately 12:35 P.M., R115 was observed with the same unkempt, long facial hair. 3. Review of the EMR showed that R73 was admitted to the facility on [DATE]. R73's diagnoses included fracture of the right femur, multiple rib fractures, palliative care, dementia, chronic obstructive pulmonary disease, and autistic disorder. The MDS dated [DATE], showed that R73 had moderately impaired in cognition. The MDS also showed that R73 required staff assistance with ADLs. The current care plan, initiated May 6, 2026, identified that R73 had an ADL self-care performance deficit and impaired mobility requiring assistance with daily needs related to limited mobility and impaired balance. Interventions included providing assistance with ADLs, including personal hygiene. During the initial facility tour on June 22, 2026, at approximately 10:40 A.M., R73 was observed lying in bed. R73 was noted to have unkempt, long facial hair. R73's fingernails were long with jagged edges and a black substance underneath the nails. During interview, R73 stated that he wanted assistance with trimming his beard and fingernails. On June 23, 2026, at approximately 12:40 P.M., R73 was observed with the same unkempt facial hair and untrimmed fingernails. 4. Review of the EMR showed that R89 was admitted to the facility on [DATE]. R89's diagnoses included cerebral infarction with hemiparesis and hemiplegia, unsteadiness on feet, abnormalities of gait and mobility, diabetes mellitus, depression, bipolar disorder, and musculoskeletal system impairments. The MDS dated [DATE], showed that R89 was cognitively intact. The MDS showed that R89 required assistance with ADLs ranging from moderate to dependent assistance from staff. The current care plan, initiated April 1, 2026, identified that R89 had an ADL self-care performance deficit and required assistance completing daily needs related to hemiplegia, hemiparesis, and muscle weakness. Interventions included providing assistance with ADLs, including personal hygiene. During the initial facility tour on June 22, 2026, at approximately 9:40 A.M., R89 was lying in bed. R89's fingernails were noted to be long with jagged edges and a black substance underneath the nails. During interview, R89 stated that she wanted her nails cleaned and trimmed. On June 23, 2026, at approximately 12:50 P.M., R89 was observed with the same untrimmed fingernail. 5. Review of the EMR showed that R42 was admitted to the facility on [DATE]. R42's diagnoses included cerebral infarction, type 2 diabetes mellitus, quadriplegia, contractures of the upper and lower extremities, convulsions, gastrostomy status, and history of physical injury and trauma. The MDS dated [DATE], showed that R42 had severely impaired cognition and required total assistance from staff for all aspects of ADLs. The care plan-initiated October 29, 2019, identified that R42 had an ADL self-care deficit and impaired mobility related to traumatic brain injury and quadriplegia. The care plan included interventions for staff to provide ADL assistance, including personal hygiene. On June 22, 2026, at 11:30 A.M., R42 was lying in bed, non-verbal, with mouth open. R42 was observed with dry, cracked lips, dry oral mucosa, and plaque buildup on existing teeth. Review of the clinical record showed that R42 was on NPO (nothing by mouth) status due to dysphagia. On June 23, 2026, at approximately 10:00 A.M., during gastric tube medication administration with V8 (Licensed Practical Nurse/LPN), R42 remained in bed with dry, cracked lips and continued to show a need for oral care. On June 25, 2026 at 9:11 AM, V2 (Director of Nursing) stated she expects staff to check residents every shift and as often as needed to maintain residents cleanliness, and activities of daily living including hygiene, nail care, shaving, and oral care. The facility's general care policy revised June 30 2025 showed that the facility will assist the resident to meet resident's physical needs including but not limited to ADLs.

Based on observation, interview and record review, the facility failed to follow its policy and perform AHA (American Heart Association) CPR (Cardiopulmonary Resuscitation).This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 5/7/26 at 5:04 PM when the facility failed provide timely rescue breaths and placement of the available AED (Automatic External Defibrillator) on an unresponsive resident designated as full code.This applies to 82 of 83 residents (R1, R3-R83) reviewed for quality of care in the sample of 83.V1 (Administrator), V2 (Director of Nursing), and V36 (Corporate Consultant) were notified of the Immediate Jeopardy on 6/9/26 at 5:50 PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 6/9/26 at 8:57 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and plan implementation.The findings include:Facility Order Listing Report, printed 6/9/26, shows R3-R83 had physician orders for full code.Face sheet, dated 6/5/26, shows R1's diagnoses included Huntington's disease, dysphagia, chorea, personal history of sudden cardiac arrest, dementia, lack of coordination, signs/symptoms involving the musculoskeletal system, and abnormality of gait/mobility. POS (Physician Order Sheet), printed 6/5/26, shows R1's had a physician order for full code dated 12/30/22.On 6/6/26 at 2:30 PM with V1 (Administrator) and V2 (Director of Nursing), facility camera footage of R1 prior to R1's death on 5/7/26 was reviewed in V1's office. The footage showed at 4:58 PM R1 sat in the dining room alone during dinner with a tray of food in front of her. Between 4:58 PM and 5:00 PM R1 appeared to pick up food items with her hands (in spite of experiencing involuntary movements of her arms) and lifted them toward her head while leaning her torso forward. At 5:02 PM, R1 became significantly more animated, began thrashing in her chair left to right, kicked her legs off of her leg rests, and reached her right hand toward the resident sitting across from her eating his dinner. At 5:04 PM, R1 ceased all movement and remained motionless in her chair. At 5:17 PM, V12 (Activity Aide) approached R1 and immediately called V15 (CNA- Certified Nursing Assistant) to attend to R1. R1 was whisked into the hallway in her wheelchair and V5 (LPN - Licensed Practical Nurse) was called to assess R1. R1 was immediately placed on the floor of the hallway and V5 began chest compressions on R1. Review of the camera showed at 5:18 PM an oxygen tank was placed near R1. At 5:19 PM V5 applied oxygen to R1 via a nasal canula and the crash cart was wheeled down the hall and positioned near R1. The crash cart was originally positioned a few resident rooms down from where R1 was laying on the floor. At 5:21 PM, V8 (Assistant Director of Nursing) began to suction R1 and V7 (Respiratory Therapist) then began administering rescue breaths using an AMBU (Artificial Manual Breathing Unit). At 5:25 PM, paramedics arrived and took over recue activities. Review of the footage showed no AED (Automated External Defibrillator) was utilized on R1 during the facility's attempts to revive R1.On 6/8/26 at 1:35 PM, V5 (LPN) when she received R1 unresponsive sitting in her wheelchair, R1 had a faint pulse but when R1 was transferred to the floor R1 no longer had a pulse and was not breathing. V5 stated she put a nasal canula on R1 to deliver oxygen because she wanted to deliver oxygen to R1 despite the AMBU bag being available on the crash cart near R1. V5 stated eventually V7 began delivering rescue breaths using an AMBU bag. V5 stated she also had an AED machine available on her crash cart at the time R1 was found to be unresponsive. V5 stated V8 brought a second AED from the first floor when he responded to R1's emergency. V5 stated staff failed to utilize either of the two available AED machines on R1 while they were performing chest compressions and/or rescue breaths before paramedics took over CPR. V5 stated they did not utilize the AED before paramedics arrived because .it was all so fast. V5 stated she was CPR certified.On 6/5/26 at 12:57 PM V15 (CNA) stated she was called to assist R1 by V12 and V15 took R1 to the hall and helped place her on the floor. V15 stated she began chest compressions on R1. V15 stated another staff later took over chest compressions for R1 and V15 then called 911. V15 stated V5 brought the crash cart to R1 during the event. On 6/5/26 at 12:15 PM, V10 (CNA) stated when she arrived while R1 was receiving chest compressions V5 brought an oxygen tank and V10 placed a nasal canula on R1. V10 stated she checked R1's radial pulse and could feel a feeble pulse. V10 stated V5 asked her to check R1's blood pressure and the blood pressure was very low. V10 stated someone asked her to take over chest compressions and after she became tired another staff took over chest compressions until the paramedics arrived. On 6/8/26 at 1:59 PM, V8 (Assistant Director of Nursing) stated he responded to R1's episode of unresponsiveness and brought an AED machine from the first floor. V8 stated when he arrived staff were performing chest compressions on R1 and R1 had a nasal cannula connected to an oxygen tank applied to her nose. V8 stated when he arrived he was unable to determine if and AED was already applied to R1 because there were many people helping R1 and he did not have a clear visual of R1. V8 stated he was asked to suction R1's mouth which he performed and V7 (Respiratory Therapist) applied the AMBU bag to R1 to provide rescue breaths. On 6/5/26 at 11:13 AM, V8 stated after he suctioned R1 he was present with R1 until the paramedics arrived and ensured everything was being done for R1. On 6/8/26 at 2:05 PM, V7 (Respiratory Therapist) stated when she arrived she could not see R1's chest rising and R1 had a nasal canula on her face. V7 stated she obtained the AMBU bag from the crash cart, switched the nasal canula for the AMBU bag, and began delivering rescue breaths to R1. R7 stated she did not recall staff utilizing the AED on R1.On 6/5/26 at 10:38 AM, V6 (RN- Registered Nurse) stated she assisted staff responding to R1 and took over performing chest compressions on R1 from another staff. V6 stated V8 suctioned R1 and V7 utilized an AMBU bag for rescue breaths.On 6/5/26 at 11:34 AM, V9 (CNA- Certified Nursing Assistant) stated he called 911 and remained nearby as staff attended to R1's emergency.Review of American Heart Association Basic Life Support CPR documentation shows V5 (LPN), V6 (RN), V7 (Respiratory Therapist) V8 (ADON), V10 (CNA) and V15 (CNA) all successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program and their certifications were current at the time R1 became unresponsive and needed CPR.On 6/9/26 at 10:28 AM, V2 (Director of Nursing) stated it was her expectation that the facility staff follow the AHA CPR and AED protocol. V2 stated if a resident is full code and unresponsive, has no pulse, and is not breathing, staff are expected to immediately start chest compressions, immediately apply the AMBU bag and provide rescue breaths, and apply the AED as soon as able. V2 stated there was no reason for the staff not apply the AED to R1 when they were unresponsive. On 6/9/26 at 4:31 PM, V26 (Physician) stated after initiating chest compressions, facility staff were required to begin rescue breaths with an AMBU bag if available. V26 also stated if the facility had an AED available, they should use the device on any collapsed patient. On 6/8/26 at 6:58 PM, V26 (Physician) stated the facility staff were expected to follow the AHA CPR BLS protocols per their CPR training on residents requiring CPR. V26 stated, Why didn't they use the AMBU bag right away - that is a valid question.On 6/8/26 at 10:53 AM, V25 (Paramedic) stated utilizing a nasal cannula for oxygen administration on an unresponsive resident did not make sense because the resident was not breathing oxygen in through their nose. V25 stated staff should immediately start chest compressions, apply an AED if available, and provide rescue breaths using an AMBU bag or CPR mask. V25 stated she was told by facility staff that the facility did not have an AED machine available. V25 stated if R1's heart was initially in a shockable rhythm, not providing oxygen would provide more strain on a resident's heart which could have been why she was no longer in a shockable rhythm when paramedics arrived. On 6/8/26 at 10:28 AM, V24 (Paramedic) stated R1's initial emergency response call was dispatched as R1 was not conscious, not breathing and CPR was ongoing. V24 stated utilizing oxygen via a nasal canula on a non-breathing resident was not effective because the oxygen only remained in the nasal passage. V24 stated after beginning chest compressions the next staff to arrive should use the AMBU bag to provide rescue breaths. On 6/9/26 at 10:51 AM, V1 and V2 stated they provided clinical staff training on emergency care guidelines including CPR as of 5/12/26 including responding to unresponsive residents, providing CPR and administering AED. V2 stated the staff were not required to provide return demonstration of the skills and competencies that were reviewed during the trainings.Facility CPR Policy, revised 6/30/26, shows, It is the policy of this facility to provide basic life support including CPR to any resident requiring such emergency procedure subject to the resident's advance directives and physician orders and in accordance with the standard of practice. 1)Basic Life Support and/or CPR will be immediately provided to a resident requiring cardiac, respiratory, or cardiopulmonary resuscitation subject to the physician orders and resident's advance directivesFacility CPR Procedure, revised 6/30/25, shows, The CPR procedure will be based on AHA's 2022 Interim Guidance to Healthcare Providers for Basic and Advanced Cardiac Life Support to provide safe and effective CPR to a resident who suffers from cardiopulmonary arrest. Code Blue & CPR Procedure: 1) When a resident is found unresponsive, check code/DNR status first. 2) If resident is a Full Code, then call for nearby help by calling Code Blue. 3) Call 911 next. 4) Get the AED and crash cart (or send someone to do it). 6) Look for no breathing or only gasping and check pulse (simultaneously) within 10 seconds. If pulse is not felt, perform CPR without delay. 7) Actively ventilate using a bag-mask device with HEPA filter on the device's ventilation exhaust port, to capture aerosolized particles. 8) Perform cardiac compressions of 30 compressions and 2 breaths using bag-mask device with HEPA filter and tight seal. 9) Attach AED once available, while CPR is being performed. 10) Stop CPR and do not touch the resident when AED is on and is assessing the resident's status. 11) Follow AED's direction whether Shock is advised or not. 12. Resume CPR until 911 paramedics arrive to take over. The procedure shows the staff is to follow the Adult Basic Life Support Algorithm for Healthcare Providers. AHA Adult Basic Life Support Algorithm for Health Care Professionals shows staff are expected to perform chest compressions and rescue breaths use an AED as soon as it is available if a resident is not breathing and has no pulse.Facility Emergency Care Guidelines - Choking document, revised 6/30/25, shows, Unconscious Resident- Lying Down (or When Unable to Reach Around the Resident) Ease the resident as gently as possible to the floor. 1. Call for help if assistance is not already present, call 911 via mobile device if appropriate, get AED and crash cart but do not leave the resident unattended. 2. Position the resident on the back with the arms at the side. 3. Inspect resident's mouth for obstruction, proceed with finger sweep if the obstruction is visible. 4. Start CPR and at the end of each CPR cycle, inspect resident's mouth for obstruction, proceed with finger sweep if the obstruction is visible 7. If obstruction is not removed, continue CPR and check for obstruction at the end of each cycle. Do a finger sweep only if the obstruction is visible. 8. Provide CPR in accordance with the resident's CODE STATUS. If the resident is a Full Code, provide CPR and document including whether AED was applied or not.Facility Code Blue policy/procedure shows, b. Emergency crash cart will be brought to the site of emergency. C. The assigned nurse will initiate the medical emergency interventions (for full code status) per facility's protocol after evaluating the signs and symptoms of cardiopulmonary arrest. D. The nurse/other staff will start the CPR if indicated.F. Other staff will initiate other emergency measures such as IV Line, suction, secretions, take turns with the CPR intervention. G. The Nursing Supervisor or designee will facilitate in maintaining a non-chaotic emergency care environment.The facility presented an abatement plan to remove the immediacy on 6/9/26. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 6/9/26, and the survey team accepted the abatement plan on 6/9/26.The Immediate Jeopardy that began on 5/7/26 at 5:04 PM and was removed on 6/9/26 at 8:57 PM, when the facility took the following actions to remove the immediacy:1) R1 was assessed immediately when identified as unresponsive, suctioned the mouth, CPR initiated, 911 called.2) In-services conducted with all certified CPR staff, CNAs, Nurses, and RT regarding policy and procedure on emergency guidelines and on CPR including AED application on 5/8/26, 5/9/26, 5/11/26, 5/12/26. Return demonstration of understanding this policy and procedure conducted by way of a quiz with completion of 6/9/263) The DON and/designee will conduct an audit of 5 staff 3 times a week for 12 weeks on different shifts to ensure that clinical staff have proper knowledge of the CPR policy and procedure.4) The incident and removal plan has been discussed and reviewed with the facility medical director on 5/7/26 and again on 6/9/26 and the medical director was in agreement with the removal plan and policy and procedure on CPR. 5) An emergency QA meeting was scheduled to discuss the incident and plans of correction with the IDT team including the medical director on 6/9/26.

Based on observation, interview, and record review, the facility failed to provide 1:1 supervision at a meal to a resident who had physician orders for 1:1 feeding assistance.This failure resulted in R1 consuming food during a meal while unsupervised and becoming unresponsive for 13 minutes before being assisted.This applies to 1 of 3 residents (R1) reviewed for meal supervision in a sample of 83.The findings include: Face sheet, dated 6/5/26, shows R1's diagnoses included Huntington's disease, dysphagia, chorea, personal history of sudden cardiac arrest, dementia, lack of coordination, signs/symptoms involving the musculoskeletal system, and abnormality of gait/mobility. Nurse practitioner progress notes, dated 4/24/26, shows R1 was at risk for aspiration and required aspiration precautions.POS (Physician Order Sheet), printed 6/5/26, shows R1 had an order dated 4/3/26 for a Mechanical Soft diet with 1:1 feeding assistance. The order shows R1 also had physician orders for swallowing precautions which included taking small bites, offering food at a slow rate, alternating liquids and solids, and ensuring R1 cleared the food in her mouth prior to taking another bite. The physician orders show R1's had a physician order for full code dated 12/30/22. Speech Pathology progress notes, dated 4/17/26, show R1 was provided 1:1 assistance with her food intake and R1 attempted to put two bites of food in her mouth quickly but was receptive to verbal cues to slow down while eating. Notes, dated 4/22/25, show R1 occasionally held food in her mouth and was receptive to verbal cues to swallow. The note shows R1 required 1:1 assistance at meals because R1 could be impulsive at times. The note shows R1 was provided maximum assistance at meals with food intake to maximize function and safety, and staff were to ensure oral food clearance prior to R1 taking another bite of food. Notes, dated 4/20/26, show R1 was provided maximum assistance with oral intake and the dining room staff were reminded to assist R1 given her risk of aspiration. The note shows R1 held food in her mouth at times and was receptive to cues for R1 to swallow. The note shows R1 required 1:1 feeding assistance at meals.On 6/5/26 at 2:19 PM, V17 (CNA) stated on 5/7/26 she escorted R1 to the neurologist and R1 received Botox injections in each cheek to reduce her drooling. V17 stated when she returned to the facility with R1, she placed R1 in the dining room and V15 was in the dining room feeding a resident. V17 stated she placed R1's tray in front of her and removed the food lid exposing the food on R1's plate. V17 then notified staff R1 was back from her appointment and ready to eat dinner. V17 stated she was not aware if R1 required 1:1 feeding assistance.On 6/9/26 at 9:02 AM, V28 (Neurology Physician Assistant) stated on 5/7/26 she injected Botox in each or R1's cheeks to attempt to decrease R1's chronic drooling. V28 stated there was a theoretical risk for difficulty swallowing after patients have their cheeks injected with Botox. On 6/6/26 at 2:30 PM with V1 (Administrator) and V2 (Director of Nursing), facility camera footage of R1 prior to R1's death on 5/7/26 was reviewed in V1's office. The footage showed at 4:58 PM, R1 sat in the dining room alone during dinner with a tray of food in front of her. Between 4:58 PM and 5:00 PM R1 appeared to pick up food items with her hands (in spite of experiencing involuntary movements of her arms) and lifted them toward her head while leaning her torso forward. The food items in R1's hand appeared smaller each time R1 moved her hand away from her face. At 5:02 PM, R1 became significantly more animated, began thrashing in her wheelchair left to right, kicked her legs off of her wheelchair leg rests, and reached her right hand toward the resident sitting across from her eating his dinner. At 5:04 PM, R1 ceased all movement and remained motionless in her chair. At 5:17 PM, V12 (Activity Aide) approached R1, attempted to arouse R1, and immediately called V15 (CNA- Certified Nursing Assistant) to attend to R1. R1 was whisked into the hallway in her wheelchair and V5 (LPN - Licensed Practical Nurse) was called to assess R1. R1 was immediately placed on the floor of the hallway and V5 began chest compressions on R1. At 5:21 PM, V8 (Assistant Director of Nursing) began to suction R1 and V7 (Respiratory Therapist) then began administering rescue breaths using an AMBU (Artificial Manual Breathing Unit). At 5:25 PM, paramedics arrived and took over recue activities. On 6/5/26 at 12:48 PM, V15 (CNA) stated on 5/7/26 during dinner she knew R1 needed feeding assistance, but she was assisting another resident in the dining room. V15 stated her back was turned to R1 while she was feeding the other resident. V15 stated she did not have visual contact with R1 while R1 was sitting at the dinner table because her back was turned to R1 while feeding a resident. V15 also stated she looked around the room while feeding her resident. V15 stated she did not place any liquids in R1's cup because R1 was going to wait to eat until V15 was done feeding another resident. V15 stated she asked R1 if she was ok while V15 was feeding the other resident but was unsure if R1 responded. V15 stated she was unsure if R1 fed herself any food while she was unsupervised and stated it would not be unusual for R1 to try to feed herself if food was in front of her. V15 stated when the noticed R1 was unresponsive she brought R1 to the nurse in the hall and immediately began chest compressions.On 5/6/26 at 12:32 PM, V12 (Activity Aide) stated on 5/7/26 during dinner he assisted passing dinner trays in the dining room. V12 stated V15 (CNA) was the only staff in the dining when he went into help. V12 stated he left the dining room for approximately 15 minutes and when he returned he saw R1 sitting at her table in the middle of the dining room with her dinner tray in front of her. V12 stated R1 had no staff with her at the table and V15 was focused on feeding another resident in the corner of the dining room. V12 stated R1 was slouching in her chair and R1 did not respond to attempts to arouse her. V12 stated he called V15 for help and they brought R1 to the nurse. V12 stated he looked at R1's tray after the incident and it appeared R1 ate a small portion of mac and cheese. V12 stated there was no biscuit but there were biscuit crumbs on the tray. On 6/5/26 at 9:41 AM, V1 (Administrator) stated the paramedics arrived while R1 was receiving CPR and were unable to revive R1. V1 stated the paramedics pronounced R1 dead at the scene. V1 stated she observed R1's tray in the dining room after R1 expired and there was a biscuit missing from her dinner tray. V1 stated there were a few crumbs of biscuit left on R1's tray as well as a plastic bag in which the biscuit was served. V1 stated it was possible R1 got to the biscuit. On 6/6/26 at 3:24 PM V1 (Administrator) provided a picture of R1's plate taken on 5/7/26 at dinner after R1 expired showing what appeared to be crumbs of biscuit on the tray / plate and an empty baggie on the table near the tray.On 6/5/26 at 10:06 AM, V5 (LPN - Licensed Practical Nurse) stated on 5/7/26 when R1 was brought to her unresponsive, the staff attempted chest compressions immediately, but she was unsure if anyone performed a finger sweep of R1's mouth during the emergency. V5 stated she examined R1's meal tray after R1 expired and saw an empty baggie at her tray.On 6/5/26 at 10:38 AM, V6 (Registered Nurse) stated on 5/7/26 during the emergency she arrived to see R1 on the floor and staff were performing chest compressions and she was not sure if staff swept R1's mouth for food prior to her arrival.On 6/5/26 at 11:13 AM, V8 (Assistant Director of Nursing) stated when he arrived R1 was already receiving chest compressions and he suctioned R1's mouth prior to V7 (Respiratory Therapist) began applying the AMBU (Artificial Manual Breathing Unit) bag to provide rescue breaths. V8 stated he did not see any staff perform a finger sweep of R1's mouth prior to his suctioning.On 6/5/26 at 10:59 AM, V7 (Respiratory Therapist) stated when she arrived R1 was already receiving chest compressions. V7 stated V8 suctioned R1's mouth prior to her applying the AMBU bag.On 6/8/26 at 10:28 AM, V24 (Paramedic) stated the initial call to 911 dispatch was of a person choking, not conscious and not breathing and in cardiac or respiratory arrest. V24 stated when they arrived and treated R1, they did not see anything in R1's airway and staff could have dislodged something in her airway prior to their arrival while they were performing chest compressions. On 6/8/26 at 10:53 AM, V25 (Paramedic) stated she was not told R1 was eating a biscuit prior to her unresponsiveness and was told by the facility she was incapable of doing anything on her own. V25 stated the paramedics were initially told by 911 dispatch that R1 was experiencing a choking emergency but when they arrived at the facility they were told by facility staff that there was a miscommunication and R1 was not choking. V24 stated if she was told R1 was choking she would have utilized different equipment to suction R1's respiratory system deeper.On 6/5/26 at 12:20 PM, V11 (Speech Language Pathologist) stated he treated R1 for dysphagia and R1 required 1:1 assistance form staff during meals for dysphagia. V11 stated R1 would feed herself but was not always successful due to her Huntington's disease and involuntary movements. V11 stated when he worked with R1 she was feeding herself and drinking from her adaptive cup which she would drop at times. V11 stated getting food out of a baggie may be difficult for her but she might be able to do it eventually. On 6/10/26 at 10:09 AM, V11 stated if R1 did not have 1:1 feeding assistance she may not be able to tolerate her mechanical soft diet. V11 stated he would provide R1 liquids to help with food residuals left in her mouth and R1 required 1:1 staff assistance at meals for safe swallowing. V11 stated he sometimes had to cue R1 to swallow the food in her mouth and R1 required staff to monitor her rate of eating, her bite sizes, to encourage her to alternate between liquids and solids, and to facility safe swallowing guidelines. On 6/10/26 at 11:38 AM, V34 (CNA) stated R1 required staff to remind her to take sips of liquid because she would hold food in her mouth and the food would build up in her mouth. V34 stated R1 could sometimes be impulsive when she ate. V34 stated R1 would put food into her mouth fast, the food would build up in her mouth, and R1 would start coughing. V34 stated if staff were not near R1 when R1 ate she would be concerned R1 would feed herself too much too fast and possibly choke. On 6/10/26 at11:16 AM, V31 (Activity Aide) stated if R1 had food placed in front of her she would be able to physically put food into her mouth. V31 stated staff were not always providing R1 1:1 feeding assistance when R1 had food in front of her at the table.On 6/6/26 at 12:41 PM, V23 (CNA) stated when assisting R1 at meals V23 would tell R1 to take small bites because R1 would try to put larger portions of food in her mouth.On 6/6/26 at 12:36 PM, V22 (LPN - Licensed Practical Nurse) stated during meals the staff would have to cue R1 to eat slower, take smaller bites, and take small sips.On 6/5/26 at 12:40 PM, V13 (RN - Registered Nurse) stated R1 could pick up food items by herself and eat them. V13 stated staff assisted R1 with eating because her involuntary movements made it difficult for R1 to feed herself. On 6/9/26 at 10:37 AM, V2 (Director of Nursing) stated R1 was expected to have 1:1 feeding assistance from staff when she was presented food.Review of R1's progress notes show R1 expired at the facility after CPR was provided for approximately 23 minutes. Facility Dysphagia and Aspiration - Clinical Guidelines, effective 7/17/25, shows, The staff and physician will identify individuals whose swallowing capabilities decline, fluctuate, or result in clinically significant complications and will adjust diet and food consistency and make other appropriate interventions.

Based on interview and record review the facility failed to respect residents' dignity by using cell phones during resident care. This applies to 3 of 3 resident (R1, R2, and R3) reviewed for resident rights in the sample of 6. The findings include:On 1/7/26 at 10:53 AM, V9 R1's Daughter stated, The CNAs (Certified Nursing Assistants) are on their phones all the time. V9 stated on one occasion she was talking to a CNA, the CNA had earbuds in, the CNA said hold on to the person she was talking to on her cell phone, reached into her pocket to pause the phone call before she could talk to V9. V9 said she has recently observed CNAs on their phone while providing care for her mother. On 1/7/26 at 10:53 AM, R1 stated, regarding staff being on their phones during resident care, I see it all the time. On 1/7/26 at 1:04 PM, V8 R3's Mother stated, I do see staff on their phones all the time. Yes, I have seen staff on their phones when providing care. I don't like it, it shouldn't happen. It is disrespectful. (R3 was nonverbal, not alert, and not oriented.) On 1/7/26 at 12:10 PM, R2 stated she does see staff on their phones while providing resident care. On 1/7/26 at 1:39 PM, V3 Director of Nursing (DON) stated cell phones should not be used while providing care. V3 said it's disrespectful for staff to be on their cell phones while caring for residents. The facility's Proper Cellphone Use policy (reviewed 2/26/21) showed, While at work, employees are expected to exercise discretion in using personal cellphones. Absent extraordinary circumstances or during scheduled employee lunch/breaks, employees are strongly discouraged from making any personal calls or texting during work time.

Based on observation, interview, and record review the facility failed to change a resident's feeding tube dressing as ordered. This applies to 1 of 3 residents (R1) reviewed for nursing care in the sample of 6. The findings include:R1's admission Record (Face Sheet) showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to functional quadriplegia (severe disability of all four limbs); ventilator dependence, and heart failure. R1's Order Summary Report (Physician Order Sheet) showed an active order started on 12/4/24 to Cleanse enteral tube feeding site with normal saline and apply dry dressing every night shift. On 1/7/26 at 10:29 AM, R1 was supine in bed feeding herself a sweet roll. There was a foul odor that appeared to be coming from R1. The odor was not consistent with stool odor. On 1/7/26 at 11:30 AM, V15 Shift Coordinator / Certified Nursing Assistant (CNA) and V16 CNA entered R1's room to provide incontinence care. During incontinence care, it was requested that V15 lift R1's hospital gown to expose her abdominal tube feeding site. R1's feeding tube dressing was a typical split 4-inch by 4-inch cotton gauze drainage dressing (A dressing with a slit extending halfway into the dressing so the dressing can encompass the feeding tube.) The dressing near the tube had dried black drainage and the odor which was noted at 10:29 AM became more pronounced. The dressing was dated 12/29 (9 days prior). On 1/7/26 at 11:44 AM, V16 stated the odor was coming from R1's feeding tube site. On 1/7/26 at 11:55 AM, V17 R1's Nurse stated the odor was coming from R1's feeding tube site. V17 stated the date on the dressing is the date the dressing was changed. V17 stated, based on the appearance of the dressing, the date was accurate. V17 stated the dressing should have been changed sometime before 1/7/26. V17 said feeding tube dressings are typically changed daily on the night shift. On 1/7/26 at 12:02 PM, V17 changed R1's dressing. The skin under R1's dressing was reddened and inflamed. V17 stated, R1's skin that was under the dressing appeared raw. R1's December 2025 Treatment Administration Record (TAR) showed R1's tube feeding dressing was documented as being done by the night shift staff on 12/30/25 and 12/31/25. R1's January 2026 TAR showed R1's tube feeding dressing was documented as being done by the night shift staff on 1/1/26 through 1/6/26. On 1/7/26 at 1:39 PM, V3 Director of Nursing stated feeding tube dressings should be changed daily on the night shift. V3 said the purpose of the dressing changes is to prevent infections. V3 said staff should not be documenting the completion of dressing changes unless the dressing change is performed. The facility's Enteral Tube Feeding Care policy (Revised 6/30/25) showed, .Enteral tube stoma care: Site must be cleansed and covered with a dry gauze daily. Dry gauze should be placed on top of the G (gastric/stomach) tube bumper, otherwise, a slim layer of light breathable gauze can be inserted under the disc.

Based on observation, interview, and record review the facility failed to provide incontinence care in a manner to prevent urinary tract infections (UTI). This applies to 1 of 3 residents (R1) reviewed for nursing care in the sample of 6. The findings include:R1's admission Record (Face Sheet) showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to functional quadriplegia (severe disability of all four limbs); ventilator dependence, and heart failure. On 1/7/26 at 11:30 AM, V15 Shift Coordinator / Certified Nursing Assistant (CNA) and V16 CNA entered R1's room to provide incontinence care. R1 had a moderate bowel movement that was tar-like. V16 started with R1 being on her back and cleaning the vaginal area. V15 then rolled R1 to her right side and V16 began cleaning R1's buttocks. V16 wiped R1's stool from the top of her buttocks toward her vagina; V16 wiped in this direction twice. V15 spoke quietly and inaudibly to V16 after she had wiped her stool in the direction of R1's vagina. R1 was then rolled onto her back and V16 had to clean her vaginal area a second time. On 1/7/26 at 1:16 PM, V15 stated he was telling V16 to wipe away from R1's vagina. V15 stated wiping the stool the toward the vagina could lead to a urinary tract infection. On 1/7/26 at 1:39 PM, V3 Director of Nursing (DON) stated stool should be wiped away from the vagina to prevent contamination or infection. The facility's Incontinence and Perineal Care policy (revised 6/30/25) showed, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition.Maintain clean techniques.

Based on observation, interview, and record review, the facility failed to provide residents with urinary catheter care. This applies to 6 of 6 residents (R1, R2, R3, R4, R5, and R6) reviewed for urinary catheters.The findings include:1. On 8/09/2025 at 10:45 AM, R1 was sitting in his wheelchair. R1's urinary catheter tube had amber urine with sediment. R1 said he had recurrent UTIs (urinary tract infections) and was receiving an oral antibiotic. R1 had an open urinary piston syringe with a bottle at bedside. R1 said the nurse would frequently irrigate his catheter because it would get clogged often. R1 said on 8/05/2025 by V11 (Licensed Practical Nurse/LPN) changed his catheter because there was no urine output. R1 said the nursing staff was emptying his catheter but not cleaning it frequently. R1 continued to say that he was dependent on the facility staff to care for his catheter. Then V4 (Certified Nurse Assistant/CNA) came to assess R1's urinary catheter. R1's catheter tube was underneath and over (in an upwards direction) in front of his incontinence brief, not secured. R1's catheter insertion site was soiled with a moderate amount of bowel residue. V4 said she had just provided R1 with catheter care approximately an hour prior. V4 proceeded to adjust R1's tube in a downward direction, and the urine then began to flow into the collection bag.On 8/09/2025 at 12:30 PM, V10 (Registered Nurse/RN) said CNAs were expected to provide routine and as-needed catheter care to prevent infections. V10 also said she was not aware of R1's catheter complications on 8/05/2025. V10 said she reviewed R1's EMR (Electronic Medical Record) and there was no documentation of R1's catheter obstruction complication and need for exchange on 8/05/2025. R1's care plan reviewed on 8/09/2025, said R1 was at risk for UTIs and required an indwelling catheter for obstructive and reflux uropathy. The care plan also said R1 required facility staff assistance with toileting hygiene. R1's interventions included checking catheter tubing for kinks, monitoring and reporting output, and monitoring for signs and symptoms of UTIs.R1's Order Summary Report dated 8/09/2025 did not have orders for routine catheter care, urine output recording, and catheter irrigation procedures.R1's Electronic Mediation Administration Record for August 2025 did not show any documentation of R1's catheter exchange procedure. 2. On 8/09/2025 at 11 AM, R2 was in bed. R2's urinary catheter bag with urine inside was hanging from the bed frame without a privacy bag, exposed. R2's urinary catheter tube had light-cloudy amber urine draining. V4 (CNA) said she had just provided R2 with catheter care approximately an hour prior. V4 assessed R2's catheter insertion site, and it had a build-up of yellowish discharge. V4 said she had noticed it prior and would now inform the nurse on duty. R2 said his catheter was being changed monthly by the nurses and was unsure why.R2's care plan reviewed on 8/09/2025, said R2 was at risk for infections and required an indwelling catheter for management of neurogenic bladder. The care plan also said R2 required facility staff assistance with toileting hygiene. R2's interventions included receiving catheter care every shift and as needed, changing foley catheter per facility protocol or MD order, and monitoring output.R2's Order Summary Report dated 8/09/2025 did not have orders for routine catheter care and urine output recording.3. On 8/09/2025 at 11:20 AM, R3 was in bed. R3's urinary catheter bag with urine inside was hanging from the bed frame without a privacy bag, exposed. R3's urinary catheter tube had thick brown-greenish sediments. R3 said her catheter had been exchanged last week because it was clogged and leaking. R3 said she was also started on a probiotic and cranberry medication because she was having bladder discomfort and vaginal irritation. R3 said her catheter bag was last emptied around 5 AM, and she last had a bowel movement last night. V6 (Registered Nurse/RN) assessed R3's urine and said it was abnormal to have greenish-thick sediment in the urine. V6 said she was not notified prior of R3's abnormal urine and expected to be notified of any abnormal urine color or appearance. V6 said she would change the drainage bag and contact R3's provider for a urine culture. V6 then assessed R3's catheter insertion site. R3's catheter was soiled with bowel residue. R3 said agency CNAs frequently did not provide her proper catheter and incontinence care. V6 proceeded to clean R3's catheter with water, and no soap was added. R3's care plan reviewed on 8/09/2025, said R3 was at risk for UTIs and required an indwelling catheter for management of neuromuscular dysfunction of the bladder. The care plan also said R3 required facility staff assistance with toileting hygiene. R3's interventions included staff to monitor her urine, report any abnormalities for signs and symptoms of UTI, and routine catheter care.R3's Order Summary Report dated 8/09/2025 did not have an order for urine output recording. The report showed a new order dated 8/09/2025 for a urinalysis and culture collection. 4. On 8/09/2025 at 11:30 AM, R4 was in bed. R4 was nonverbal. R4's urinary catheter bag had a scant amount of urine inside and was hanging from the bed frame without a privacy bag, exposed. R4's catheter tube had urine sediments. V6 (RN) assessed R4's catheter insertion site. R4's catheter was soiled with bowel residue. V6 said R4's incontinence brief was not soiled, and V7 (CNA) had just provided R4 incontinence care. R4's catheter was wrapped around his scrotal area and unsecured. V6 proceeded to adjust R4's tube in a downward direction, and then the urine began to flow into the collection bag. At 12 PM, V7 (CNA) said she had provided R4 with catheter care at 10 AM after he had an incontinent bowel episode. R4's care plan reviewed on 8/09/2025, said R4 was at risk for UTIs and required an indwelling catheter for management of neuromuscular dysfunction of the bladder. The care plan said R4 required facility staff assistance with toileting hygiene. R4's interventions included checking catheter tubing for kinks and having staff to clean the peri-area.5. On 8/09/2025 at 11:45 AM, R6 was in bed. R6 was nonverbal. R6's urinary catheter bag with urine inside was hanging from the bed frame without a privacy bag, exposed. V9 (CNA) said she provided R6 with incontinence and catheter care at approximately 8 AM. V9 assessed R6's catheter insertion site. R6's catheter was soiled with bowel residue, and his foreskin of his penis had a yellow discharge buildup. R6's catheter tube was not secured. V9 proceeded to provide R6 with catheter care. V9 wiped R6's catheter with multiple upstrokes towards R6's urethra and then downstrokes using the same towel. V9 said R6's incontinent brief was not soiled and secured it back in place.R6's care plan reviewed on 8/09/2025, said R6 was at risk for UTIs and required an indwelling catheter for management of neurogenic bladder. The care plan said R6 required facility staff assistance with toileting hygiene. R6's interventions included catheter care every shift and as needed.R6's Order Summary Report dated 8/09/2025 did not show an order for routine catheter care and urine output recording. 6. On 8/09/2025 at 11:50 AM, R5 was in bed. R5 was nonverbal and severely contracted. R5's urinary catheter bag with a small amount of urine was hanging from the bed frame without a privacy bag, exposed. V7 said she had provided R5 with catheter care and incontinence care approximately a few hours prior. V7 assessed R5's catheter insertion site. R5's catheter was underneath his contracted legs and over his right thigh area, not secured. R5's catheter insertion site and penis area were soiled with dry bowel residue. V7 said it was difficult to properly position R5's catheter tube and clean his catheter due to his contractures.R5's care plan reviewed on 8/09/2025, said R5 was at risk for infections and required an indwelling catheter for management of neuromuscular dysfunction of the bladder. The care plan said R5 required facility staff assistance with toileting hygiene. R5's interventions included catheter care every shift and as needed. On 8/09/2025 at 1:30 PM, V2 (Director of Nursing/DON) said she expected residents to be monitored for catheter complications such as obstructions. V2 said the nurse should be notifying the physician of any abnormalities and documenting any catheter procedures in the resident's EMR. V2 also said nursing staff were expected to follow physician urinary catheter management orders and the facility's urinary catheter care policy to prevent residents from having complications, such as UTIs. The facility's policy titled Urinary Catheter Care dated 7/03/2025, said The purpose of this procedure is to prevent catheter-associated urinary tract infections.General Guidelines.b. Maintain Unobstructed Urine Flow.Infection Control.Routine hygiene.Complications 1. Observe the resident for complications associated with urinary catheters.b. Check the urine for unusual appearances (i.e., color, blood, etc.).e. Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately.Steps in the Procedure.Put on gloves.Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry.retract the foreskin of the uncircumcised male resident.14. Assess the urethral meatus. 15. For a female resident: Use a washcloth with warm water and soap to cleanse the labia.For a male resident male: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke.cleanse and rinse the catheter from the insertion site to approximately four inches outward.Remove gloves and discard into designated container. Wash and dry your hands thoroughly.

Based on observation, interview and record review, the facility failed to ensure a resident's wheelchair was in safe repair to prevent injuries. The failure resulted in R340 sustaining an L shaped laceration on her right lower leg when she bumped her right leg and scraped it on the uncapped right front wheel connector. R340 was sent to the hospital and received 11 sutures for the laceration on her right leg. This applies to 1 out of 1 (R340) resident reviewed for accidents in the sample of 33. The findings include: On 5/20/2025 at 10:36 AM, R340 was in her room with a soiled dressing on her right lower leg. R340 said on 5/18/2025 at around 5:00 AM, she was in the bathroom and when she was transferring from her wheelchair to the toilet, the skin on her right leg caught on the uncapped right front wheel connector of her wheelchair. She said she was bleeding so much that she was sent to the hospital and she has 11 stitches on her right leg. R340's Progress Notes from the Emergency Department of the local hospital dated 5/18/2025 documents R340 said she sustained laceration because her leg got caught on her wheelchair. Length of laceration is 7 cm (centimeters). Wound was closed with eleven stitches. On 5/21/2025 and 5/22/2025, the right front wheel connector on R340's wheelchair was uncapped. On 5/22/2025 at 1:21 PM, V22 (LPN-Licensed Practical Nurse) said around 5:00 AM, he noticed R340's call light was on. V22 stated he noted blood. V22 said R340 told him she bumped into her wheelchair from transferring from toilet to wheelchair. V22 said R340's wound was gaping and bleeding profusely and he immediately provided wound treatment. V22 said R340's wheelchair had nothing sticking out but said he did not notice the uncapped right front wheel connector of R340's wheelchair. On 5/22/2025 at 9:45 AM, V19 (Rehab Director) checked R340's wheelchair. R340 told V19 that she got caught on the uncapped right front wheel connector, was sent to the hospital and got 11 stitches. V19 said the wheelchair's part where resident was claiming she hit her leg on was supposed to be capped. On 5/22/2025 at 9:57 AM, V20 (NP-Nurse Practitioner) said the uncapped right front wheel connector can be the reason of the laceration because she hit her leg on it. She said R340 might not have the laceration if the wheelchair was kept in good and safe repair. On 5/22/2025 at 1:11 PM, V3 (DON-Director of Nursing) said she expects her staff to inform her of any medical equipment in disrepair including the wheelchair. She said medical equipment should be in good, safe repair to prevent injuries. Facility's Maintenance Policy adopted 1/2/16 and reviewed and revised on 8/16/24 documents it is the facility's policy to maintain equipment and the building environment.

Based on observation, interview, and record review, the facility failed to label residents' opened insulin pens and vials with the residents' name, opened-on, and expiration dates, and failed to remove expired medication. This applies to 7 of 8 residents (R30, R31, R48, R54, R64, R67, R189) reviewed for medications in a sample of 33. The findings include: On [DATE] at 10:54 AM, on the 2nd floor, inside V10's (LPN-Licensed Practical Nurse) medication cart, the following observations were made: 1. R48's Toujeo insulin (Glargine Pen) had no open or expiration date. R48's POS (Physician Order Set) shows an order of Toujeo SoloStar Subcutaneous Solution Pen-Injector 300 Unit/ML (Milliliters) (Insulin Glargine)-Inject 22 units subcutaneously every 12 hours. 2. R189's Glargine insulin had no open or expiration date. R189's POS shows an order of Insulin Glargine Solostar Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Glargine)-Inject 60 units subcutaneously two times a day. There was a Humalog Kwik pen with no resident name, also with no dates. There was a vial of Humulin R insulin with an opened on date of [DATE] with no resident name. On [DATE] at 11AM, V10 stated that all insulin pens should be labeled with the resident's name and should have an open and expiration date. On [DATE] at 11:12 AM, on the first floor, inside V15's (LPN) medication cart, the following observations were made: 3. R30's Basaglar insulin pen had no open or expiration date. R30's POS shows an order of Basaglar KwikPen 100 Unit/ML Solution pen-injector---Inject 8 units subcutaneously in the evening. 4. R64 had two insulin pens. His Lyumjev Kwik pen had no open or expiration date. His Lantus insulin pen had no open or end date. R64's POS shows orders of Lyumjev KwikPen 100 Unit/ML Solution Pen-Injector-Inject 7 units subcutaneously with meals. Hold if blood sugar is less than 100 and Lantus Solostar 100 Unit/ML Solution pen-injector---Inject 30 units subcutaneously every 12 hours for hyperglycemia. Hold insulin if blood sugar is less than 110. 5. R54 had two vials of insulin. His Lantus insulin had no open or expiration date. His Humalog insulin had no open or expiration date. R54's POS shows orders of Humalog injection solution 100 Unit/ML (Insulin Lispro)-Inject 2 units subcutaneously with meals. Hold for blood sugar less than 100. Insulin Detemir 100 Units/ML-Inject 30 units subcutaneously every 12 hours. Hold if glucose level is less than 110, or if not eating. 6. R31's vial of Lantus insulin had no open or expiration date. R31's POS shows an order of Insulin Glargine Subcutaneous Solution 100 Unit/ML-Inject 30 units subcutaneously one time a day. Hold if blood glucose is less than 100. On [DATE] at 11:18AM, V15 stated all insulins should have an open and expiration date because some are good for 28 days and some are good for 30 days. 7. On [DATE] at 9:07 AM, surveyor went to the the first floor medication room with V3 (DON-Director of Nursing). Inside the fridge, R67 had two vials of Ativan 2MG/ML that expired on [DATE] ad [DATE]. R67's current May POS does not show any orders for Ativan. On [DATE] at 9:15 AM, V3 stated, The nurse should have discarded these Ativans with another nurse because they are expired. Facility's policy titled Medication Storage, Labeling, and Disposal (Revised [DATE]) shows: Policy Statement-It is the facility's policy to comply with federal regulations in storage, labeling, and disposal of medications. Medication labeling: 1. All opened medication vials in the refrigerator should be labeled with the date when it was opened and discarded within 28 days of opening except for Levemir insulin which can be discarded 42 days after opening. 3. Insulin vials are to be discarded within 28 days after opening, except for Levemir which are to be discarded 42 days after opening.

Based on observation, interview, and record review, the facility failed to follow treatment orders as prescribed for residents with pressure wounds. This applies to 2 of 4 residents (R128 and R8) reviewed for pressure injuries in a sample of 33. The findings include: 1. On 5/21/2025 at 9:00 AM, V6 Wound Care Nurse (WCN) said R8 had a present-on-admission stage 4 pressure injury to her sacrum. V7 (WC Aide) assisted V6 with changing R8's sacral wound dressing. V6 removed a white bordered gauze dressing with moderate amount of serous sanguineous drainage (no other dressing was present). V6 said R8's ordered treatment included collagen (tissue growth stimulator) and calcium alginate (absorbent) dressings. V6 said R8's wound had slough tissue and undermining approximately from 5 o'clock through 8 o'clock. V6 said she was unsure why R8's ordered treatment dressings were not followed. V34's (WC NP/Nurse Practictioner) Wound Assessment Report dated 5/16/2025 said R8's stage 4 sacrum wound status showed delayed wound closure. The report said the wound measured 4.5 cm x 2.0 cm x 0.5 cm with an undermining of 0.3 cm from 5 o'clock to 7 o'clock. The report continued to say the wound had 100% granular tissue with moderate serosanguineous drainage. V34's treatment order said to apply collagen and calcium alginate with a bordered gauze dressing three times per week and PRN (as necessary). R8's Order Summary Report dated 5/22/2025 had active scheduled and PRN orders initiated on 5/09/2025 for her sacrum, Treatment: Sacrum: Cleanse w/ wc, apply collagen and calcium alginate, cover with bordered gauze. R8's skin integrity care plan for her sacrum initiated on 8/09/2025 said Follow facility protocols for treatment of injury (see treatment orders)/POS. 2. On 5/20/2025 at 10:30 AM, R128 said he acquired a wound to his right heel from the pressure of his feet being up against the footboard of his bed. On 5/21/2025 at 8:45 AM, V6 (Wound Care Nurse/WCN) said R128 had a facility-acquired unstageable pressure injury to his right heel. V7 (Wound Care Aide) assisted V6 (WCN) with changing R128's right heel dressing. V6 removed R128's dressing and said the wound had necrotic tissue. V6 cleaned R128's wound and applied a pre-made dressing. V6 said R128's applied dressing was medihoney ointment then an adaptic (non-adherent) dressing with an ABD pad and secured with kerlix. V6 said V34 (WC Nurse Practitioner/NP) managed R128's right heel pressure injury weekly. R128's Order Summary Report dated 5/22/2025 had an active order initiated on 5/14/2025 for his right heel, Medihoney Wound/Burn Dressing External Paste (Wound Dressings) Apply to R Heel topically every day shift every Wed, Fri, Sun for wound Cleanser w/, apply medihoney w/ calcium alginate and ABD and rolled gauze. V34's (WC NP) Wound Assessment Report dated 5/16/2025 said R128's right heel wound was full-thickness and measured 2.5 cm (centimeters) x 3.0 cm x 1.0 cm. The report continued to say the wound had exposed subcutaneous tissue with 20% granulation and 80% slough tissue (0 % necrotic) with scant serosanguineous drainage. V34's 5/16/25 treatment order said to apply Medical grade honey with an ABD pad and rolled gauze three times per week and PRN (as needed). R128's TAR (Treatment Administration Record) for 5/01/2025-5/31/2025 did not show V34's (WC NP) order from 5/16/2025 was implemented. On 5/22/2025 at 9:50 AM, V6 (WCN) said she applied an adaptic dressing to R128's right heel on 5/21/2025 because she believed that was the order prescribed by V34 (WC NP) on 5/16/2025. V6 (WCN) said the wound care team was responsible for reviewing and transcribing V34's (WC NP) wound care treatment orders. V6 continued to say nurses were expected to follow treatment orders as prescribed to promote wound healing, prevent complications, and assess if prescribed treatment orders were effective. The facility's policy titled Skin Care Regimen and Treatment Formulary dated 3/24/2025 said It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown .2. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee daily .8. Stage III and IV pressure injuries may be referred to wound care specialist (either an advanced nurse practitioner or physician specializing in wound care and ostomy management) for further clinical and treatment consultation in accordance with facility protocol and standard of care.

Based on observation, interview and record review, the facility failed to administer medications as ordered. There were 25 opportunities with 3 errors resulting in a 12% error rate. This applies to 2 of 7 residents (R127, R190) observed during the medication pass. The findings include: 1. On 5/21/25 at 8:05 AM, V16 (RN-Registered Nurse/Agency) administered one pill of Zinc 50 MG (Milligrams) to R127. Review of R127's POS (Physician Order Sheet) shows an order of Zinc Sulfate Oral Tablet 110 MG (Milligrams)-Give 1 tablet my mouth two times a day. On 5/21/25 at 2:00 PM, surveyor went upstairs and checked V16's medication cart with her. V16 showed surveyor the house stock bottle where she pulled the Zinc from. On the bottle, it showed Zinc 50 MG. V16 stated she did not give the correct dosage. V16 said, I'm aware of the problem. That's not enough as per the doctor's orders. The doctor should have been notified to change the order. Sometimes, before the end of my shift, I will go give her another 50 MG of the Zinc tablet, but I don't document that. I know, it doesn't solve the problem because that only equals 100 MG. So, 10 MG will be missing. 2. On 5/21/25 at 8:44 AM, V17 (LPN-Licensed Practical Nurse) started administering medications to R190. V17 administered 3 capsules of Duloxetine 20 MG (total 60 mg) to R190. V17 also administered Fluticasone Propionate Salmeterol inhaler to R190. After inhaling one puff, V17 did not provide R190 water and encouragement to rinse his mouth. Review of R190's POS shows orders of: Duloxetine HCL oral capsule delayed release particles 30 MG-Give 3 capsules by mouth one time a day for depression. Give 3 capsules which equals 90 MG and Advair Diskus Aerosol Powder Breath Activated 500-50 MCG (Micrograms)/Dose (Fluticasone-Salmeterol)-1 inhalation-inhale orally every 12 hours for SOB (Shortness of Breath). On 5/21/25 at 2:30 PM, V17's medication cart was checked. V17 pulled out two different medication cards of Duloxetine for R190. One card had capsules of 20 MG and the other card had capsules of 30 mg. Surveyor told V17 that she administered the 20 MG of Duloxetine instead of the 30 MG to R190. V17 stated the 20 MG medication card should not be in the medication cart. On 5/21/25 at 2:50 PM, V3 (DON-Director of Nursing) stated nurses should follow doctor's orders and administer the correct dosage of medications. V17 also confirmed after administering steroid inhalers like Advair, the resident's mouth should be rinsed out with water to prevent yeast infections such as thrush. Facility's policy titled Physician Orders (Revised 8/16/24) shows the following: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS. Facility's policy titled Medication Pass (Revised 8/16/24) shows the following: 3. Inhalers: C. Rinse mouth with water afterwards. Some inhalers do not need to be rinsed with water after administration. Manufacturer's guidelines for Fluticasone Propionate and Salmeterol Inhalation Powder document the following: Rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it.

Based on the interview and record review, the facility failed to coordinate transportation procedure/activities to avoid several missed appointments to residents. This applies to 3 of 3 residents (R52, R91, R127) reviewed for outside appointments and transportation in a sample of 33. The findings include: 1. R91 is a [AGE] year-old female with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. On 5/21/25 at 11:15 AM, during resident groups, R91 stated she went for an ortho appointment yesterday and couldn't see the Ortho physician as the facility didn't send the proper paperwork. R91 stated she needed to go back again. R91 stated the nurse didn't know about R91's appointment to prepare the paperwork for it. R91 blamed V18 (Transportation Coordinator) for not communicating with nurses. R91 stated it was not the first time she missed my appointments. R91's nursing progress note dated 5/21/25 documents that R91 had an ortho appointment yesterday and was unable to be seen so it needed to be rescheduled. A review of the general progress note dated 5/6/25 documented that R91 had two scheduled appointments on 5/6/25 and was unable to attend due to transportation issues. On 05/21/25 at 01:59 PM V15 (R91's Nurse) stated they were not notified of R91's appointment on 5/20/25. V15 stated V18 was supposed to post it on the resident's calendar, but it wasn't entered. V15 stated R91 went for an appointment without having paperwork. V15 stated this is not the first time she and other residents have missed their appointments. V15 stated if staff get a notification, they could prepare the resident for their appointments. On 05/22/25 at 11:37 AM, V18 (Transportation Scheduler) stated she set up R91's appointment and put it on the facility calendar but she did not put it in R91's electronic medical record calendar or tell the nurses. On 05/21/25 at 01:41 PM, reviewed R91's electronic medical record (EMR) with V33 (Receptionist) and no appointment details were posted in R91's EMR. V33 stated, V18 is the medical records person who also arranges transportation. The nurses prepare the paperwork for appointments after they get notification from V18. The facility presented the Appointment and transportation policy revised on 7/12/24 document: The facility will assist in arranging transportation for the resident unless the resident or the resident's responsible party will arrange the transportation themselves. 45906 2. On 5/20/25 at 11:32 AM, R52 said in the Fall of 2024 she had problems with missed doctor's appointments due to V18 (Medical Records/Transportation Coordinator) dropping the ball. R52 said V18 had problems with setting up transportation for appointments, thus making R52 miss appointments. On 5/22/25 at 11:46 AM, V18 said R52 refused to go to 1 or 2 appointments because her insurance wouldn't pay for a medicar and she did not want to go by regular car. V18 said she keeps records of all scheduled and canceled appointments on paper. V18 said she does not document canceled appointments in the medical record. On 5/22/25 at 12:27 PM, V18 provided surveyor with Appointment Schedule Forms for R52's appointments scheduled on 10/15/24 and 10/22/24. Both forms say canceled at the top of them and have transportation by Medicar checked. V18 said she is not sure why the appointments were canceled, she did not record that on the forms. R52's Care Plan does not say anything about her refusal to go to doctor's appointments. R52's progress notes do not say anything about her refusal to go to doctor's appointments on 10/15/24 or 10/22/24. 3. R127's MDS dated [DATE] shows her cognition is intact. On 5/20/25 at 10:45 AM, R127 said she is worried because she needs to have an appointment to see the doctor and she had an appointment on April 28th that was canceled. R127 said the appointment was canceled because of problems with transportation and V18 did not set up an escort to go with her to her appointment. R127 said the doctor's appointment cancellation was out of her control; it was not canceled because of her or the doctor's office, it was canceled due to the poor communication of V18. R127 said V18 has not been back in to talk to her since the April 28th appointment was canceled and R127 does not know if the appointment has been rescheduled. R127 said V18 has accused her of canceling appointments in the past that she did not cancel. On 5/22/25 at 11:46 AM, V18 said R127's appointment on April 28th was canceled because R127 refused to go. V18 said R127 told her nurse that she did not feel like going. On 5/22/25 at 12:41 PM, V18 provided surveyor with R127's Appointment Schedule Form for appointment on 4/28/25. The form shows that escort is needed and has the phone number for the transportation service that was scheduled. On 5/22/25 at 1:21 PM the transportation service was called and V32 (Transport Services) said they did not have any records showing R127's name for an appointment on 4/28/25. V32 said he did not have any email or text message correspondence with V18 regarding an appointment for R127 on that date. On 5/22/25 at 1:27 PM, V18 said there is no progress note documented on 4/28/25 saying why her appointment was canceled. On 5/22/25 at 11:07 AM, V30 (LPN/Licensed Practical Nurse) said both R52 and R127 have had problems with doctor's appointments being canceled because of V18. V30 said R52's appointments were not canceled because of the doctor's office or R52, the appointments were canceled because transportation did not show up because V18 never set it up. V30 said she was R127's nurse on April 28th when her doctor's appointment was canceled. V30 said R127 was all ready to go to her appointment, but she needed an escort and V18 did not set up an escort for the appointment. V30 said transportation showed up, but there was no escort scheduled and when the escort was finally available, the transportation had left so the appointment was canceled. The facility's policy titled, Appointment and Transportation Policy last revised 7/12/24 states, Policy: When a resident requires an appointment outside the facility, the appointment will be scheduled in a timely manner as outlined below. Procedure: . 3. The facility will assist in arranging transportation for the resident . 4. Depending on the resident's medical, physical and cognitive needs and condition, the resident may require an escort while out of the facility for an appointment. If the resident has no representative, family member, friend, etc. to escort him/her during the appointment, the facility will provide one.

Based on observation, interview, and record review the facility failed to process reccommendations for and then provide residents their dietary nutritional supplements. This applies to 3 of 3 residents (R57, R4, and R8) reviewed for nutrition in a sample of 33. The findings include: 1. On 5/21/2025 at 12:10 PM, V11 (Restorative Aide) was feeding R57 in the dining room. R57 appeared thin. At 12:40 PM, V11 said she finished feeding R57, and R57 had consumed approximately less than 20% of her lunch. On 5/22/2025 at 12:20 PM, R57 was in bed for lunch. V24 (Agency Certified Nurse Assistant/CNA) said she tried to feed R57 her lunch, but she refused. V24 said she would ask the nurse for R57's prescribed supplement drink. On 5/22/2025 at 11:30 AM, V23 (Registered Nurse/RN) reviewed R57's orders. V23 said R57 had an order to receive 237 ml (milliliters) of her nutritional supplement twice a day. On 5/22/2025 at 1:00 PM, V26 (Registered Dietician/RD) said R57 was being monitored weekly for her significant weight loss. V26 said she reviewed R57's weight and nutritional intake on 5/05/2025 and believed she made new recommendations to increase R57's nutritional supplement drink amount. V26 said she enters a progress note in the resident's EMR (Electronic Medical Record) and e-mails V3 (Director of Nursing/DON) her weekly dietary log recommendations. On 5/22/2025 at 1:40 PM, V3 (DON) said she reviews and carries out V26's (RD) weekly dietary recommendations to ensure nutritional interventions are provided to residents to prevent weight loss. V3 said she received R57's new dietary recommendation on 5/07/2025 to increase her nutritional supplement to three times a day. R57's EMR showed R57's weights decreased from 112 pounds on 3/3/2025 to 103 pounds on 5/12/2025 to 100 pounds on 5/22/2025. V26's (RD) 5/5/2025 progress note titled Sig WT Change Note: -5.2% in 30 days showed R57 continued to trigger for significant weight loss. The note said V26 recommended to increase Ensure to TID (three times a day) to provide additional support. Facility's document titled RD Recommendations & Tracking Form log dated 5/07/2025 showed R57's recommendation to increase her nutritional supplement to three times a day was not implemented. R57's Order Summary Report dated 5/22/2025 showed an active order initiated on 2/11/2025 for Ensure two times a day for supplement Give 237 mL and drink by mouth. 2. On 5/20/2025 at 12:20 PM, R4 was in bed eating his lunch. R4's lunch ticket said he was to receive a nutritional frozen dessert supplement with the meal. R4's served lunch did not include any nutritional supplements. On 5/22/2025 at 12:25 PM, V24 (Agency CNA) served R4's lunch tray. No nutritional supplements were present on R4's served tray. On 5/22/2025 at 12:25 PM, V25 (Dietary Manager) said residents should be served their nutritional frozen dessert or alternative might shake supplements as indicated in their meal ticket as part of their ordered weight management interventions. V25 said the residents' ordered nutritional frozen and shake supplements were provided by the kitchen. V25 said the nutritional supplements should be served with the residents' meal trays when being prepared in the kitchen line before being delivered to the units. R4's Dietary Evaluation assessment dated [DATE] said R4 was identified to have significant weight loss and was malnourished. The assessment showed R4 was to continue to receive his nutritional supplements including a Magic Cup daily (nutritional frozen dessert). 3. On 5/20/2025 at 12:20 PM, R8 was in bed eating her lunch. R8's lunch ticket said she was to receive a nutritional frozen dessert supplement with the meal. R8's served lunch did not have a nutritional supplement. On 5/21/2025 at 12:35 PM, R8 was served her lunch tray. R8's was not served her nutritional dessert nor shake supplement as indicated in her lunch ticket. R8's Dietary Evaluation assessment dated [DATE] said R8's weight was suboptimal for her age and she had increased nutritional needs due to her stage 4 sacral pressure injury. The assessment said R8 was to continue to receive her supplements, including her Mighty Shake (nutritional shake supplement). On 5/22/2025 at 3:00 PM, V1 (Administrator) and V8 (Regional Nurse Consultant) said the facility did not have a policy regarding nutrition or nutritional supplements.

Based on observation, interview and record review, the facility failed to assess and obtain treatment orders for a resident with a laceration. This applies to 1 out of 1 resident (R340) reviewed for wound treatments in a sample of 33. The findings include: On 5/20/2025 at 10:35 AM, R340 was noted with a wrapped gauze dressing on right lower leg. The gauze was brown in color with dried blood stains and was unraveling. R340 said on 5/18/2025, her right leg caught on her wheelchair and she sustained a laceration. R340 said the wound was bleeding too much that she was sent to a local hospital where she got eleven stitches. R340 said no staff has come to assess her wound and the dressing on her wound has not been changed since she returned from the hospital. On 5/21/2025 (three days after R340 returned from the hospital) at 8:57 AM, R340's right leg wound dressing still had the same dried blood stains and the gauze was still unraveling. On 5/21/2025 at 9:05 AM, V15 (LPN- Licensed Practical Nurse) reviewed R340's POS (Physician Order Sheet) and said she cannot find any treatment orders for R340's right lower leg wound. On 5/21/2025 at 10:15 AM, V6 (Wound Care Director) reviewed R340's POS and said she could not find wound care orders for R340's leg wound. V6 said she has not assessed R340's wound since she came back from the hospital. On 5/22/2025 at 10:07 AM, V6 said the receiving nurse should have verified and carried out R340's wound care orders. V6 said she should have assessed R340's wound as soon as she came back to the facility. V6 stated that prompt assessment and obtaining and carrying out wound care orders should be done to avoid delay in care. On 5/22/2025 at 12:10 PM, V21 (Treatment Nurse) said she changed R340's wound dressing on 5/21/2025. V21 stated there were no wound orders transcribed into R340's POS, and she said she got the treatment orders from R340's hospital records. V21 said she worked on 5/18/2025 but was not able to assess R340 when she came back to the facility. Facility's Policy on Skin Care Regimen and Treatment Formulary (reviewed 3/24/2025) documents Policy Statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown .

Based on observation, interview, and record review, the facility failed to provide nail care to residents who require assistance. This applies to 3 of 3 residents (R1, R81, and R86) reviewed for activities of daily living (ADL) care in a sample of 33. The findings include: 1. R81 is a [AGE] year-old male with severe cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R81 is dependent on personal hygiene. On 05/20/25 at 01:44 PM, R81 was on his bed and had long nails with a brownish substance accumulated underneath nails, with a left contracted hand and right partially contracted hand. On 05/20/25 at 01:50 PM, V27 LPN (Licensed Practical Nurse) stated CNAs (Certified Nursing Assistants) or activity aides should trim residents' nails and that R81's long nails with contracted left hand can cause a palm ulcer. R81's ADL care plan documented performance deficit and impaired ability with dressing and grooming, such as unable to complete tasks with personal hygiene. The ADL care plan interventions include total staff participation and with personal hygiene 2. R1 is a [AGE] year-old female with mild cognition impairment as per the Minimum Data Set (MDS) dated [DATE]. MDS also documents that R1 requires partial/moderate assistance to personal care. On 05/20/25 at 01:59 PM, R1 had a broken nail approximately 6 millimeters (mm) long hanging from the left point fingertip. All of R1's other fingers had long dirty nails. On 05/20/25 at 2:02 PM, V23 (Registered Nurse/RN) stated that residents should get nail trimming and grooming on shower days. R1's care plan documents that R1 was care planned for extensive care needs and requires the support/services of the long-term care setting with intervention including the facility will provide care to establish the resident to function at their most practical level. 3. R86 is an [AGE] year-old male with moderate cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R86 requires partial/moderate assistance to personal hygiene. On 05/20/25 at 01:46 PM, R86 was on his bed and his left hand nails were long and he had a broken jagged nail on his left fourth finger. R86's ADL care plan documented performance deficit and impaired ability with dressing and grooming, such as unable to complete task with personal hygiene. On 05/21/25 at 10:17 AM, V3 (Director of Nursing) stated the CNAs are supposed to provide nail trimming and grooming on shower days. The facility's Nail Care policy (revised 8/16/24) showed Nursing staff shall check the residents for Nail Care which includes cleaning and regular trimming

Based on observation, interview, and record review, the facility failed to cohort and implement transmission-based precautions for a resident with an acute GI (gastrointestinal) infection. The facility also failed to follow Enhanced-Barrier Precautions (EBP). This applies to 3 out of 5 residents (R48, R74, R45) reviewed for infection control in a sample of 33. The findings include: 1. On 5/21/2025 at 2:45 PM, V5 (Infection Preventionist/IP Nurse) said R48 started having acute diarrhea on 5/12/2025. V5 said R48's stool was collected on 5/12/2025 to screen for C. difficile (an acute contagious GI infection). V5 said R48's stool resulted positive for C. diff on 5/14/2025 and was started on Vancomycin (antibiotic) treatment. V5 confirmed the facility had other available rooms to move R74 (R48's roommate). V5 said R74 and R48 were roommates until 5/15/2025 (three days later). V5 said R48 should have been placed in contact transmission based precautions when he was suspected to have C. diff infection. V5 said R74 was at risk for infections and should have been moved immediately when R48 was suspected and confirmed to have C. diff infection. R48's care plan initiated on 5/16/2025 had a focus problem for his C-Difficile infection and said he required contact precautions. The care plan said, Maintain contact isolation precaution in accordance with Centers for Disease Control (CDC) guidelines. R48's Order Summary Report dated 5/21/2025 showed an order for Vancomycin HCI 25 MG/ML (milligrams/milliliters) Solution reconstituted Give 125 mg via G-Tube four times a day for C-DIFF initiated on 5/13/2025. R48's report also had an order for Strict Contact Isolation (C. Diff) initiated on 5/15/2025. R48's Lab Results Report showed his stool specimen was collected on 5/12/2025 and resulted positive for C. difficile Toxin [NAME] on 5/14/2025. R74's Room Transfer Notification form dated 5/15/2025 said R74 was moved to another room on 5/15/2025 at 1:00 PM. R74's care plan reviewed on 5/22/2025 said he was at risk for infections because of his multiple comorbidities. The care plan said, Initiate proper precaution per facility policy. The facility's document titled Infectious Disease Isolation Guideline & Care dated 11/08/2024 said residents with acute diarrhea and C. Diff diseases required the implementation of contact precautions. The document also said residents with C. Diff were only allowed to be cohorted with another resident with a C. Diff infection. The facility's policy titled Infection Prevention and Control dated 2/10/2025 said The facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility. The facility will also maintain a record of incidents and corrective actions implemented for the identified infection .Precautions to Prevent Transmission of Infectious Agents and Transmission Based Precautions .Contact Precaution- intended to prevent transmission of infectious agents spread by direct or indirect contact with patient or the environment. Examples of infectious organisms requiring contact precautions are C. Difficile . 45906 2. On 5/21/25 at 7:55 AM, outside of R45's room, there was a sign on the door that says EBP (Enhanced Barrier Precautions). On 5/21/25 at 8:20 AM, V15 (LPN-Licensed Practical Nurse) put on gloves and entered R45's room without putting on a gown. V15 flushed R45's g-tube (gastrostomy tube) with 30 ML (Milliliters) of water. She then administered his Enulose and Docusate Sodium through R45's g-tube. Throughout the entire medication administration, V15 did not wear a gown. On 5/21/25 at 2:45 PM, V3 (DON-Director of Nursing) stated, Nurses have to wear full PPE (Personal Protective Equipment) including a gown because (R45) is on EBP precautions. When a nurse takes care of resident's g-tube or administers meds through the g-tube, she has to wear a gown. R45's care plan shows that he is receiving gastric tube feeding due to inability to eat. He has a g-tube and therefore is at risk for infections. Another care plan shows R45 is on enhanced barrier precautions related to CRE (Carbapenem-resistant Enterobacteriaceae) (urine and rectal) and GT (Gastrostomy) status. Interventions: Ensure that gown and gloves are used during high-contact resident care activities like device care-feeding tube that provide opportunities for transfer of MDRO's (Multidrug Resistant Organism) to staff hands and clothing. Facility's policy titled Enhanced Barrier Precaution (Revised 7/26/24) shows: EBP involves the use of gown and gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents known to be colonized or infected with MDRO's as well as residents with wounds and/or indwelling medical devices. Procedure: EBP will be used for any resident in the facility that has indwelling medical devices such as feeding tube. Examples of high-contact resident care activities requiring gown and glove use among residents that trigger EBP use include g.) device care: feeding tube. 31327

Based on interview and record review, the facility failed to implement it's antibiotic stewardship program to monitor usage of prescribed antibiotics for residents. This applies to 2 out of 3 residents (R109 and R85) reviewed for antibiotic use in a sample of 33. The findings include: 1. On 5/21/2025 at 2:15 PM, V5 (Infection Preventionist/IP Nurse) said as part of the facility's antibiotic stewardship program she reviews residents who are prescribed antibiotics, including their laboratory results, to ensure they are receiving appropriate antibiotic treatment. V5 said nurses were responsible for initiating a McGeer's assessment form when receiving orders for antibiotics. V5 continued to say she then reviews and completes the assessment forms to determine if the residents met the criteria for the use of their prescribed antibiotics. V5 said R109 was started on an antibiotic for a UTI (urinary tract infection) on 5/17/2025. V5 said R109 had an abnormal urinalysis (UA) specimen that resulted on 5/18/2025. V5 said she noted today, on 5/21/2025 (four days later) that R109's UA specimen request lab form was not checked to be analyzed for sensitivity as ordered. V5 reviewed R109's 5/17/2025 assessment and said the form was not completed to determine if R109's prescribed antibiotic was reviewed for appropriate antibiotic use. R109's McGeer Criteria for Infection assessment form reviewed on 5/21/2025 said R109 was started on Ceftriaxone intramuscular injection daily for a UTI on 5/17/2025. The form included the following microbiologic specimen organism criteria instructions needed for review, Urine specimens for culture should be processed as soon as possible. R109's form was not completed to determine if he was reviewed for appropriate antibiotic use. R109's urinalysis lab result report showed his urine specimen was collected on 5/15/2025 and the final report without a sensitivity analysis was reported to the facility on [DATE]. R109's Order Summary Report dated 5/21/2025 showed an active order for Ceftriaxone Sodium Injection Solution Reconstituted 1 GM Inject 1 gram intramuscularly one time a day for UTI for 7 Days initiated on 5/17/2025. 2. On 5/21/2025 at 2:30 PM, V5 (IP Nurse) said R85 was receiving Vancomycin and Meropenem antibiotics. V5 said she was unsure why R85 was receiving Vancomycin via his gastrostomy tube but believed it was for prophylaxis use. V5 said she also believed R85 was receiving Meropenem for a UTI. Upon review, V5 said R85's McGeer's assessment form was only initiated for R85's Meropenem and did not include a review of his Vancomycin antibiotic use. V5 continued to review R85's form and said it was initiated for a review of a UTI with an indwelling catheter, but it was incomplete. V5 said she had to further clarify why R85 was prescribed his Meropenem because the form said it was for MRSA (methicillin-resistant Staphylococcus aureus) in his blood and urine, and R85's prescribed order said it was for MRSA and ESBL (Extended-Spectrum Beta Lactamases) in the blood. R85's McGeer Criteria for Infection assessment form reviewed on 5/21/2025 said R85 was started on Meropenem intravenously for MRSA in the blood and urine on 5/16/2025. The form did not include a review of R85's prescribed Vancomycin. R85's Order Summary Report dated 5/22/2025 showed active orders for Vancomycin HCI Oral Solution Reconstituted 50 MG/ML Give 2.5 ml via G-Tube one time a day for prophylaxis for 9 Days and Meropenem Intravenous Solution Reconstituted 500 MG Use 500 mg intravenously three times a day for MRSA, ESBL in blood for 10 days. The facility's policy titled Antibiotic Stewardship Program Policy dated 7/12/2024 said The facility will comply with federal regulations in establishing an antibiotic stewardship program .Document the dose, route, duration, indication .Establish best practices for use of microbiology testing .Perform Antibiotic Time Outs 3 days after the initial dose of antibiotic was started, a formal process of reassessment of the ongoing need for and choice of antibiotic is required to be performed by the clinical team as during this period, culture result is in .

Based on observation, interview, and record review, the facility failed to ensure services were provided to residents with indwelling urinary catheters in a manner to prevent infection. This applies to 2 of 2 residents (R441 and R58) reviewed for urinary catheters. The findings include: 1. On 5/20/25 at 12:04 PM, R441 was noted with indwelling urinary catheter draining cloudy yellow urine. R441 said the staff in the facility empty the urine from his drainage bag, but they don't ever clean his urinary catheter tubing. R441 said only the doctor at the doctor's office cleaned the tubing. On 5/22/25 surveyor asked to observe catheter care and at 10:11 AM, V11 and V12 (Restorative Aides) were observed providing catheter care for R441. Prior to the start of catheter care, R441's catheter drainage bag was noted to be hanging on the lower side rail of R441's bed, with the bottom of the bag resting on the floor. Prior to starting urinary catheter care, V11 and V12 noted that R441 had a bowel movement. V11 provided incontinence care first. While R441 was lying on his left side, she cleaned his stool with a soapy washcloth, then used a large dry towel to wipe between his buttocks and pat him dry. V11 then used that same large towel that she just used to wipe R441's buttocks to drape over him while V12 went into the hall to get more supplies. When V11 and V12 turned R441 onto his right side, V12 removed the dirty towel/brief/pad from under R441 and placed them on a clean area of the bed, by the resident's feet. V11 then unclipped the urinary catheter drainage bag from the bed frame and placed it on R441's bed. V11 then proceeded to perform catheter care, but she did not clean the top 1 inch of the catheter tubing by the insertion site/urethra. V11 then touched R441's sheets and his side rail buttons to raise the head of his bed back up, with the same soiled gloves she just used to touch R441's perineal area and catheter tubing. R441's Care Plan initiated 4/7/25 shows he has an indwelling urinary catheter due to neurogenic bladder and interventions include to perform catheter care every shift and as needed. Care Plan dated 4/8/25 shows R441 was on antibiotic therapy related to UTI (Urinary Tract Infection). R441's POS (Physician Order Summary) shows an order dated 4/7/25 to perform catheter care every shift. On 5/22/25 at 10:11 AM, V11 and V12 (Restorative Aides) said catheter care is done once daily as part of morning care. V11 and V12 said urinary catheter care should be documented in the EMR (Electronic Medical Record) under tasks. V11 and V12 said urinary catheter care is usually done by either the CNAs (Certified Nurse Assistants) or the Restorative Aides. On 5/22/25 at 11:30 AM, neither R58 nor R441 had a task in their EMR for performing catheter care. No documentation in either chart was found for catheter care being performed every shift. On 5/22/25 at 12:58 PM, V3 (DON/Director of Nursing) said catheter care should be done every shift. V3 said the urinary catheter drainage bag should never touch the floor because of the risk of cross contamination and for infection control purposes. V3 said the entire urinary catheter tubing should be cleaned, including the first inch by the insertion site. V3 said dirty linens and briefs should not be placed on the resident's bed because of the risk of cross contamination. V3 said the urinary catheter drainage bag should never be placed on the resident's bed because of the risk of back flow of urine into the bladder which could lead to UTI. V3 said the staff should change their gloves and perform hand hygiene after performing catheter care and before touching clean linens or the side rails, because of the risk of cross contamination from the soiled gloves. 2. On 5/20/25 at 1:48 PM, R58's indwelling urinary catheter bag was hanging on his wheelchair armrest, above the level of his bladder, with urine back-flowing into the bladder. R58 said he had been transported to the hospital a few times with UTIs (Urinary Tract Infections) and they give him antibiotics in the facility on a regular basis. R58 said the facility staff do not regularly clean his catheter tubing. On 5/22/25 surveyor asked to observe catheter care and at 10:39 AM, V11 and V12 (Restorative Aides) were observed providing catheter care for R58. Prior to starting, R58's urinary catheter drainage bag was clipped to the low part of bed frame with the lower part of the bag resting on the floor. V12 lifted the drainage bag up and placed in on the resident's bed while catheter care was performed. After V11 and V12 completed catheter care, V11 raised R58's urinary catheter drainage bag up above his body while he was lying flat in bed, and threaded the drainage bag through the leg of the new pull up brief. When V11 raised the drainage bag up, urine backflow could be visualized moving towards the resident's bladder. On 5/22/25 at 11:00 AM, after catheter care was completed, R58 was asked how often the staff clean his catheter tubing as they had just done. R58 said, Not often, maybe never. R58 said sometimes the nurse will flush his catheter, but they don't clean the tubing like they just did. R58's Care Plan dated 1/10/24 says he has an indwelling urinary catheter due to diagnosis of obstructive and reflux uropathy. Interventions include position catheter drainage bag and tubing below the level of the bladder. Another Care Plan dated 1/10/24 says R58 has potential for infection related to history of urinary tract infections. Interventions include initiate proper precautions per facility protocol. The facility's policy titled, Urinary Catheter Care last revised 8/19/24 states, Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident . General Guidelines .b. Maintaining Unobstructed Urine Flow: .iii. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Infection Control: 2.b. Be sure the catheter tubing and drainage bag are kept off the floor .Steps in the Procedure .17. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward . Documentation: 1. The date and time that catheter care was given .

Based on observation, interview, and record review the facility failed to handle soiled cleaning supplies and soiled bedding in a manner to prevent cross-contamination. This applies to 1 (R1) of 3 residents reviewed for incontinence care in the sample of 3. The findings include: On 1/16/25 at 9:20 AM, R1's room had an odor of feces. V5 (CNA-Certified Nursing Assistant) was providing incontinence care for R1. V5 stated R1 had a bowel movement, and she was cleaning him up. V5 had placed R1's soiled bedding on the floor and she had placed a stool covered washcloth on the bedside nightstand. R1 also had a name band on to his left wrist. The name band had a brown smear that appeared to be stool. V5 did not remove the name band. On 1/16/25 at 1:04 PM, V9 (Licensed Practical Nurse-LPN) stated the substance on the name band appeared to be feces. V9 stated the purpose of the name band is for identifying residents on the memory care unit. On 1/16/25 at 12:45 PM, V11 (R1's Family) stated she had visited R1 on 1/15/25. V11 stated R1's hands were covered in stool, and it also was on his name band. V11 stated it took staff two washcloths to clean his hands. On 1/16/25 at 1:36 PM, V2 (Director of Nursing) stated all incontinence care material, soiled bedding, and soiled items should be placed directly into a plastic bag and not set on the floor or other horizontal surfaces. V2 said this is to prevent cross-contamination. The facility's Incontinent and Perineal Care Policy (revision 7/31/24) showed, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition .Discard disposable items into designated containers/plastic bag .

Based on observation, interview, and record review the facility failed to assess and treat a wound when it was first identified. This applies to 1 (R1) of 3 residents reviewed for wound care in the sample of 3. The findings include: R1's Admission Record (Face Sheet) showed an admitted [DATE]. The Face Sheet showed diagnoses to include but not limited to Alzheimer's, Pressure ulcer, contractures of the legs, failure to thrive, and palliative care. R1's Admission Minimum Data Set (MDS) from 11/26/24 showed he had short and long-term memory loss. The MDS showed he had limited range of motion in all extremities. The MDS showed R1 was dependent upon staff for every activity of daily living to include oral care, feeding, toileting hygiene, dressing, and personal hygiene. On 1/13/25 at 11:36 AM, V11 (R1's family) addressed an email to the state health department. The email showed, V11 was at the facility on 1/7/25, she was in R1's room during incontinence care, and she noted a wound to R1's scrotum that she was not previously aware of. On 1/16/25 at 10:00 AM, V4 (Wound Care Director) began providing wound care for R1 while (V7 Wound Care Nurse Practitioner) assessed R1's wounds. At the request of the state surveyor, R1's perineal area was assessed, and a quarter sized wound was observed to R1's scrotum. The wound was not draining and was superficial. R1 has black skin tone, and the wound was bright pink. V4 and V7 both stated they were not aware of the wound. V7 provided an order for a petroleum type jelly for protection. V7 stated she would also request an order from hospice for a catheter to promote healing of this wound as well as his other wounds. On 1/16/25 at 11:00 AM, V5 (Certified Nursing Assistant-CNA) stated she reported R1's scrotum wound weeks ago. V5 stated it was also documented in R1's Electronic Health Record (EHR). V5 demonstrated where she would document skin alterations. R1's Shower/Bathing and Skin Monitoring charting from 11/15/24 through 1/16/25 showed no documented skin alterations. On 1/16/25 at 12:06 PM, V5 was informed there were no documented skin alterations to R1's scrotum. V5 was not able to explain this; however, she reiterated R1's scrotum wound had been reported and the wound had been there for several days. On 1/16/25 at 12:45 PM, V11 stated she was at the facility on 1/7/25. V11 stated R1 had a bowel movement, and she requested the staff provide incontinence care. V11 stated, during the incontinence care, she noted the wound to R1's scrotum and requested staff apply an ointment. On 1/16/25 at 1:15 PM, V4 (Wound Care Director) stated he was not aware of R1's scrotum wound. V4 stated either herself or her wound care staff should have been notified of the scrotal wound when it was first found. V4 stated the importance of notification is so assessment and treatments can be initiated. V4 stated the assessment provides a baseline of the wound for tracking and it also dictates the treatments that will be applied. V4 stated treatments are important to prevent infection and promote healing. R1's 1/16/25 wound assessment (Authored by V7 Nurse Practitioner) identified the wound as moisture associated skin damage (MASD) and was 3.0 cm (centimeters) by 1.5 cm. The facility's wound report, provided on 1/16/25 at 11:00 AM, showed no documented wounds to R1's scrotum. R1' Treatment Administration Record (TAR) from 1/16/25 at 11:46 AM, showed no treatments were in place for R1's scrotum. The facility's Wound Care Guideline policy (Revised 1/24/24) showed, .The resident's skin alteration/breakdown shall be documented in the resident's clinical records in accordance with the facility's policy and in compliance to current regulatory standards .

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by V3 (Agency CNA-Certified Nursing Assistant), when V3 punched R1 in the face and grabbed R1's lower arm. This applies to 1 of 4 residents (R1) reviewed for staff-to-resident abuse in the sample of 7. This failure resulted in R1 experiencing bruising on her face and lower arm and R1expericing a psychosocial impact. R1 stated she can still see V3's fist coming towards her face when she closes her eyes. The Immediate Jeopardy began on April 27, 2024, at 8:00 PM when V3 (Agency CNA) punched R1 in the face and grabbed R1's lower arm. V26 (Assistant Administrator), V25 (Vice President of Operations), and V19 (Regional Nurse Consultant) were notified of the Immediate Jeopardy on May 7, 2024, at 1:41 PM. The facility presented an abatement plan to remove the immediacy on May 7, 2024, at 2:16 PM, and the survey team accepted the abatement plan on May 7, 2024, at 2:59 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on May 7, 2024, at 2:16 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: On April 30, 2024, at 11:09 AM, R1 was lying in bed in her room. R1 had dark purple bruising underneath her left eye, and dark purple bruising above her right eye in the crease between her eyelid and eyebrow. [NAME] bruising was also visible across the bridge of R1's nose, and fading, yellow bruising was visible on R1's left forearm from her wrist up towards her elbow, approximately four to six inches. R1 stated the bruising on her forearm happened after V3 (CNA) tightly grabbed her wrist and forearm on Saturday, April 27, 2024. R1 stated the bruising on her face, around her eyes and across her nose happened the same day, after she was punched in the face by V3 (CNA). R1 stated, It was Saturday, April 27, after dinner. I did not like the way [V3] (CNA) was trying to change me, and I told her to stop. Then she started using a pillow and was hitting me all over my body with it, over and over. I kept telling her to stop it. Then she used her big fist and punched me right in the face. [V3] grabbed my arms and left bruising on my left arm that is now going away. I said, Stop it! Stop it! Stop it! It was very scary. I have three roommates, but they do not talk and could not help me. I prefer to not talk about it because it was a bad thing, and I don't like to think about bad things. But every time I close my eyes, all I can see is her giant fist coming towards my face. I did not put on my call light because I was afraid to. Later, [V15] (LPN-Licensed Practical Nurse) came in to check on me. I asked her for pain medication because my face was hurting. She asked me what happened, and I told her [V3] (CNA) hit me. The EMR (Electronic Medical Record) shows R1 is a [AGE] year-old female who was admitted to the facility on [DATE]. R1 has multiple diagnoses including, thoracic and lumbosacral intervertebral disc disorder, pressure ulcer of the right buttock, reduced mobility, chronic kidney disease, chronic pain syndrome, diabetes, dementia, bipolar disorder, depression, congestive heart failure, COPD (Chronic Obstructive Pulmonary Disease), and history of transient ischemic attack and cerebral infarction. R1's MDS (Minimum Data Set) dated March 22, 2024, shows R1 is cognitively intact, requires set up assistance with eating, substantial/maximal assistance with oral hygiene, dressing, and bed mobility, and is dependent on facility staff for toilet hygiene, showering/bathing, personal hygiene, and transfers between surfaces. R1 has an indwelling urinary catheter and is always incontinent of stool. The EMR shows R1 has a care plan for being resistive to care, manifested by her depression and bipolar disorder diagnosis. The care plan was initiated on March 26, 2024. Multiple interventions initiated on March 26, 2024, show: Create a warm, safe, and inviting environment for care, make sure lighting is adequate, try to create a home-like bathroom/shower area. Emphasize dignity. Emphasize soothing, kind, slow, and compassionate speech. Do not rush or hurry. Use body language that communicates patience. On April 30, 2024, at 11:22 AM, V15 (LPN) stated, Around 7:45 PM, [R1] asked for her Tramadol (pain medication). V15 stated R1's Tramadol is scheduled to be administered at 9:00 PM. V15 stated I asked R1 why she needed pain medication early. She (R1) turned on her room light and was pointing to her right forehead, and I could see a bump and bluish discoloration around her right forehead, and she said [V3] (CNA) hit her. My whole body went cold because I have never had that happen, that someone said they were hurt by a staff member. The bruising was on her forehead, and I called [V1] (Administrator), the doctor, and the NP (Nurse Practitioner), and left a message for the family member. I then called the police, and the fire department. The paramedics came to the facility, but [R1] refused to go to the hospital and signed a paper to show she refused to go to the hospital. So, we did an X-ray. [R1] is a very particular resident about her care. She can be bossy. She is very alert. I sent [V3] (CNA) home right away. On April 27, 2024, at 7:45 PM, V15 (LPN) documented, While making rounds, resident complained of pain on her forehead. Assessed complete body of resident. Resident noted right forehead bump with bluish discoloration of the skin. Skin intact in the surrounding area. When the resident was asked what happened, the resident said, The assigned CNA hit my face during ADLs (Activities of Daily Living). Ice pack applied to the site immediately. Neuro check started. No change in resident baseline mental status. Scheduled Tramadol given. Resident alert, oriented x/time 4 and verbally responsive. [V22] (Physician) and [V23] (NP) informed and ordered X-ray of the facial and nasal bones STAT. [V1] (Administrator informed. [V24] (Family member of R1) informed. Police were called and notified, with report number. Resident refused to go to the hospital to be checked even encouraged by NOD (Nurse on Duty) and the paramedics. Assigned CNA was sent home, pending investigation. Will continue to monitor resident. The facial and nasal bone X-ray dated April 27, 2024, showed: Normal X-ray examination of the nasal bones. Follow-up by CT/computerized tomography scan of the facial bones. On April 30, 2024, at 5:14 AM, V21 (NP) documented, Reason for visit: Comprehensive skin assessment. [R1] in bed. Awake, alert, and verbal. Noted to have ecchymosis surrounding around both of her eyes. When asked patient what happened to her eyes, she states, Oh that's something else. [R1] did not want to continue to talk about it. On May 1, 2024, at 10:41 AM, V1 (Administrator) stated, I was not able to speak to [V3] (CNA). On Monday, the detective came and told me that they found [V3] and there are approved charges to pick her up for aggravated battery. [V3] did not answer my calls. [R1] said [V3] came in to change her brief and [V3] pushed the resident on one side to remove the brief. [R1] told her she has a curved spine and when you put her in this position it hurts her. [R1] was trying to explain to [V3] how the other CNAs are able to do it, so it does not hurt her. When the CNA went around the other side and pushed her over in the bed, [R1] told [V3] I told you it hurts me how you are doing it. The CNA started hitting her with the pillow. [R1] said she did not scream out for help. [R1] said she was back onto her back and told [V3] (CNA) she was a bully and possibly called her a dummy and that is when [V3] (CNA) punched her. [R1] did not call anyone for help and it was not discovered until [V15] (LPN) was making rounds. [V15] found the injury and reported it to me right away and we sent the CNA home. On May 1, 2024, at 12:08 PM, V16 (Police Detective) said, I interviewed [V3] (CNA) on April 29, 2024, and she admitted to me that she punched [R1] and hit her with a pillow. She was charged with aggravated battery of a person 60 plus years old and she was taken to the county jail. On May 6, 2024, at 2:42 PM, V21 (NP) said she was asked to examine R1 on Tuesday, April 30, 2024, due to the abuse allegation. V21 found R1 to have bruising around both eyes which was not present on her last examination of R1 on April 25, 2024. V21 continued to say R1 can be particular about turning for wound and incontinence care and prefers to roll in bed on her own. If the CNA would have talked to her, [R1] would have told her how we turn her. We never turn her; she turns on her own. She has her way, and it works for her. She never complains of pain because she turns slowly on her own. She had to be punched right between her eyes to cause bruising on both eyes like that. It is fair to say the bruising around her eyes was caused by the punch. The facility's Abuse Report Final Form, submitted to (the State Agency) on May 2, 2024, at 2:00 PM shows R1 as the alleged victim, and V3 (CNA) as the alleged perpetrator. The final report shows: A thorough investigation was conducted and physical abuse allegation against Agency CNA, namely [V3] has been substantiated. The facility's Abuse and Neglect Policy, effective date 7/14/23 shows: Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigations. Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Types of Abuse and Examples: 1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling. The Immediate Jeopardy that began on April 27, 2024, at 8:00 PM was removed on May 7, 2024, at 2:16 PM when the facility took the following actions to remove the immediacy: R1 remains in the facility with psychosocial services available to R1. R1 was seen by a psychotherapist on May 3, 2024, and wellness checks by the Social Services Department have been ongoing from April 28, 2024, and will continue three times a week for 30 days. V3 (Agency CNA) was removed and placed on the do not return list on April 27, 2024, and has not returned to the facility since. Police were notified on April 27, 2024. On April 27, 2024, the facility notified the staffing agency that V3 was asked not to return due to an abuse allegation. On April 27, 2024, the facility opened an abuse allegation related to R1 and this investigation was concluded and substantiated. V3 (Agency CNA) was reported to the State Agency Healthcare Worker Registry on May 2, 2024. All agency staff will be provided abuse training prior to the start of their shift by the DON (Director of Nursing) or designee. This will include an audit questionnaire to validate return demonstration of understanding. Staff were re-educated on the facility Abuse and Neglect Policy by the Administrator and/or designee on April 30, 2024, and is ongoing. This re-education will continue and be completed by May 8, 2024. Return demonstration of understanding was provided by way of conducting an audit questionnaire. An audit was conducted on all residents cared for by V3 (Agency CNA) on March 24, 2024, March 30, 2024, April 11, 2024, April 21, 2024, and April 27, 2024, to ensure abuse did not occur with anyone else. Residents with specific preferences and/or behaviors are being identified on May 7, 2024. Care cards listing these items will be placed in a binder at the nurse's station on each floor for staff knowledge. This will be updated as needed by the Social Services Department. This will be completed by May 8, 2024. All staff, including agency staff will be educated on the care card location, and to check the care card prior to providing care. This will be completed by May 8, 2024. Quality assurance audit will be conducted daily by the Administrator and/or designee to ensure agency staff have been educated on abuse with return demonstration of understanding. This will start on May 7, 2024, and continue for the first month. All identified trends will be reviewed by the monthly QAPI (Quality Assurance and Performance Improvement) Committee, and a plan will be discussed and implemented until resolution. The incident and abatement plan will be discussed and reviewed with the facility Medical Director on May 7, 2024, at 4:30 PM. Emergency QAPI meeting will be conducted on May 8, 2024, at 10:00 AM.

Based on observation, interview, and record review the facility failed to identify, report, assess, and obtain physician orders for new skin breakdown; failed to ensure treatment dressings were in place, soiled dressings were changed for residents with stage 3 and stage 4 pressure ulcers; and failed to implement pressure ulcer interventions. As a result of these failures, R41 had an unidentified right ischium wound with 25% necrotic tissue that was uncovered with no treatment; R24 had a right ischium wound with necrotic muscle tissue exposed with no treatment; and R18 had a right ischium wound with no treatment that increased in size from previous assessments. This applies to 5 of 5 residents (R9, R18, R24, R41, and R66) reviewed for pressure ulcers in a sample of 30. The findings include: 1. The EMR (Electronic Medical Record) showed R41 admitted to the facility on [DATE] with multiple diagnoses including multiple pressure ulcer stage, diabetes type 2, nutritional deficit, and tracheostomy dependent on a respiratory ventilator. The MDS (Minimum Data Set) dated 3/19/2024 showed R41 was cognitively impaired and was dependent on facility staff for ADLs (activities of daily living). The MDS continued to show R41 was at risk for developing pressure ulcers because R41 had multiple unhealed stage 3 and unstageable pressure ulcers. On 4/02/2024 at 10:21 AM, R41 was in bed. V11 (Wound Care Nurse/WCN) and V27 (Certified Nurse Assistant/CNA) turned R41 to perform wound care. R41 was soiled with stool and his left ischium dressing was saturated with yellow drainage and had an open wound to his right ischium without a treatment dressing in place. V11 stated R41's left ischium dressing was soiled from the wound drainage. V11 cleaned the stool off the right ischium wound and said it was her first time seeing the wound, V11 stated the wound had 25% necrotic tissue and the rest was granulation tissue and it appeared like a stage 3 pressure ulcer. V11 continued to remove the soiled dressing then cleansed the wound and applied new treatment dressings to R41's wounds. V11 continued to say she needed to have the Wound NP (Nurse Practitioner) assess the new wound before staging it. Then R41's left corner bed sheet had blood stains and the surveyor asked V11 to assess R41's left foot. R41's left heel was covered with a white island dressing dated 4/03/2024. V11 stated she had never seen the wound before, and she removed the dressing and said it had a medihoney dressing covering the wound bed. V11 then cleaned the wound and it started to bleed, V11 stated the wound bed had 100% slough tissue. V11 stated she had to ask the Wound NP to also assess and measure R41's new left heel wound. R41's Order Review Report dated 4/04/2024 showed an order for Left Ischium-Cleanse area with normal saline, apply collagen and calcium alginate and cover with dry dressing as needed and every day shift for treatment; and Right lateral lower leg: Cleanse with NSS, apply skin prep, and leave open to air as needed AND every day shift every Tue, Thu, Sun for Skin Alteration. The order report did not show a treatment order for the left heel and right ischium. R41's Skin and Wound Note from the NP dated 4/02/2024 showed R41's left ischium stage 3 pressure ulcer measured 4.2cm x 3cm x 0.5cm with undermining from 11-1 o'clock measuring 1cm with a heavy amount of serosanguineous exudate and right lateral lower leg stage 3 pressure ulcer measured 1cm x 0.5cm x 0.1cm. R41's Skin and Wound Note from the NP dated 4/04/2024 showed R41 had a facility-acquired right ischium stage 3 pressure that reopened measuring 2.5cm x 1cm x 0.1cm and a new diabetic foot ulcer with partial thickness skin loss measuring 1cm x 1.8cm x 0.1cm with scant amount of serosanguineous exudate. On 4/05/2024 at 11:17 AM, V11 (WCN) stated the Wound NP assessed R41's new wounds, V11 continued to say R41's right ischium was a reopened stage 3 pressure ulcer, and the left heel was classified as a diabetic ulcer. V11 stated they could not determine the etiology of R41's left heel wound, and they looked at R41's diagnoses to help them classify the wound and made an educated guess. V11 said she was not able to find out who applied a dressing to R41's left heel wound or when it was identified. V11 stated when a new skin alteration is identified nurses should assess it, report to the Wound NP or primary physician to get treatment orders, update the family, and document it in the chart. 2. The EMR showed R24 admitted to the facility on [DATE] with multiple diagnoses including pressure ulcers stage 4, multiple sclerosis, tracheostomy dependent on respiratory ventilator, muscle wasting and atrophy, and malnutrition. The MDS dated [DATE] showed R24 was cognitively impaired and was dependent on facility staff for ADLs. The MDS continued to show R24 was at risk for developing pressure ulcers because R24 had two unhealed stage 4 pressure ulcers present on admission. On 4/02/2024 at 10:50 AM, R24 was in bed. V11 (WCN) and V27 (CNA) turned R24 to perform wound care. R24's sacrum and left ischium dressings had a foul odor and were saturated, the drainage seeped into the incontinence pad underneath. R24's right ischium was observed without a treatment dressing in place and had necrotic muscle tissue exposed. V11 removed the soiled dressings then cleansed the wounds and applied new treatment dressings. V11 said R24's wounds should have been covered and if the dressing were soiled, they should have been changed. V11 said she expected the floor nurses to cover the wounds as ordered because the wounds could deteriorate. R24's Care Plan dated 4/04/2024 showed R24 had actual impaired skin integrity to his sacrum a stage 4 pressure ulcer, left ischium stage 4 pressure ulcer, and right ischium unstageable initiated on 2/09/2024. R24's Order Review Report dated 4/04/2024 showed an order for Medihoney Ca Alginate 4x5 External Pad Apply to left ischium topically as needed for treatment. Apply to left ischium topically every day shift for treatment. Cleanse wound with normal saline, apply medihoney + calcium alginate and cover with dry dressing; Right ischium: Cleanse with NSS, apply Medihoney, and cover with bordered gauze as needed and every day shift every Tues, Thu, Sun for Skin Alteration; and Sacrum: Cleanse with NSS, apply hydrogel and silver alginate, and cover with bordered foam as needed for Skin Alteration and every day shift for Skin Alteration. R24's Skin and Wound Note from the NP dated 4/02/2024 showed R24's sacrum stage 4 pressure ulcer measured 12cm x 17cm x 1.5cm with undermining from 10-11 o'clock measured at 1.8 cm and with fragile peri-wound and heavy amount of serosanguineous exudate, left ischium stage 4 pressure ulcer measured 5.4cm x 4cm x 2.3cm with tunneling at 12 o'clock measured at 5.3cm and with a moderate amount of serosanguineous exudate, and right ischium stage 4 pressure ulcer measured 6.2cm x 6cm x 0.8cm with exposed tendon/ligament and a moderate amount of serosanguineous exudate. R24's initial Skin and Wound Note from the NP dated 2/13/2024 showed R24's sacrum stage 4 pressure ulcer measured 7.5cm x 7.5cm x 1cm with no undermining with a moderate amount of serosanguineous exudate and left ischium stage 4 pressure ulcer measured 6.5cm x 3cm x 1cm with no tunneling and with a moderate amount of serosanguineous exudate. The note did not show any assessment for R24's right ischium stage 4. R24's Skin and Wound Note from the NP dated 2/15/2024 showed R24's had a new right ischium wound classified as MASD (Moisture Associated Skin Damage) measuring 0cm x 0cm x 0cm with a scant amount of serosanguineous exudate. On 4/05/2024 at 11:17 AM, V11 (WCN) stated R24's right ischium stage 4 pressure wound was acquired a few months ago as a DTI (deep tissue injury) and then progressed as an unstageable. V11 said the initial assessment was done by the Wound NP, she believes it was found during their wound rounds. 3. The EMR showed R18 admitted to the facility on [DATE] with multiple diagnoses including pressure ulcer stage 4, quadriplegia, tracheostomy dependent on respiratory ventilator, and malnutrition. R18's MDS dated [DATE] showed R18 was cognitively intact and was dependent on facility staff for ADLs. The MDS continued to show R18 was at risk for developing pressure ulcers because R18 had an unhealed facility-acquired stage 4 pressure ulcer. On 4/02/2024 at 10:04 AM, R18 was in bed. V11 (Wound Care Nurse/WCN) and V27 (Certified Nurse Assistant/CNA) turned R18 to perform wound care. R18's right ischium pressure ulcer was observed without a treatment dressing in place and was soiled with stool. V11 cleaned the stool off the wound and said there should have been a dressing covering the wound as ordered. R18's Order Review Report dated 4/04/2024 showed an order for Right ischium: Cleanse with NSS, apply collagen, and secure with border gauze as needed for Skin Alteration and every day shift every Tues, Thu, Sat for Skin alteration. R18's Skin and Wound Note from the NP dated 4/02/2024 showed R18's right ischium stage 4 pressure ulcer measured 4.5 cm x 4 cm x 0.1 cm. R18's initial Skin and Wound Note from the NP dated 7/25/2023 showed R18's right posterior upper thigh (right ischium area) had a partial thickness wound measuring 3 cm x 0.8 cm x 0.01cm classified as a skin tear/laceration. R18's TAR (Treatment Administration Record) for April 2024 showed R18 received wound care to her right ischium pressure wound once on 2/02/2024 by V11. On 4/04/2024 at 11:41 AM, V2 (Director of Nursing/DON) stated she expected the nurses to change dressings when needed and not wait for the WCN. V2 stated each floor had wound care supplies if needed. V2 stated the Wound NP is the one measuring and assessing the facility wounds and notifies her of any changes when she rounds at the facility. 46380 4. On 4/2/2024 at 10:03 AM, while V6 (CNA-Certified Nurse Assistant) and V7 (CNA) were providing incontinence care to R9, it was noted that R9 did not have any wound dressing on her sacral wound. V6 stated it was the first time during her shift (7 AM to 3 PM) that she was providing incontinence care to R9. V6 said it was reported that R9 was last changed around 6 AM. After incontinence care was done, V6 applied incontinent briefs and said she will inform the nurse and the wound care nurse that R9 needed new wound dressing. On 4/2/2024 at 11:54 AM, skin check was done with V6. R9 still had no wound dressing on her stage four pressure ulcer on her sacrum. On 4/2/2024 at 1:06 PM, V11 (Wound Care Nurse) stated she has not been to the third floor to do wound dressings. V11 denied being informed that R9 had no wound dressing for the entire morning. V11 stated R9 had a stage 4 on her sacrum. V11 stated there should always be a wound dressing to prevent the wound from being exposed to urine and feces. V11 stated the dressing also is needed for wound healing. V11 said if there is no wound dressing, the wound has potential for infection and the wound may become worse. On 4/3/2024 at 9:05 AM, R9's back and buttocks were soaked with fluid coming out from her feeding tube machine. V6 CNA stated V13 (RN-Registered Nurse) informed her at 9:00 AM that R9 needed to be changed because she was soaked. While V6 and V12 (CNA) were providing care, R9's wound dressing on her sacrum was peeled off due to moisture. The wound appeared macerated with wound edges appearing whitish from being soaked in fluid. On 4/3/2024 at 9:06 AM, V13 stated she did not touch R9's feeding tube. V13 stated the last time the feeding tube was touched was when R9 received her medications around anywhere from 5:00 AM to 7:00 AM. She said fluid seeped out because the valve was not properly clamped. She said she discovered R9 was soaked and informed V6 right away. On 4/3/2024 at 10:37 AM, V13 measured R9's sacral wound. Measurement was 3.8 cm (centimeters) width x 4.9 cm length x 0.3 cm depth. She said the wound edges appeared macerated and fragile. R9's face sheet documents she was admitted to facility on 10/3/2022. Diagnoses include hemiplegia, hemiparesis, Alzheimer's disease, aphasia, and dysphagia. R9's MDS (Minimum Data Sheet) documents R9 has severely impaired cognitive functions and is dependent on staff for ADLs (Activities of Daily Living). R9's POS (Physician Order Sheet) dated 3/8/2024 has an order to cleanse sacral wound with normal saline, apply xerofoam, and cover with dry dressing every day shift every Tuesday, Thursday, Saturday and as needed. R9's care plan dated 1/3/2024 shows wound care plan has interventions to follow facility protocols for treatment of injury and to keep skin clean and dry. R9's wound assessment done on 3/28/2024 shows sacral wound measured 4 cm width x 4 cm length x 0.10 cm depth. 5. On 4/3/2024 at 10:07 AM, V11, Wound Care Nurse did a skin check on R66. V11 stated R66 had no open areas and skin is being protected with moisture barrier. When R66's incontinence briefs were removed, she turned R66 to her left side, open wounds were noted on her left and right buttocks. V11 did not assess the wounds and did not measure the wounds. V11 applied hydrocolloid dressing to wounds on left buttock and right buttock. V1 said Wound Nurse Practitioner will be in the facility tomorrow. R66's face sheet documents she was admitted to facility on 10/12/2022. Diagnoses includes thoracic, thoracolumbar, and lumbosacral intervertebral disc order, hypertension, dementia, and type II diabetes mellitus. R66's MDS documents she has intact cognitive functions, is always incontinent of bowel and bladder and needs extensive assist from staff for turning and repositioning in bed. R66's Wound Assessment Report dated 3/28/2024 documents wound on right buttock and sacrum were resolved. R66's POS shows there was no treatment order received for her wounds on left and right buttocks on 4/3/2024 when the wounds were discovered. Review of R66's Progress Notes show no notes were recorded on 4/3/2024 regarding the wounds discovered on R66's right and left buttocks and informing physician of the new wounds. Last skin evaluation on R66 was done on 3/22/2024. On 4/4/2023 at 10:52 AM, V15 (Wound Nurse Practitioner) stated resident should not be sitting in moisture like urine or feces or fluid from feeding tubes because there is a potential that resident will develop pressure ulcers or resident's pressure ulcer will deteriorate. V15 stated sitting in moisture could also cause infection and can make wound healing take longer. V15 stated if a resident's wound dressing is not applied, there is a potential for infection and potential for deterioration of the wound. V15 stated R9's sacral wound decline could be in part caused by not applying wound dressing and being soaked in liquid from the feeding tube. She said if wounds were discovered, she expects the nurses to assess the wound, measure the wound, document findings, and inform her about it. Facility Policy on Wound Care Guidelines dated 12/1/2015 and revised on 1/24/2024 stated the following: .3. Prevention of skin breakdown includes but not limited to: .c. Inspection of the skin every shift with care for signs of breakdown.e. Keeping local areas of skin clean, dry, and free of body wastes, perspiration, and wound drainage.4. Activity, Mobility, and Positioning .h. Keep the linens dry and wrinkle free.9. Documentation .d. The resident's skin alteration/breakdown (pressure ulcer, arterial, diabetic, venous ulcers and etc .) shall be documented in the resident's clinical records in accordance with the facility's policy and in compliance to current regulatory standards. 10. Pressure Injuries Treatment .a. Initiate wound care treatment upon identification of the wound with physician's order.c. Timely referral to the facility's Wound Care Specialist for all pressure injuries and/or wounds.

Based on observation, interview, and record review the facility failed to assess and document urinary output for a resident who had returned from the emergency room with hematuria. The facility also failed to assess, document urine output on residents with indwelling urinary catheters. This failure resulted in R1 experiencing pain due to urinary retention, continued urine retention and hematuria, and a return to the hospital within 24 hours. This applies to 3 of 3 residents (R1, R5, and R10) reviewed for indwelling urinary catheters in a total sample of 10. The findings include: 1. According to the Electronic Health Record (EHR) R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] showed R1 needed extensive assistance of one person for bed mobility, transfers, walking, dressing, hygiene, and toilet use; and needed supervision set up help only for eating. R1 had an indwelling urinary catheter and was frequently incontinent of bowel. The MDS showed R1's cognition was moderately impaired. A care plan showed R1 is on anticoagulant therapy with interventions to monitor, document and report blood tinged or frank blood in urine; has an indwelling urinary catheter due to obstructive and reflux [CONDITION(S)] with interventions including to keep the collection bag below the level of the bladder, check for kinks and leaks, report any discomfort, blood-tinged urine, no output, or deepening of color. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/06/2022 at 12:12 PM, V19 (R1's family member) stated she received a telephone call on 05/25/2022 from R1 complaining of extreme abdominal pain. R1 had been to the emergency room (ER) the night before due to blood in his urine and then returned to the facility the same evening. V19 stated she called a facility nurse to assess R1 since he was complaining of pain. Two hours later V19 received a call from R1 again still complaining of abdominal pain. V19 stated when the hospital called to inform her R1 was going to be admitted to the hospital, they had told her R1 came to the ER without an indwelling urinary catheter in place and they obtained one liter of bloody urine when they had inserted an indwelling urinary catheter. A Hospital Urology Physician Note dated 05/25/2022 at 10:07 PM showed R1 had been seen in theER on [DATE] with hematuria in the catheter. A three-way catheter was inserted, the bladder was irrigated, and R1 was discharged back to the facility. On 05/25/2022, R1 returned to the ER for urinary retention. A catheter was placed and returned one liter of bloody urine. Continuous bladder irrigation was restarted and the urine has been clearing. An abdominal computerized tomography (CT) did not show any [CONDITION(S)] pathology for hematuria and the preliminary urine culture was negative. The abdominal CT dated 05/25/2022 showed the urinary bladder collapsed around an indwelling urinary catheter with urinary bladder wall thickening. R1's prostate is enlarged and may relate to bladder outlet obstruction. On 06/07/2022 at 3:25 PM, V4 (Licensed Practical Nurse/LPN agency) stated she was working the evening shift on 05/24/2022 when R1 had complained of feeling weak and noted to have thick maroon blood in his indwelling urinary catheter and drainage bag. V4 stated it was a full drainage bag and it looked like it was all blood and no urine. V4 was told by an unknown CNA (Certified Nursing Assistant) she had emptied R1's urinary drainage bag once already with the same amount and color. V4 stated she did send R1 out to the emergency room and was surprised R1 had returned to the facility around 11:00 PM while she was giving report to the night shift nurse (V9). V4 stated she had told the oncoming night shift nurse what had occurred with R1 and pointed out R1 was the one returning from the hospital as he passed the nurse's station. On 06/06/2022 at 5:53 PM, the hospital emergency room staff member stated R1 arrived at theER on [DATE] at 7:25 PM and was discharged back to the facility at 10:56 PM the same evening. On 06/06/2022 at 5:03 PM, V9 (LPN agency) stated she had worked on 05/24/2022 from 11:00 PM to 05/25/2022 till 8:15 AM. V9 stated she could not recall caring for R1 during this shift and would have to review her notes in the EHR. At 5:23 PM, after looking at the notes in the EHR, V9 stated R1 must have been kept in the hospital overnight because she never did an admission note. V9 stated the hospitals usually don't send residents back to the facility after 8:00 PM. According to V9, the nurses are supposed to do a readmission note when a resident returns from the hospital and she did not see one for R1. I know I didn't readmit him on the night shift of 05/24/2022 into 05/25/2022 because I never saw him. On 06/07/2022 at 9:44 AM, V11 (Registered Nurse/RN agency) stated R1 was definitely in the facility on 05/25/2022 when V11 started work at 7:00 AM. V11 stated R1 was not having much urine output, it was hematuria, and R1 was experiencing discomfort. V11 stated he was not going to add to R1's discomfort by flushing or reinserting an indwelling urinary catheter and felt R1 should have returned to the ER to have the issue addressed. V11 could not recall the timing during the day shift but thought he may have sent R1 to the hospital in the afternoon before 3:00 PM. V11 was unaware if any other nurses tried to reinsert R1's indwelling urinary catheter. On 06/06/2022 at 2:13 PM, V8 (CNA) stated on 05/25/2022 around 9:00 AM, R1 had put the call light on and asked for the nurse to send him back to the hospital for his indwelling urinary catheter. V8 thought his catheter was okay but it did have only a small amount of dark red bloody urine in the drainage bag. V8 stated she reported it to an unknown female nurse (not V11) who had also spoke with R1. V8 stated R1 was able to communicate his needs but he did have confusion. On 06/07/2022 at 11:25 AM, V7 (RN agency) stated she had been stopped by R1 in the hallway during the afternoon of 05/25/2022. R1 asked V7 to be sent back to the hospital because his indwelling urinary catheter wasn't working. On 06/06/2022 at 3:21 PM, V3 (LPN Restorative Nurse) stated on 05/25/2022, V11 (RN agency) reported R1 had blood in the urine and bladder pain. V3 thought it was when she was doing rounds with the residents approximately 8:00 AM. V3 stated she did a bladder scan on R1 which revealed over 900 milliliters (ml) in the bladder. V3 stated R1 did not have any urine in the tubing or the drainage bag, just approximately 25 ml of blood. V3 stated she was unable to flush any normal saline into the catheter, called the nurse practitioner, and removed the indwelling urinary catheter. V3 was unable to insert a new catheter and decided to send R1 to the hospital. A Progress Note dated 05/25/2022 at 12:22 PM (V3,Restorative Nurse) showed R1 was observed with blood in catheter bag with no urine present. Resident readmitted from hospital on 5/24 with hematuria. Resident complains of lower abdominal pain at this time. NP notified with orders to perform bladder scan. Upon scanning resident is noted to have 999 ml currently in bladder, (catheter) taken out and attempt made to insert new (catheter). Attempts were unsuccessful no urine return noted. NP notified with orders to send resident to VA (Veteran's hospital) for further evaluation and (catheter) insertion. Message left for emergency contact. On 06/07/2022 at 12:43 PM, V13 (Attending MD/Medical Director) stated residents should not be retaining 1000 ml of urine. That is nursing fault for not caring for the resident and monitoring the urine output. The bleeding is not the fault of the nursing staff but failure to monitor a resident for not having urine output is a nursing fault. V13 stated R1 had gone to the ER with hematuria, had urinary retention, and it was irrigated the night before. The nurses should have been watching the urine output more closely. If the urine output was less than 300 ml, they should be discussing it with the physician or nurse practitioner or doing the bladder scan to find out what is going on with the resident. V13 stated This is not the first time this has happened with residents not being monitored for urine output. They (the facility) had an IJ (Immediate Jeopardy) there a couple of months ago with a couple of patients. I mean this is the same issue, so what improvement have they had? None. On 06/07/2022 at 3:51 PM, approximately 350 milliliters (ml) cloudy yellow urine was noted in R1's indwelling urinary catheter drainage bag. R1 did not think anyone had emptied his bag after the day shift. 2. According to the EHR, R10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] showed R10 needed extensive assistance of two people for bed mobility; needed extensive assistance of one person for dressing, eating, and toilet use; and needed total dependence of two people for transfers. R10 had a [CONDITION(S)] and an indwelling urinary catheter. The MDS showed R10's cognition was severely impaired. R10 did not have a care plan for an indwelling urinary catheter. The POS showed an order to monitor and record indwelling urinary drainage catheter output every shift. On 06/07/2022 at 4:09 PM, V15 (CNA) stated she was working the evening shift and did not think anyone had emptied R10's indwelling urinary catheter drainage bag. Approximately 400 ml of cloudy yellow urine was noted in the tubing and the drainage bag. R10 was unsure how often they emptied the drainage bag. The Monitoring Record showed R10 only had urine output recorded only six out of 19 shifts in June 2022 and 53 out of 93 shifts in May 2022. The CNA task tab from 05/07/2022 to 06/07/2022 did not have any documented urinary output. 3. According to the EHR, R5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] showed R5 needed extensive assistance of two people for bed mobility, dressing; was totally dependent on two staff for transfers; and needed extensive assistance of one person for toilet use. R5 had a [CONDITION(S)] and a suprapubic urinary catheter. The MDS showed R5's cognition was intact. A care plan showed R5 had a suprapubic urinary catheter with interventions to monitor and report for no output. The POS showed an order to monitor and record suprapubic urinary drainage catheter output every shift. On 06/07/2022 at 4:00 PM, R5 stated she didn't think the urinary drainage bag was emptied at the end of the day shift. Approximately 400 ml of slightly cloudy urine in tubing and urinary catheter drainage bag noted. V20 (CNA) stated let me tell you about the catheter drainage bag. V20 stated the regular CNA staff members will empty the drainage bag at the end of their shift. V20 stated the agency CNAs disregard emptying the urinary drainage bags and most of them won't empty the drainage bag. V20 stated the CNAs are not supposed to combine the output for two shifts so the drainage bags should be emptied at the end of the shift. A sign posted at the nurse's station showed the CNAs should report a resident's urine output towards the end of their shift to the nurse on duty, The nurses should document the urine volume in the Monitoring Tab section monitor and record (indwelling urinary catheter)/suprapubic catheter output every shift. The facility's Urinary Catheter Care policy dated 07/28/2021 included to observe the urine output for increases or decreases and report to the physician or supervisor if it stays the same or in the event of bleeding. Maintain an accurate record of the resident's daily output. Empty the collection bag at least every eight hours.

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect when it failed to provide structures and processes to care for residents receiving anti-[CONDITION(S)] medications, residents with indwelling urinary catheters, and a resident with respiratory condition changes requiring a STAT X-ray. The facility neglected to follow their medication pass and controlled medication policies for two residents (R2 and R9) receiving anti-[CONDITION(S)] medications. This failure resulted in R2 and R9 experiencing multiple breakthrough seizures. R2 required hospitalization for [CONDITION(S)], Aspiration Pneumonia due to [CONDITION(S)] activity, sedation, and intubation with mechanical ventilation. R9 required treatment at the local emergency room for a [CONDITION(S)] [MEDICATION(S)] more than 10 minutes and not relieved by medication ordered for breakthrough seizures. The facility neglected to follow their policy for following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility neglected to follow their policy for following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R12 expired at the facility waiting for the chest X-ray to be completed as ordered. This applies to 4 of 5 residents (R2, R8, R9, and R12) reviewed for neglect and delay of care in the sample of 26. The immediate Jeopardy was noted to begin on [DATE], when the facility failed to provide the anticonvulsant medication [MEDICATION(S)] ([MEDICATION(S)]). The Immediate Jeopardy was identified on February 14, 2022. V1 (Administrator), V2 (DON-Director of Nursing), and V27 (Regional Director of Operations) were notified of the Immediate Jeopardy on February 17, 2022, at 2:25 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on February 22, 2022, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the plan of correction, including in-service training of staff, administration of medications as ordered by the physician, and documentation of controlled-substance medications. The findings include: 1. On February 1, 2022, at 1:04 PM, R2 was lying in bed. R2 was not responsive to verbal stimuli. R2 had an indwelling urinary catheter and a Gastrostomy tube (G-tube) in place. The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE]. The EMR continues to show R2 was transferred to the local hospital on [DATE], due to uncontrolled seizures. R2 returned to the facility on [DATE]. R2 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS (Minimum Data Set) dated [DATE], shows R2 is in a persistent vegetative state. R2 is totally dependent on facility staff for all ADLs (Activities of Daily Living). R2 is always incontinent of bowel and bladder. R2's [CONDITION(S)] care plan, initiated [DATE], shows multiple interventions initiated on [DATE], including: Obtain and monitor lab/diagnostic work as ordered. Report laboratory results to MD and follow up as indicated. Post-[CONDITION(S)] treatment: Turn on side with head back, hyper-extended to prevent aspiration. Keep airway open. After [CONDITION(S)] take vital signs and neuro check . [CONDITION(S)] documentation: location of [CONDITION(S)] activity, type of [CONDITION(S)] activity (jerks, convulsive movements, trembling) duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after [CONDITION(S)] activity. On [DATE], at 9:01 AM, V7 (RN-Registered Nurse) documented, [R2] has [CONDITION(S)] activity for 25 minutes started at 0815 (8:15 AM). [MEDICATION(S)] ([MEDICATION(S)]) 2 mg IM given at 8:18 AM, still has active [CONDITION(S)]. 911 called. 0840 (8:40 AM); transferred patient to [Local Hospital]. Report given to paramedic assistance. POA (Power of Attorney) wife informed. [V10] (Medical Director/Physician) paged and informed. Vital signs: BP (Blood Pressure) ,d+[DATE], Pulse ,d+[DATE], R (Respirations) 30, T 99.5 F (Fahrenheit), 02 sat 99% with 5L N/C (Nasal Cannula). Hospital records dated [DATE], at 11:05 AM show R2's [MEDICATION(S)] level was 2.6. The laboratory report continues to show the Reference Range for [MEDICATION(S)] is 10.0 to 20.0 ug/ml (micrograms/milliliter). On [DATE], at 11:15 AM, V19 (Hospital Physician) documented, R2 required intubation and placement on a ventilator at the hospital. V19 documented multiple concerns, including [CONDITION(S)] with management using three anti-[CONDITION(S)] medications, including [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], and likely aspiration during the [CONDITION(S)] causing left lung Pneumonia. R2's [DATE] MAR (Medication Administration Record) shows an order dated [DATE], for [MEDICATION(S)] (anti-[CONDITION(S)] medication) 100 mg/4 ml (milligrams/milliliter). Give 6 ml via G-tube (Gastrostomy tube) every 8 hours for seizures. The facility does not have documentation to show R2 received the [MEDICATION(S)] medication as ordered on: [DATE], at 10:00 PM [DATE], at 10:00 PM [DATE], at 6:00 AM and 2:00 PM. Facility documentation shows R2's G-tube became dislodged on [DATE], at 10:00 PM and was reinserted at the local hospital on [DATE]. The facility does not have documentation to show R2's physician was notified of the missed doses of [MEDICATION(S)] on [DATE]. R2's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 8 ml via G-tube every 8 hours for seizures. The facility does not have documentation to show R2 received the medication at 6:00 AM on February 4, 2022, and February 12, 2022. The EMR shows an order dated [DATE], and [DATE], for [MEDICATION(S)] solution 10 mg/ml. Give 20 ml via G-tube every 12 hours for seizures. Nursing staff documented on R2's MARs for [DATE], [DATE], and February 2022 the [MEDICATION(S)] was administered as ordered. Further review of the facility's Controlled Drug Administration Record with V2 (DON) showed facility staff did not administer the [MEDICATION(S)] medication as ordered on the following dates: [DATE], x 1 dose [DATE], x 1 dose [DATE], x 1 dose [DATE], x 2 doses [DATE], x 1 dose Unable to review doses for [DATE], to [DATE], due to missing Controlled Drug Administration Record sheets. [DATE], x 1 dose [DATE], x 1 dose [DATE], x 1 dose [DATE], x 1 dose [DATE], x 1 dose Resident hospitalized [DATE], to [DATE] [DATE], x 1 dose February 2, 2022, x 2 doses February 3, 2022, x 2 doses February 5, 2022, x 1 dose The EMR shows orders dated [DATE], and [DATE], for [MEDICATION(S)] 2 mg/ml. Inject 2 mg/ml IM (Intramuscular) every 6 hours PRN (as needed) for seizures. The EMR shows R2 required [MEDICATION(S)] for breakthrough seizures on: [DATE] [DATE] [DATE] February 12, 2022 The facility does not have documentation to show R2's location of [CONDITION(S)] activity, the type of [CONDITION(S)] activity, or monitoring R2's vital signs following the breakthrough seizures as shown on R2's care plan. Facility documentation shows R2's [MEDICATION(S)] level was low on [DATE], with a reading of 8.7. The [MEDICATION(S)] Reference Range is ,d+[DATE] ug/ml. The facility does not have documentation to show R2's [MEDICATION(S)] level was rechecked between [DATE], and [DATE]. On February 2, 2022, at 12:24 PM, V10 (Medical Director/Physician) said, [R2's] [MEDICATION(S)] level was extremely low at the hospital when he arrived with a reading of 2.6. This is a stable patient with the current dose of three [CONDITION(S)] medications, if the medications are given at the appropriate time and as ordered. If I had been informed his G-tube came out and he had missed several doses of his [CONDITION(S)] medications, I would have told the staff to administer the medications he missed. This resident went into a critical situation, had Aspiration Pneumonia and needed to be intubated. It is a major failure on the part of the facility. They needed to call and let us know [R2] was not getting his medications and had a critical low lab value. It then becomes the physician's decision how to handle the medication situation. Without being informed, that decision is taken away from the physician. I had no idea this resident was having breakthrough seizures. This information was never reported to me. If the information is reported to me, I am made aware and I can adjust the resident's treatment plan. How can I do that if this is not reported to me? On February 10, 2022, at 1:57 PM, V10 (Medical Director/Physician) said, Facility staff should be documenting on both the Controlled Drug Administration Record and on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In reviewing the nursing documentation, it is obvious [R2] has not been getting his [MEDICATION(S)] medication as ordered. His subtherapeutic level of [MEDICATION(S)] was caused by missing doses of [MEDICATION(S)]. I have no doubt in my mind, [R2] missing the doses of his [CONDITION(S)] medications, especially the [MEDICATION(S)] caused his [CONDITION(S)] on [DATE], and resulted in this resident requiring hospitalization . On February 14, 2022, at 1:27 PM, V22 (Pharmacist/Director of Quality Assurance) said, [MEDICATION(S)] is a controlled substance. The medication needs to be accounted for on the controlled substance sign out sheets and on the facility's MAR. 2. On February 9, 2022, at 12:03 PM, R9 was lying in bed. R9 did not respond to verbal stimuli. R9 had a [CONDITION(S)], Gastrostomy tube, and an indwelling urinary catheter. R9's bilateral legs were severely contracted at the knees and hips. The EMR shows R9 was admitted to the facility on [DATE]. R9 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's MDS dated [DATE], shows R9 has severe cognitive impairment, is totally dependent on facility staff for all ADLs, has an indwelling urinary catheter, and is always incontinent of stool. The EMR shows an order dated [DATE], for [MEDICATION(S)] 100 mg. Give 1 tablet via G-tube two times a day for seizures (order discontinued February 9, 2022, at 12:22 PM). The EMR shows an order dated February 9, 2022, for [MEDICATION(S)] 150 mg. Give 1 tablet via G-tube two times a day for seizures (order discontinued February 10, 2022, at 11:15 AM). The EMR shows an order dated February 10, 2022, for [MEDICATION(S)] 100 mg. Give 1 tablet via G-tube two times a day for seizures. Nursing staff documented on R9's MARs for [DATE], [DATE], and February 2022 the [MEDICATION(S)] was administered as ordered. Further review of the facility's Controlled Drug Administration Record with V2 (DON) showed facility staff did not administer the [MEDICATION(S)] medication as ordered on the following dates: [DATE], x 1 dose [DATE], x 1 dose Unable to review doses for [DATE], through [DATE], due to missing Controlled Drug Administration Record sheets. [DATE], x 1 dose (V20 documented R9 sent to local hospital on [DATE] at 10:00 PM for uncontrolled [CONDITION(S)]. V21 (Nurse) documented R9 returned to facility on [DATE] at 7:27 AM). [DATE], x 1 dose [DATE], x 1 dose [DATE], x 1 dose [DATE], x 1 dose February 9, 2022, x 1 dose February 10, 2022, x 1 dose February 11, 2022, x 1 dose The EMR shows an order dated [DATE], for [MEDICATION(S)] 2 mg/ml. Inject 2 mg/ml IM (Intramuscular) every 6 hours prn (as needed) for seizures. The EMR shows R9 required [MEDICATION(S)] for breakthrough seizures on: [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] February 5, 2022 February 12, 2022 On February 10, 2022, at 10:27 AM, V2 (DON) said, [R9's] [MEDICATION(S)] dose was increased by the physician on February 9, 2022 due to a low [MEDICATION(S)] level obtained on [DATE] and multiple breakthrough seizures. On February 10, 2022, at 1:48 PM, V10 (Medical Director/Physician) said, The facility staff should follow the policy for controlled substance medication sign out documentation and follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They just need to give the medication correctly, that's it! These residents are having breakthrough seizures because they are not getting their [CONDITION(S)] medications as ordered. On February 10, 2022, at 1:28 PM, V2 (DON) stated, after reviewing the Controlled Drug Administration Records for R2 and R9, MARs, and the pharmacy delivery manifests, discrepancies were noted between what is documented on the Controlled Drug Administration Records and on the resident's MARs, and facility staff have not been administering the [MEDICATION(S)] as ordered. The facility's policy entitled Physician Orders, revised [DATE], shows Policy Statement: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's policy entitled Controlled Medications Count, revised [DATE], shows: Procedure: 1. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken. 2. After administration of the controlled medication, the nurse will sign off the eMAR (Electronic Medication Administration Record). 3. If the controlled medication needs to be wasted, another nurse should witness the wasting of the controlled medication. 3. On February 10, 2022, at 9:45 AM, R8 was lying in bed. R8 was not responsive to verbal stimuli. R8 had a [CONDITION(S)], a Gastrostomy tube, an indwelling urinary catheter, and a rectal tube in place. The EMR shows R8 was admitted to the facility on [DATE]. Facility documentation continues to show R8 was sent to the local hospital on February 6, 2022, and returned to the facility on [DATE]. R8 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's MDS dated [DATE], shows R8 has severe cognitive impairment, is totally dependent on facility staff for all ADLs (Activities of Daily Living), has an indwelling urinary catheter, and is always incontinent of stool. The EMR shows the following order for R8 dated [DATE]: Monitor and record [indwelling urinary catheter] output every shift. The facility does not have documentation to show facility staff monitored and recorded R8's urine output as ordered. Facility staff did not document R8's urine output on February 4, 2022, between 7:00 AM and 11:00 PM, and from 11:00 PM on February 4, 2022, to 7:00 AM on February 5, 2022. The EMR shows the following order for R8 dated February 5, 2022, at 11:00 PM: Bladder scan every shift. Insert [indwelling urinary catheter] if bladder scanner reading is above 350 cc (cubic centimeters). The facility does not have documentation to show facility staff scanned R8's bladder as ordered by the physician. On February 6, 2022, at 8:34 AM, V14 (LPN-Licensed Practical Nurse) documented, Writer called to [R8's] room by RT (Respiratory Therapist) for change in condition of resident. Resident observed to have labored breathing, elevated heart rate 124 BPM (Beats Per Minute), and elevated temperature 101.4. Resident is currently on IV ABT (Intravenous Antibiotics) and IV fluids. MD on call paged to update. Orders received to send resident to ER (emergency room ) for evaluation. Contacted responsible parties' voicemail left at this time due to no answer. Hospital documentation dated February 7, 2022, at 7:11 AM, shows V10 (Medical Director/Physician) documented R8 was admitted to the local hospital on February 6, 2022, with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On February 10, 2022, at 1:30 PM, V10 (Medical Director/Physician) said, I am [R8's] physician at the facility, and I also cared for him at the local hospital. I want the facility staff to follow my orders and document the resident's urine output every shift. If there is no urine output and I am notified, then I tell them to flush the catheter if the resident has one and do a bladder scan. Urine output is critical. When [R8] went to the hospital, he had pus coming from the tip of his penis. There was 1200 ml of urine in his bladder, his urine was very cloudy, and that is the reason he went into [CONDITION(S)]. His Ureters were dilated, and he had hydronephrosis. The facility staff should have noticed he was anuric (without urine output) and notified me. When the urine output decreases, we know there is a catheter issue, and in [R8's] case, that could have been easily corrected. Any line that goes into the body is the responsibility of the healthcare staff to care for. An infection caused by the urine catheter indicates poor care. There's no excuse for that type of infection and this was caused by poor care at the facility. The Hydronephrosis R8 experienced was as a direct result of the extreme amount of urine in [R8's] bladder. On February 15, 2022, at 1:22 PM, V15 (Nurse) said, I did get an order on February 5, 2022, to do a bladder scan on [R8]. His [indwelling urinary catheter] got pulled out and the doctor wanted to check how much urine was in his bladder before we put in a new catheter. It happened at the end of my shift, around 11:00 PM, so I put the order in the computer, but I did not do the bladder scan. I endorsed that order over to the next shift that was starting at 11:00 PM. [R8] needed a certain size urinary catheter, and the facility did not have that specific size. I did not insert a new urine catheter before I left my shift. The facility does not have documentation of R8's indwelling urinary catheter being pulled out or removed on February 5, 2022. On February 15, 2022, at 3:06 PM, V16 (LPN) said, Me and the other nurse were not able to find the bladder scanner in the building so I could not do the bladder scan on [R8]. Also, we could not find any [indwelling urinary catheters] in the building, so I was unable to start a new catheter for the resident. [R8] did not have any urine output during my shift. I did not notify the physician that we were unable to do the bladder scan or that the resident did not have any urine output during my shift. I told the nurse taking over at 7:00 AM on February 6, 2022, to follow up with the bladder scan. On February 15, 2022, at 3:37 PM, V17 (LPN) said, I was working on the night shift on February 6, 2022 (11:00 PM to 7:00 AM). I can't remember if I was assigned to [R8] that night but I know I helped out with him. We are supposed to have a bladder scanner in the building up on the third floor, but when we found the scanner, all that was there was the stand. The scanner was missing. I did not put a urinary catheter in [R8] that night. He did not have any urine output that night. I did not report the lack of urine output to the doctor. At approximately 6:50 AM on February 6, I was giving report to the next shift, and we noticed [R8] was having a change in condition. His breathing seemed labored, and he was sweating. We called the doctor and the doctor said to send him out. The facility does not have documentation to show facility staff performed the bladder scan as ordered by the physician, inserted a new urinary catheter, or measured R8's urine output between 11:00 PM on February 5, 2022, and 7:00 AM on February 6, 2022. The facility's policy entitled Urinary Catheter Care, revised [DATE], shows: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. General Guidelines: a. Input/output: i. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. ii. Maintain an accurate record of the resident's daily output, per facility policy and procedure. Complications: 1. Observe the resident for complications associated with urinary catheters.b. Check the urine for unusual appearance (i.e., color, blood, etc.). c. Notify the physician or supervisor in the event of bleeding, or if the catheter is accidentally removed.e. Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately.16. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. The facility's policy entitled Physician Orders, revised [DATE], shows Policy Statement: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 4. The EMR shows R12 was a [AGE] year-old resident, admitted to the facility on [DATE], and expired at the facility on February 6, 2022. R12 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's MDS dated [DATE], shows R12 was cognitively intact, required supervision with locomotion on the unit and eating, and extensive assistance with bed mobility, transfers between surfaces dressing, toilet use, personal hygiene, and bathing. R12 was always incontinent of bowel and bladder. R12's hospital discharge orders dated [DATE], show an order to follow up with the Pulmonologist in two weeks. This information is also noted on the facility's Nursing Admission Report dated [DATE]. The facility does not have documentation to show R12's Pulmonologist consult was ordered by the facility. The facility does not have documentation to show R12 was seen by a Pulmonologist while residing at the facility, or that V10 (Medical Director/Physician) was notified R12 did not see the Pulmonologist. On February 17, 2022, at 9:26 AM, V2 (DON) stated, I checked with the Pulmonologist office and [R12) has not been in there. So [R12] never went to the appointment. On February 1, 2022, at 7:29 PM, V23 (RT-Respiratory Therapist) documented: Called to room to place [CONDITION(S)] (Bi-level Positive Airway Pressure). Arrived in room and SPO2 (Oxygen saturation) was 69%. HR (Heart Rate) correlating. Placed on [CONDITION(S)] ,d+[DATE] (pressure settings) with 10L (Liter) bleed-in from O2 tank. No breath sounds heard. [R12] wanted [CONDITION(S)] off. Placed on 6L [nasal cannula]. [SPO2] 88 [percent]. [R12] placed on [CONDITION(S)] ,d+[DATE] with nasal cannula at 7L. [SPO2] at 93%. Report given to [night] shift. The facility does not have documentation to show V10 (Medical Director/Physician) was notified of R12's change in condition, including oxygen saturation level of 69 percent. The EMR shows V24 (LPN-Licensed Practical Nurse) entered an order on February 4, 2022, at 3:00 PM for a STAT chest X-ray, 2 views, due to oxygen desaturation. The facility does not have documentation to show R12 received the chest X-ray as ordered by the physician. The facility does not have documentation to show facility staff followed up with the X-ray provider to determine when the X-ray would take place. The facility does not have documentation to show V10 (Medical Director/Physician) was notified R12 did not receive the STAT chest X-ray as ordered. On February 14, 2022, at 3:42 PM, V25 (Vice President of Sales and Marketing) said, Our policy on STAT orders is four hours from order to report. Routine X-rays should be 24 hours from order to report. We did notify [V24] (LPN) when she ordered the STAT X-ray we were running late. We do not notify the physician we are running late. That is the facility's responsibility. The X-ray ended up getting canceled on February 6, 2022, because [R12] expired. We never did the X-ray. On February 6, 2022, at 7:14 PM documented the following timeline for R12: 3:30 PM, V18 (Nurse) documented: It was endorsed that resident will have a stat chest X-ray to be done this afternoon. 16:30 (4:30 PM), V18 documented R12 was wearing her [CONDITION(S)] with an oxygen saturation level of 90 percent. 17:15 (5:15 PM) dinner tray served by CNA (Certified Nursing Assistant); no apparent distress noted. Remains on O2 per N/C (nasal cannula). 18:05 (6:05 PM) CNA went to get dinner tray and found resident unresponsive. No pulse noted. Code status verified and resident is DNR (Do Not Resuscitate) Time of death at 18:05 confirmed by two RNs R12's State of Illinois Certificate of Death Worksheet, dated February 10, 2022, shows R12 expired on February 6, 2022, at 6:05 PM. V10 (Medical Director/Physician) documented the cause of death on the death certificate as Arrhythmia, Pulmonary [CONDITION(S)] Hypertension, and Restrictive Lung disease. On February 14, 2022, at 12:47 PM, V10 (Medical Director/Physician) said, [R12] had a STAT chest X-ray ordered on February 4, 2022. We should have had results from that X-ray by 7:00 PM that same night. It was ordered STAT because she was having difficulty breathing while the nebulizer treatment was going on. This patient has Respiratory Lung disease, due to [CONDITION(S)]. It is the standard of care to do a chest X-ray for breathing difficulties. My order was not completed on February 4 as I expected it to be, and this resident expired on February 6, 2022, still waiting for the X-ray to be completed. STAT means STAT. It means no delay. There's a reason to do a STAT order because there is limited time to get the results, otherwise I would have just ordered a routine X-ray. The STAT order must be done within 4 hours. Even a routine order must be done within 24 hours. If the chest X-ray isn't being done, and they can't do it, the facility needs to inform me. They can't keep it a secret. The facility did not communicate with me. If the order is STAT, and if it isn't done, then it is neglect not to inform the physician. You can see I wrote the death certificate according to her Chronic Lung disease. She could have gone into an Arrythmia due to breathing difficulties. After she expired, her POA (Power of Attorney) questioned why the X-ray wasn't done. The whole purpose for ordering the chest X-ray was to exclude a mucous plug or Pneumothorax. If this patient had a mucous plug, or a collapsed lung, we could have prevented her death with treatment. It is possible that she had a reversible condition. If this patient had any of those reversible things, she would still be alive if we had treated her accordingly. This resident was harmed. We are dealing with the death of a resident here. It was hard to write the death certificate because I didn't have the information, I could have gotten from a chest X-ray. I had to go by her chronic medical condition. Death and harm happened because the chest X-ray was not done. The lack of X-ray absolutely killed [R12]. The choice to treat the resident was taken away from me. The facility should not accept these residents if they cannot take care of these them and now harm has happened. This is a respiratory facility. They are supposed to take care of respiratory patients. The rate for death is higher due to the acuity of the residents they care for here. If you are promising to take care of this population of residents, and you don't provide care, this is an absolute failure. Multiple requests were made to the facility for policy and procedures regarding obtaining routine and STAT X-rays. Each time the policies were requested, V1 (Administrator) stated the facility does not have policies for obtaining X-rays. The facility's policy entitled Physician Orders, revised [DATE], shows Policy Statement: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Immediate Jeopardy that began on [DATE], was removed on February 22, 2022, when the facility took the following actions to remove the immediacy: All Nursing Staff (Nurses and CNAs) were and continue to be re-educated on the facility Abuse and Neglect policy by the Administrator and/or designee on February 17, 2022, and was completed on February 22, 2022. Staff who were not in-serviced due to leave or vacation will be in-serviced prior to their next shift worked. Re-education emphasis was on identifying immediate care needs for a resident and following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . All nursing staff (nurses) were re-educated by the DON and/or designee on February 17, 2022, and continued and was completed on February 22, 2022, on but not limited to, the facility policy and procedure on medication administration. The re-education emphasized medication administration importance on anti-convulsant medications as ordered by physician. The education included documentation of the administration on the controlled substance record and when a medication is unavailable, for any reason, or unable to be administered for any reason, to notify the provider immediately and to call the medical director if a physician is not returning the call timely (timely defined as within 30 minutes and/or using nursing professional judgement based on the resident's clinical condition) and to send declining residents to the emergency room . Staff who were not in-serviced due to leave or vacation will be in-serviced prior to their next shift worked. The re-education emphasis was on identifying immediate care needs for a resident and following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . All nursing staff (nurses and CNAs) were re-educated by the DON and/or designee on February 17, 2022, and continued through February 22, 2022, on but not limited to, the facility policy and procedure on indwelling urinary catheters. The re-education emphasized documentation on

Based on interview and record review the facility failed to administer anticonvulsant medications to residents as ordered by the physician and failed to follow the facility policy for medication administration and documentation. This failure resulted in R2 and R9 experiencing breakthrough seizures, R2 requiring hospitalization for [CONDITION(S)], and R9 requiring treatment at the local emergency room for a [CONDITION(S)] [MEDICATION(S)] more than 10 minutes and not relieved by medication ordered for breakthrough seizures. This applies to 3 of 3 residents (R2, R4, R9) reviewed for medications in the sample of 26. The immediate Jeopardy was noted to begin on December 2, 2021, when the facility failed to provide the anticonvulsant medication [MEDICATION(S)] ([MEDICATION(S)]). The Immediate Jeopardy was identified on February 14, 2022. V1 (Administrator), V2 (DON-Director of Nursing), and V27 (Regional Director of Operations) were notified of the Immediate Jeopardy on February 17, 2022, at 2:25 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on February 22, 2022, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the plan of correction, including in-service training of staff, administration of medications as ordered by the physician, and documentation of controlled-substance medications. The findings include: 1. On February 1, 2022, at 1:04 PM, R2 was lying in bed. R2 was not responsive to verbal stimuli. R2 had an indwelling urinary catheter and a Gastrostomy tube (G-tube) in place. The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE]. The EMR continues to show R2 was transferred to the local hospital on January 19, 2022, due to uncontrolled seizures. R2 returned to the facility on [DATE]. R2 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS (Minimum Data Set) dated December 12, 2021, shows R2 is in a persistent vegetative state. R2 is totally dependent on facility staff for all ADLs (Activities of Daily Living). R2 is always incontinent of bowel and bladder. R2's [CONDITION(S)] care plan, initiated November 11, 2018, shows multiple interventions initiated on November 11, 2018, including: Obtain and monitor lab/diagnostic work as ordered. Report laboratory results to MD and follow up as indicated. Post-[CONDITION(S)] treatment: Turn on side with head back, hyper-extended to prevent aspiration. Keep airway open. After [CONDITION(S)] take vital signs and neuro check . [CONDITION(S)] documentation: location of [CONDITION(S)] activity, type of [CONDITION(S)] activity (jerks, convulsive movements, trembling) duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after [CONDITION(S)] activity. On January 19, 2022, at 9:01 AM, V7 (RN-Registered Nurse) documented, [R2] has [CONDITION(S)] activity for 25 minutes started at 0815 (8:15 AM). [MEDICATION(S)] ([MEDICATION(S)]) 2 mg IM (Intramuscular) given at 8:18 AM, still has active [CONDITION(S)]. 911 called. 0840 (8:40 AM); transferred patient to [Local Hospital]. Report given to paramedic assistance. POA (Power of Attorney) wife informed. [V10] (Medical Director/Physician) paged and informed. Vital signs: BP (Blood Pressure) 202/77, Pulse 111-140, R (Respirations) 30, T 99.5 F (Fahrenheit), 02 sat 99% with 5L N/C (Nasal Cannula). Hospital records dated January 19, 2022, at 11:05 AM show R2's [MEDICATION(S)] level was 2.6. The laboratory report continues to show the Reference Range for [MEDICATION(S)] is 10.0 to 20.0 ug/ml (micrograms/milliliter). On January 19, 2022, at 11:15 AM, V19 (Hospital Physician) documented, R2 required intubation and placement on a ventilator at the hospital. V19 documented multiple concerns, including [CONDITION(S)] with management using three anti-[CONDITION(S)] medications, including [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], and likely aspiration during the [CONDITION(S)] causing left lung Pneumonia. R2's December 2021 MAR (Medication Administration Record) shows an order dated September 22, 2021, for [MEDICATION(S)] (anti-[CONDITION(S)] medication) 100 mg/4 ml (milligrams/milliliter). Give 6 ml via G-tube (Gastrostomy tube) every 8 hours for seizures. The facility does not have documentation to show R2 received the [MEDICATION(S)] medication as ordered on: December 12, 2021, at 10:00 PM December 23, 2021, at 10:00 PM December 27, 2021, at 6:00 AM and 2:00 PM. Facility documentation shows R2's G-tube became dislodged on December 26, 2021, at 10:00 PM and was reinserted at the local hospital on December 27, 2021. The facility does not have documentation to show R2's physician was notified of the missed doses of [MEDICATION(S)] on December 27, 2021. R2's January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 8 ml via G-tube every 8 hours for seizures. The facility does not have documentation to show R2 received the medication at 6:00 AM on February 4, 2022, and February 12, 2022. The EMR shows an order dated March 9, 2021, and January 27, 2022, for [MEDICATION(S)] solution 10 mg/ml. Give 20 ml via G-tube every 12 hours for seizures. Nursing staff documented on R2's MARs for December 2021, January 2022, and February 2022 the [MEDICATION(S)] was administered as ordered. Further review of the facility's Controlled Drug Administration Record with V2 (DON) showed facility staff did not administer the [MEDICATION(S)] medication as ordered on the following dates: December 2, 2021, x (times) 1 dose December 7, 2021, x 1 dose December 8, 2021, x 1 dose December 9, 2021, x 2 doses December 11, 2021, x 1 dose Unable to review doses for December 17, 2021, to January 1, 2022, due to missing Controlled Drug Administration Record sheets. January 9, 2022, x 1 dose January 10, 2022, x 1 dose January 11, 2022, x 1 dose January 12, 2022, x 1 dose January 18, 2022, x 1 dose Resident hospitalized [DATE], to January 27, 2022 January 30, 2022, x 1 dose February 2, 2022, x 2 doses February 3, 2022, x 2 doses February 5, 2022, x 1 dose The EMR shows orders dated March 13, 2021, and January 27, 2022, for [MEDICATION(S)] 2 mg/ml. Inject 2 mg/ml IM (Intramuscular) every 6 hours prn (as needed) for seizures. The EMR shows R2 required [MEDICATION(S)] for breakthrough seizures on: December 24, 2021 January 3, 2022 January 19, 2022 February 12, 2022 The facility does not have documentation to show R2's location of [CONDITION(S)] activity, the type of [CONDITION(S)] activity, or monitoring R2's vital signs following the breakthrough seizures as shown on R2's care plan. Facility documentation shows R2's [MEDICATION(S)] level was low on December 29, 2021, with a reading of 8.7. The [MEDICATION(S)] Reference Range is 10-20 ug/ml. The facility does not have documentation to show R2's [MEDICATION(S)] level was rechecked between December 29, 2021, and January 19, 2022. On February 2, 2022, at 12:24 PM, V10 (Medical Director/Physician) said, [R2's] [MEDICATION(S)] level was extremely low at the hospital when he arrived with a reading of 2.6. This is a stable patient with the current dose of three [CONDITION(S)] medications, if the medications are given at the appropriate time and as ordered. If I had been informed his G-tube came out and he had missed several doses of his [CONDITION(S)] medications, I would have told the staff to administer the medications he missed. This resident went into a critical situation, had aspiration Pneumonia and needed to be intubated. It is a major failure on the part of the facility. They needed to call and let us know [R2] was not getting his medications and had a critical low lab value. It then becomes the physician's decision how to handle the medication situation. Without being informed, that decision is taken away from the physician. I had no idea this resident was having breakthrough seizures. This information was never reported to me. If the information is reported to me, I am made aware and I can adjust the resident's treatment plan. How can I do that if this is not reported to me? On February 10, 2022, at 1:57 PM, V10 (Medical Director/Physician) stated, Facility staff should be documenting on both the Controlled Drug Administration Record and on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In reviewing the nursing documentation, it is obvious [R2] has not been getting his [MEDICATION(S)] medication as ordered. His subtherapeutic level of [MEDICATION(S)] was caused by missing doses of [MEDICATION(S)]. I have no doubt in my mind, [R2] missing the doses of his [CONDITION(S)] medications, especially the [MEDICATION(S)] caused his [CONDITION(S)] on January 19, 2022, and resulted in this resident requiring hospitalization . On February 14, 2022, at 1:27 PM, V22 (Pharmacist/Director of Quality Assurance) said, [MEDICATION(S)] is a controlled substance. The medication needs to be accounted for on the controlled substance sign out sheets and on the facility's MAR. 2. On February 9, 2022, at 12:03 PM, R9 was lying in bed. R9 did not respond to verbal stimuli. R9 had a [CONDITION(S)], a Gastrostomy tube, and an indwelling urinary catheter. R9's bilateral legs were severely contracted at the knees and hips. The EMR shows R9 was admitted to the facility on [DATE]. R9 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's MDS dated [DATE], shows R9 has severe cognitive impairment, is totally dependent on facility staff for all ADLs, has an indwelling urinary catheter, and is always incontinent of stool. The EMR shows an order dated November 1, 2021, for [MEDICATION(S)] 100 mg. Give 1 tablet via G-tube two times a day for seizures (order discontinued February 9, 2022, at 12:22 PM). The EMR shows an order dated February 9, 2022, for [MEDICATION(S)] 150 mg. Give 1 tablet via G-tube two times a day for seizures (order discontinued February 10, 2022, at 11:15 AM). The EMR shows an order dated February 10, 2022, for [MEDICATION(S)] 100 mg. Give 1 tablet via G-tube two times a day for seizures. Nursing staff documented on R9's MARs for December 2021, January 2022, and February 2022 the [MEDICATION(S)] was administered as ordered. Further review of the facility's Controlled Drug Administration Record with V2 (DON) showed facility staff did not administer the [MEDICATION(S)] medication as ordered on the following dates: December 2, 2021, x 1 dose December 19, 2021, x 1 dose Unable to review doses for December 22, 2021, through January 2, 2022 due to missing Controlled Drug Administration Record sheets. January 7, 2022, x 1 dose (V20 documented R9 was sent to local hospital on 1/7/2022 at 10:00 PM for uncontrolled [CONDITION(S)]. V21 (Nurse) documented R9 returned to facility on 1/8/2022 at 7:27 AM). January 8, 2022, x 1 dose January 9, 2022, x 1 dose January 25, 2022, x 1 dose January 26, 2022, x 1 dose February 9, 2022, x 1 dose February 10, 2022, x 1 dose February 11, 2022, x 1 dose The EMR shows an order dated November 2, 2021, for [MEDICATION(S)] 2 mg/ml. Inject 2 mg/ml IM (Intramuscular) every 6 hours prn (as needed) for seizures. The EMR shows R9 required [MEDICATION(S)] for breakthrough seizures on: December 3, 2021 December 26, 2021 December 28, 2021 January 2, 2022 January 4, 2022 January 20, 2022 January 22, 2022 January 25, 2022 January 29, 2022 February 5, 2022 February 12, 2022 On February 10, 2022, at 10:27 AM, V2 (DON) said, [R9's] [MEDICATION(S)] dose was increased by the physician on February 9, 2022, due to a low [MEDICATION(S)] level obtained on January 10, 2022, and multiple breakthrough seizures. On February 10, 2022, at 1:48 PM, V10 (Medical Director/Physician) stated, The facility staff should follow the policy for controlled substance medication sign out documentation and follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They just need to give the medication correctly, that's it! These residents are having breakthrough seizures because they are not getting their [CONDITION(S)] medications as ordered. 3. On February 1, 2022, at 10:40 AM, R4 was observed sitting in his room. R4 was not interviewable due to his cognitive status. The EMR shows R4 was admitted to the facility in May 2017. R4 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's MDS dated [DATE], shows R4 has severe cognitive impairment, requires extensive assistance with bed mobility, transfers between surfaces, dressing, toilet use, personal hygiene and bathing. R4 requires supervision with eating. R4 is always incontinent of bowel and bladder. The EMR shows an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 10 ml by mouth two times a day related to conversion disorder with seizures or convulsions. Nursing staff documented on R4's MARs for December 2021, January 2022, and February 2022 the [MEDICATION(S)] was administered as ordered. Further review of the facility's Controlled Drug Administration Record with V2 (DON) showed facility staff did not administer the [MEDICATION(S)] medication as ordered on the following dates: December 14, 2021, x 1 dose December 17, 2021, x 1 dose December 24, 2021, x 1 dose December 30, 2021, x 1 dose January 10, 2022, x 1 dose January 14, 2022, x 1 dose January 15, 2022, x 1 dose January 16, 2022, x 1 dose January 18, 2022, x 2 doses January 23, 2022, x 1 dose January 30, 2022, x 1 dose February 1, 2022, x 1 dose Unable to review doses for February 5, 2022, and February 7, 2022, at 9:00 AM due to missing Controlled Drug Administration Record sheets. Facility documentation dated February 5, 2022, at 10:55 PM shows, Results: [MEDICATION(S)] < (less than) 0.5 ug/ml. The documentation continues to show the reference range for [MEDICATION(S)] is 5.0 to 10.0 ug/ml. R4's physician was notified, and orders were received to increase R4's dose of [MEDICATION(S)] to 15 ml by mouth two times a day and repeat a [MEDICATION(S)] level on February 19, 2022. On February 10, 2022, at 1:10 PM, V10 (Medical Director/Physician) stated, We shouldn't be increasing a resident's medication due to a low lab level if the reason the level is low is because the resident is not receiving the medication as ordered. The staff need to give the medication as ordered. On February 10, 2022, at 1:28 PM, V2 (DON) stated, after reviewing the Controlled Drug Administration Records, MARs, and pharmacy delivery manifests for R2, R4, and R9, discrepancies were noted between what is documented on the Controlled Drug Administration Records and on the residents' MARs, and facility staff have not been administering the [MEDICATION(S)] as ordered. The facility's policy entitled Physician Orders, revised July 28, 2021, shows Policy Statement: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's policy entitled Controlled Medications Count, revised July 27, 2021, shows: Procedure: 1. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken. 2. After administration of the controlled medication, the nurse will sign off the eMAR (Electronic Medication Administration Record). 3. If the controlled medication needs to be wasted, another nurse should witness the wasting of the controlled medication. The Immediate Jeopardy that began on December 2, 2021, was removed on February 22, 2022, when the facility took the following actions to remove the immediacy: All Nursing Staff (nurses) were re-educated by V2 (DON) and/or designee on February 17, 2022, and continued to completion on February 22, 2022, on but not limited to, the facility policy and procedure on medication administration. The re-education emphasized medication administration importance on anti-convulsant medications as ordered by physician, including documentation on the controlled substance record. When the medication is unavailable for any reason or unable to be administered for any reason, to notify the provider immediately and to call the medical director if a physician is not returning the call timely (timely defined as within 30 minutes and/or using nursing professional judgement based on the clinical condition) and to send declining residents to the emergency room via 911 using professional assessment and judgement. Staff will be re-educated prior to their next shift worked. Agency staff will be educated during nurse-to-nurse report process by the off-going nurse or designee utilizing the agency in-service education tool or during staff education. The facility's pharmacy conducted medication pass audits on February 16, 2022, and medication cart audits on February 16, 2022, and continued on February 18, 2022. Audits will be conducted quarterly. QA (QA-Quality Assurance) audits will be conducted by (DON) and/or designee three times per week of three residents receiving anti-convulsant medications for four weeks, then weekly times four weeks to ensure staff are administering medications as ordered by the physician specifically anti-convulsant medications. this includes a review of the controlled substance records and notifying physicians timely if the medication is not administered for any reason or any discrepancies with administration. All identified trends will be reviewed by the QAPI (Quality Assurance and Performance Improvement) committee quarterly and a plan will be discussed and implemented until resolution. The incident and abatement plan has been discussed and reviewed with the facility medical director on February 17, 2022, at 3:13 PM. Emergency QAPI meeting was held on February 18, 2022, at 2:00 PM. QA audit tools will start on February 22, 2022.

Based on observation, interview, and record review the facility failed to provide catheter care and follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] This failure resulted in R8 experiencing marked distension of the urinary bladder with urine retention of 1200 ml (milliliters) of purulent urine, Hydronephrosis (swelling of the kidney), purulent drainage from the penis, indwelling catheter associated Urinary Tract Infection, [CONDITION(S)] due to Urinary Tract Infection, and hospitalization . This applies to 16 of 16 residents (R8, R9, R13-R26) reviewed for indwelling urinary catheters in the sample of 26. The Immediate Jeopardy began on February 6, 2022, at 7:00 AM when the facility failed to monitor and document R8's urine output and failed to provide the physician-ordered bladder scan. The Immediate Jeopardy was identified on February 15, 2022. V1 (Administrator), V2 (DON-Director of Nursing), and V27 (Regional Director of Operations) were notified of the Immediate Jeopardy on February 17, 2022, at 2:25 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on February 22, 2022, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the plan of correction, including in-service training of staff, documentation of catheter care, urine output, and initiation of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: 1. On February 10, 2022, at 9:45 AM, R8 was lying in bed. R8 was not responsive to verbal stimuli. R8 had a [CONDITION(S)], a Gastrostomy tube, an indwelling urinary catheter, and a rectal tube in place. 1. The EMR (Electronic Medical Record) shows R8 was admitted to the facility on [DATE]. Facility documentation continues to show R8 was sent to the local hospital on February 6, 2022, and returned to the facility on [DATE]. R8 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's MDS (Minimum Data Set) dated November 25, 2021, shows R8 has severe cognitive impairment, is totally dependent on facility staff for all ADLs (Activities of Daily Living), has an indwelling urinary catheter, and is always incontinent of stool. The EMR shows the following order for R8 dated November 19, 2021: Monitor and record [indwelling urinary catheter] output every shift. The facility does not have documentation to show facility staff monitored and recorded R8's urine output as ordered. Facility staff did not document R8's urine output on February 4, 2022, between 7:00 AM and 11:00 PM, and from 11:00 PM on February 4, 2022, to 7:00 AM on February 5, 2022. The EMR shows the following order for R8 dated February 5, 2022, at 11:00 PM: Bladder scan every shift. Insert [indwelling urinary catheter] if bladder scanner reading is above 350 cc (cubic centimeters). The facility does not have documentation to show facility staff scanned R8's bladder as ordered by the physician. On February 6, 2022, at 8:34 AM, V14 (LPN-Licensed Practical Nurse) documented, Writer called to [R8's] room by RT (Respiratory Therapist) for change in condition of resident. Resident observed to have labored breathing, elevated heart rate 124 BPM (Beats Per Minute), and elevated temperature 101.4. Resident is currently on IV ABT (Intravenous Antibiotics) and IV fluids. MD on call paged to update. Orders received to send resident to ER (emergency room ) for evaluation. Contacted responsible parties' voicemail left at this time due to no answer. Hospital documentation dated February 7, 2022, at 7:11 AM, shows V10 (Medical Director/Physician) documented R8 was admitted to the local hospital on February 6, 2022, with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On February 10, 2022, at 1:30 PM, V10 (Medical Director/Physician) stated, I am [R8's] physician at the facility, and I also cared for him at the local hospital. I want the facility staff to follow my orders and document the resident's urine output every shift. If there is no urine output and I am notified, then I tell them to flush the catheter if the resident has one and do a bladder scan. Urine output is critical. When [R8] went to the hospital, he had pus coming from the tip of his penis. There was 1200 ml of urine in his bladder, his urine was very cloudy, and that is the reason he went into [CONDITION(S)]. His Ureters were dilated, and he had Hydronephrosis. The facility staff should have noticed he was Anuric (without urine output) and notified me. When the urine output decreases, we know there is a catheter issue, and in [R8's] case, that could have been easily corrected. Any line that goes into the body is the responsibility of the healthcare staff to care for. An infection caused by the urine catheter indicates poor care. There's no excuse for that type of infection and this was caused by poor care at the facility. The Hydronephrosis R8 experienced was a direct result of the extreme amount of urine in [R8's] bladder. On February 15, 2022, at 1:22 PM, V15 (Nurse) stated, I did get an order on February 5, 2022, to do a bladder scan on [R8]. His [indwelling urinary catheter] got pulled out and the doctor wanted to check how much urine was in his bladder before we put in a new catheter. It happened at the end of my shift, around 11:00 PM, so I put the order in the computer, but I did not do the bladder scan. I endorsed that order over to the next shift that was starting at 11:00 PM. [R8] needed a certain size urinary catheter, and the facility did not have that specific size. I did not insert a new urinary catheter before I left my shift. The facility does not have documentation of R8's indwelling urinary catheter being pulled out or removed on February 5, 2022. On February 15, 2022, at 3:06 PM, V16 (LPN) stated, Me and the other nurse were not able to find the bladder scanner in the building so I could not do the bladder scan on [R8]. Also, we could not find any [indwelling urinary catheters] in the building, so I was unable to start a new catheter for the resident. [R8] did not have any urine output during my shift. I did not notify the physician that we were unable to do the bladder scan or that the resident did not have any urine output during my shift. I told the nurse taking over at 7:00 AM on February 6, 2022, to follow up with the bladder scan. On February 15, 2022, at 3:37 PM, V17 (LPN) stated, I was working on the night shift on February 6, 2022 (11:00 PM to 7:00 AM). I can't remember if I was assigned to [R8] that night but I know I helped with him. We are supposed to have a bladder scanner in the building up on the third floor, but when we found the scanner, all that was there was the stand. The scanner was missing. I did not put a urinary catheter in [R8] that night. He did not have any urine output that night. I did not report the lack of urine output to the doctor. At approximately 6:50 AM on February 6, I was giving report to the next shift, and we noticed [R8] was having a change in condition. His breathing seemed labored, and he was sweating. We called the doctor and the doctor said to send him out. The facility does not have documentation to show facility staff performed the bladder scan as ordered by the physician, inserted a new urinary catheter, or measured R8's urine output between 11:00 PM on February 5, 2022, and 7:00 AM on February 6, 2022. 2. On February 9, 2022, at 12:03 PM, R9 was lying in bed. R9 did not respond to verbal stimuli. R9 had a [CONDITION(S)], a Gastrostomy tube, and an indwelling urinary catheter. R9's bilateral legs were severely contracted at the knees and hips. V12 (CNA-Certified Nursing Assistant) and V13 (CNA) assisted R9 to turn to his side and exposed R9's indwelling urinary catheter. The catheter was caked with a greenish brown substance from the tip of R9's penis to approximately 1 inch down the length of the catheter. Cloudy, yellow urine was visible in the catheter tubing and collection bag. The EMR shows R9 was admitted to the facility on [DATE]. R9 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's MDS dated [DATE], shows R9 has severe cognitive impairment, is totally dependent on facility staff for all ADLs, has an indwelling urinary catheter, and is always incontinent of stool. The EMR shows the following order for R9 dated November 1, 2021: Monitor and record [indwelling urinary catheter] output every shift. The EMR shows facility staff did not document R9's urine output for day shift on January 1, 4, 6, 7, 9, 12, 14, 15, 16, 19, 22, 25, 26, 27, 29, 30, and 31, 2022. On February 4, 2022, facility staff did not document urine output on day or PM shift, a total of 16 hours. Facility staff did not document any urine output for the 24-hour period on February 10, 2022. Facility staff did not document urine output on February 11, 2022, on day shift or PM shift. 3. The EMR shows R26 was recently hospitalized and returned to the facility on [DATE], at 11:04 AM with an indwelling urinary catheter. The facility does not have documentation to show R26's urine output was monitored or recorded from readmission on February 12, 2022, through February 15, 2022, at 4:00 PM. The facility did not obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. On February 15, 2022, at 12:56 PM, the facility provided a list of residents with indwelling urinary catheters. The list shows R8, R9, and R13-R26 have indwelling urinary catheters. Monitoring Records were reviewed for R8, R9, and R13-R26, and concerns were identified regarding urine output monitoring for all 16 residents. For the period of February 1 to February 15, 2022, the facility did not have documentation to show facility staff are monitoring the resident's urine output as ordered by the physician and as shown on the facility's policy. On February 15, 2022, at 1:27 PM, V2 (DON) stated, facility staff should document resident's urine output every shift as ordered by the physician. V2 stated day shift is from 7:00 AM to 3:00 PM, evening shift is 3:00 PM to 11:00 PM, and night shift is 11:00 PM to 7:00 AM. V2 continued to say facility staff should notify the physician if a resident does not have urine output during any 8-hour shift. V2 stated when a resident's indwelling urinary catheter is discontinued, becomes dislodged or accidentally removed, facility staff should document the condition of the resident as well as the urinary catheter in the progress notes. V2 stated the facility had a bladder scanner available for the facility staff on February 5 and 6, 2022 and facility staff should have followed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated she has identified concerns regarding residents being admitted with indwelling urinary catheters and facility staff not obtaining orders for catheter care and monitoring urine output. The facility's policy entitled Urinary Catheter Care, revised July 28, 2021, shows: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. General Guidelines: a. Input/output: i. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. ii. Maintain an accurate record of the resident's daily output, per facility policy and procedure. Complications: 1. Observe the resident for complications associated with urinary catheters.b. Check the urine for unusual appearance (i.e., color, blood, etc.). c. Notify the physician or supervisor in the event of bleeding, or if the catheter is accidentally removed.e. Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately.16. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. The facility's policy entitled Physician Orders, revised July 28, 2021, shows Policy Statement: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Immediate Jeopardy that began on February 6, 2022, at 7:00 AM was removed on February 22, 2022, when the facility took the following actions to remove the immediacy: All Nursing Staff (nurses and CNAs) were re-educated by V2 (DON) and/or designee on February 17, 2022, and continued and completed on February 22, 2022, on but not limited to the facility policy and procedure on indwelling urinary catheters. The re-education emphasized documentation on urine output as ordered by physician, actions to take when an indwelling catheter needs to be replaced, notification of the provider if the resident is without urine output and with bladder distention and/or discomfort. Staff were educated on procedures for bladder scans. This re-education emphasized routine versus intermittent bladder scan orders. Education included notification of the provider if the resident is without urine output and with bladder distention and/or discomfort and timely notification of the physician if the bladder scan is unable to be completed. Timely notification of the provider included notifying the medical director if the physician does not respond within 30 minutes. Any staff who were on leave, vacation, etc., will be re-educated prior to their next shift. Agency staff were educated during staff in-servicing or during nurse-to-nurse report by the off-going nurse or designee utilizing the agency in-service education tool. QA (QA-Quality Assurance) audits will be conducted on 3 random residents three times per week for four weeks then weekly for four weeks. Quality assurance will be reviewed to ensure documentation of urine output as ordered by the physician, actions to take when an indwelling catheter needs to be replaced, notification of the provider if the resident is without urine output and with bladder distention and/or discomfort and timely notification of the physician. All identified trends will be reviewed by the QAPI (Quality Assurance and Performance Improvement) committee quarterly and a plan will be discussed and implemented until resolution. The incident and abatement plan has been discussed and reviewed with the facility medical director on February 17, 2022, at 3:13 PM. Emergency QAPI meeting was held on February 18, 2022, at 2:00 PM. QA Audit tools will start on February 22, 2022.

Based on interview and record review, the facility failed to follow their policy to notify the physician for change in residents' condition. This applies to 3 of 5 residents (R8, R7, and R12) reviewed for delay in care and neglect in the sample of 26. This failure resulted in R8 experiencing marked distension of the urinary bladder with urine retention of 1200 ml (milliliters) of purulent urine, Hydronephrosis (swelling of the kidney), purulent drainage from the penis, indwelling catheter associated Urinary Tract Infection, [CONDITION(S)] due to Urinary Tract Infection, and hospitalization . This failure also resulted in R12 waiting more than 36 hours for a STAT chest X-ray to be completed as ordered by the physician. This failure also resulted in R7 waiting more than 48 hours for a STAT X-ray of the hip and experiencing a delay in surgical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: 1. The EMR (Electronic Medical Record) shows R8 was admitted to the facility on [DATE]. Facility documentation continues to show R8 was sent to the local hospital on February 6, 2022 and returned to the facility on [DATE]. R8 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR shows the following order for R8 dated [DATE]: Monitor and record [indwelling urinary catheter] output every shift. The facility does not have documentation to show facility staff monitored and recorded R8's urine output as ordered. Facility staff did not document R8's urine output on February 4, 2022, between 7:00 AM and 11:00 PM, and from 11:00 PM on February 4, 2022, to 7:00 AM on February 5, 2022. The EMR shows the following order for R8 dated February 5, 2022, at 11:00 PM: Bladder scan every shift. Insert [indwelling urinary catheter] if bladder scanner reading is above 350 cc (cubic centimeters). The facility does not have documentation to show facility staff scanned R8's bladder as ordered by the physician. Hospital documentation dated February 7, 2022, at 7:11 AM, shows V10 (Medical Director/Physician) documented R8 was admitted to the local hospital on February 6, 2022, with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility does not have documentation to show facility staff notified the physician they were unable to perform the bladder scan as ordered by the physician, insert a new urinary catheter, or measure R8's urine output between 11:00 PM on February 5, 2022, and 7:00 AM on February 6, 2022. On February 10, 2022, at 1:30 PM, V10 (Medical Director/Physician) stated, I am [R8's] physician at the facility, and I also cared for him at the local hospital. I want the facility staff to follow my orders and document the resident's urine output every shift. If there is no urine output and I am notified, then I tell them to flush the catheter if the resident has one and do a bladder scan. Urine output is critical. When [R8] went to the hospital, he had pus coming from the tip of his penis. There was 1200 ml of urine in his bladder, his urine was very cloudy, and that is the reason he went into [CONDITION(S)]. His Ureters were dilated, and he had Hydronephrosis. The facility staff should have noticed he was Anuric (without urine output) and notified me. 2. The EMR shows R12 was a [AGE] year-old resident, admitted to the facility on [DATE]. R12 expired at the facility on February 6, 2022. R12 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On February 1, 2022, at 7:29 PM, V23 (RT-Respiratory Therapist) documented: Called to room to place [CONDITION(S)] (Bi-level Positive Airway Pressure). Arrived in room and SPO2 (Oxygen saturation) was 69%. HR (Heart Rate) correlating. Placed on [CONDITION(S)] ,d+[DATE] (pressure settings) with 10L (Liter) bleed-in from O2 tank. No breath sounds heard. [R12] wanted [CONDITION(S)] off. Placed on 6L [nasal cannula]. [SPO2] 88 [percent]. [R12] placed on [CONDITION(S)] ,d+[DATE] with nasal cannula at 7L. [SPO2] at 93%. Report given to [night] shift. The facility does not have documentation to show V10 (Medical Director/Physician) was notified of R12's change in condition, including oxygen saturation level of 69 percent. The EMR shows V24 (LPN-Licensed Practical Nurse) entered an order on February 4, 2022, at 3:00 PM for a STAT chest X-ray, 2 views, due to oxygen desaturation. The facility does not have documentation to show R12 received the chest X-ray as ordered by the physician. The facility does not have documentation to show facility staff followed up with the X-ray provider to determine when the X-ray would take place. The facility does not have documentation to show V10 (Medical Director/Physician) was notified R12 did not receive the STAT chest X-ray as ordered. On February 14, 2022, at 12:47 PM, V10 (Medical Director/Physician) stated, [R12] had a STAT chest X-ray ordered on February 4, 2022. We should have had results from that X-ray by 7:00 PM that same night. It was ordered STAT because she was having difficulty breathing while the nebulizer treatment was going on. This patient has Respiratory Lung disease, due to [CONDITION(S)]. It is the standard of care to do a chest X-ray for breathing difficulties. My order was not completed on February 4 as I expected it to be, and this resident expired on February 6, 2022, still waiting for the X-ray to be completed. STAT means STAT. It means no delay. There's a reason to do a STAT order because there is limited time to get the results, otherwise I would have just ordered a routine X-ray. The STAT order must be done within 4 hours, even a routine order must be done within 24 hours. If the chest X-ray isn't being done, and they can't do it, the facility needs to inform me. They can't keep it a secret. The facility did not communicate with me. Death and harm happened because the chest X-ray was not done. The lack of X-ray absolutely killed [R12]. The choice to treat the resident was taken away from me. 3. The EMR shows R7 was admitted to the facility on [DATE]. R7 was sent to the local hospital on February 3, 2022, with a right femur fracture following a fall. R7 has not returned to the facility. R7 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], at 11:55 AM, V26 (Nurse) documented: Prior to incident [R7] was sitting up in the wheelchair in his room. Heard resident alarm. Staff responded STAT, noted resident attempting to stand up from the wheelchair. Staff was unable to hold up resident and assisted [R7] to the floor in sitting position. Body check assessment. No apparent injury noted at this time. On February 3, 2022, at 8:16 AM, V6 (Restorative Nurse) documented the following late entry for [DATE], at 1:12 PM: Therapy director reported to writer that [R7] has been having difficulty today with standing and ambulating and bearing general weight to R-leg (Right leg). Resident denied pain when questioned by therapy. When resident was interviewed by writer, he also denied having pain and he could not give details on why he was having difficulty with his leg. NP (Nurse Practitioner) paged and gave order for STAT X-ray to R-leg and hip to rule out FX (Fracture). NOD (Nurse on Duty) notified to follow up with orders. The EMR shows the following order for R7 dated [DATE], at 1:34 PM: X-ray to R (right) leg and hip STAT for rule out fracture. Hospital documentation shows R7 had surgical repair of his right femur fracture on February 4, 2022, at 12:38 PM. On February 7, 2022, at 11:20 AM, V26 (Nurse) stated, I was caring for [R7] on the day he fell . He did not appear to be injured after my assessment. I did not work on the weekend, but I returned on Monday, [DATE], and worked the day shift, from 7:00 AM until 3:30 PM. I was told by the restorative nurse that a STAT X-ray had been ordered for the resident because he was having difficulties during therapy. The X-ray company did not come during my shift, so I endorsed the X-ray order to the next shift. When I returned the following day, I asked if the X-ray had been done. I was told the resident did not receive the X-ray as ordered. I followed up with the X-ray company and they said they were coming, but they never did. I did not notify the physician or the NP the STAT X-ray had not been completed as ordered. On February 7, 2022, at 10:41 AM, V2 (DON-Director of Nursing) stated, This delayed X-ray is a problem. [R7] had a fall on [DATE]. A few days later he was found to be guarding his right leg. It was on [DATE] he had the pain symptoms. A STAT X-ray was ordered for him on [DATE], but the X-ray did not happen until February 2, 2022, and this is a problem. For some reason the X-ray company did not come within four hours. It was followed up the next day (February 1, 2022), and they said they were coming. They didn't arrive until late in the evening on February 2. He was found to have a fracture of the hip and he was transferred to the local hospital. The physician should have been notified the STAT X-ray was not done as ordered, to see if the physician wanted the resident sent to the hospital for an X-ray or to change his treatment in some way. Our staff did not notify the physician about the delayed X-ray. The facility's policy entitled Physician Orders, revised [DATE], shows Policy Statement: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's policy entitled Notification for Change of Condition, revised [DATE], shows: Policy Statement: The facility will provide care to residents and provide notification of resident change in status. Procedures: 1. The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: a. An accident involving the resident which results in injury and has the potential for requiring physician intervention. 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). c. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) .

Based on observation, interviews, and record review, the facility failed to implement interventions to prevent pressure ulcers for residents at risk. This applies to 1 resident (R2) in the sample of 4 reviewed for pressure ulcers. As a result, R2 developed a new pressure ulcer. R2 was admitted to the facility 2/6/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 does not communicate and is not responsive to others. On 10/26/21 at 11:30am, R2 was in bed in a prone position and turned ½ to the left, propped with pillows under the right side. R2 was observed again at 12:03pm, 12:23pm, 12:49pm, 12:59pm, 1:30pm, 3:09pm, 3:29pm, 3:58pm and remained in the same position until the Nurse was informed, at 4:10pm, of the resident having been left for greater than 4 ½ hours. The most recent comprehensive assessment done for R2 was dated 8/20/21 and shows R2 to be incapable of changing position on her own and needs the assistance of 2 persons for any change of position. On 10/27/21 at 10:20am, V2 CNA (Certified Nurse Assistant) and V5 (Restorative CNA) turned R2, and a pressure wound was visible on the left buttock. There was no dressing on the wound, and it had fresh red blood visible. On 10/27/21 at 10:21, V2 stated she thought the wound was there the day before. The wound had bright red blood and no dressing or other visible evidence of having been treated. V2 stated she does her best to turn everyone at least every 2 hours and was apologetic regarding not turning R2 during her last shift. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/27/21 at 10:35am, V3 (Wound treatment Nurse) stated she had not been informed of a new wound and was not aware of a wound on R2's left buttock and had been treating other wounds on R2 daily. V3 stated leaving R2 in one position for more than 2 hours could cause a pressure wound. V3 stated R2 is at High Risk of developing a pressure wound. The treatment record dated 10/25/21 provided by the facility shows a long-standing stage 4 pressure wound in R2's sacral area and 2 pressure wounds on the left hand. There is no treatment record for a left buttock or other wound. On 10/27/21 at 12:05pm, V3 stated she had conferred with V4 (Wound Doctor) and the new wound is classified as a stage 3 pressure wound. On 10/27/21 at 12:20, V4 (Wound Doctor) stated R2 should be turned at least every 2 hours to prevent pressure wound and leaving her longer would lead to a wound. Records of wound care done for R2 at an out-patient wound care center show that R2 had a stage 3 pressure wound in the same left buttock area that was healed in May 2021. On 10/28/21, V4 stated that having a previous stage 3 wound in the same area on the left buttock would cause that area to need to be protected because it is more fragile than an area that had not had a previous wound. V4 stated it would be his expectation that R2 should be turned at least every two hours The facility provided Braden pressure wound risk assessments. The Braden assessments dated 10/18/21, 9/16/21, 8/17/21, and 7/18/21 show R2 to be at Very High Risk for pressure wound. The Care Plan for R2 shows R2 has potential impairment to skin integrity related to fragile skin, impaired mobility, incontinence of bowel and bladder, and other diagnoses. Amongst the interventions the care plan shows identify/document potential causative factors and eliminate/resolve where possible. The Care plan specifies R2 is totally dependent on staff for repositioning and turning in bed. Please assist R2 to turn and reposition at least every 2 hours or more often as needed for comfort and pressure relief. The facility provided their policy titled: Wound Care Program Care Guidelines dated July 3. 2020. This policy included, under Procedures: 4. c. While in bed or in wheelchair, resident should be turned/repositioned at least every 2 hours or as indicated in the resident's plan of care. 4. f. Frequency of position changes is individualized according to the resident's plan of care.

Based on observation, interview, and record review the facility failed to provide the necessary care and services by not identifying a significant change in condition, not notifying the physician of a change of condition and a temperature greater than 104 degrees, and not initiating timely emergency care for a resident in a rapidly declining condition for 1 of 3 residents (R1) reviewed for care and services. This failure resulted in delayed emergency medical intervention being provided and contributed to R1's death on [DATE] at 4:20 PM. The Immediate Jeopardy began on [DATE] at 7:33 AM when R1's temperature was assessed at 104.5 degrees and no notification was made to R1's physician. The Immediate Jeopardy was identified on [DATE]. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 11:17AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's face sheet showed he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's facility admission assessment dated [DATE] showed he was in a comatose state and was dependent upon staff for all cares. R1's temperature readings on [DATE] were documented as ranging between 98.6 and 101.3 degrees. On [DATE], R1's temperature readings were as follows: 7:33 AM-104.5, 7:45 AM-104.5, 11:09 AM-102.6, 11:47 AM-104.7, 3:18 PM-101.3, 6:36 PM-104.0, and 10:51 PM-100.9. R1's medical record did not show any evidence of notification to R1's primary care physician or Infectious Disease Nurse Practitioner regarding these elevated temperatures. On [DATE] the temperature log showed 2:30 AM - 98.9, 6:30 AM-102, 8:53 AM-99.9, 10:57 AM-104.5 and 1:18 PM-101.4. R1's general progress note dated [DATE] showed, 7:30 AM . resident in bed. Noted resident is warm to touch and resting. Cool compress in place, not in any distress . 8:45 AM vitals checked and recorded. Noted a temp 99.9. Cold compress applied . 10:45 AM, Vitals checked and recorded. Temp 104.5 . HR (heart rate) 112. PRN (as needed) Tylenol and cold packs applied. Paged [V7 R1's Primary Care Provider] for resident's status (Over 30 hours after R1 started running temperatures exceeding 104 degrees). Waiting for call back . 12:35 PM Respiratory Therapist informed the nurse that resident's heart rate noted ,d+[DATE] after suction. Nurse assessed the resident. Resident is not in any distress or pain . 1255 Paged [V7 R1's Primary Care Provider] 1315 (1:15 PM) NOD (Nurse on Duty) checked resident and noted temp of 101.4 and HR (heart rate) 118. Cold Packs applied. 2:15 NOD did rounds and noted resident resting without any distress. 3 PM Paged [V7] and answering service transferred the call to [V7] and he answered (over 4 hours after the first call was made). Informed [V7] about resident's condition and doctor ordered transfer the resident to the ER. 3:05 PM Called [ambulance service] for transportation and [ambulance service] gave ETA (estimated time of arrival) of 90 minutes. 3:10 PM Respiratory Therapist called NOD for assessment of resident because RT noticed resident's breathing is shallow . NOD assessed noted breathing is shallow called for help . HR 134 . RT started ambu bagging with 100% oxygen. 3:15 PM Called 911. 3:23 PM 911 arrived and assessed the resident. Paramedics took over the resident. Paramedics started CPR (Cardiopulmonary Resuscitation) . Paramedics connected the defibrillator and noted residents HR 147 . 3:42 PM Paramedics left the facility with resident . R1's death certificate showed he expired on [DATE] at 4:20 PM. R1's [DATE] acute care hospital documentation showed R1 arrived to the emergency department at 4:02PM. The Emergency Department Provider note from [DATE] showed, . Patient presents to the ED (Emergency Department) from the [Long Term Care Facility] in Cardiopulmonary arrest. EMS (Emergency Medical Services) was called for respiratory distress and found the patient without spontaneous respirations, CODE BLUE called on their arrival . EMS states that patient had no respirations or pulses on their arrival. Pulses were regained twice during transfer after 2 rounds of CPR (Cardiopulmonary Resuscitation) . ED Course: Patient present to the ED after arresting at his care facility. Suspect Respiratory Arrest, possibly due to Pneumonia . Patient pronounced dead at 1620 . R1's [DATE] Infectious Disease Note entered by V8 (Infectious Disease Nurse Practitioner) showed, . Patient is a [AGE] year-old male who is being consulted by ID (Infectious Disease) for fever . he was reported with a fever of 100.4 Plan: . Nursing staff will continue to monitor and will contact ID NP (Infectious Disease Nurse Practitioner) or PCP (Primary Care Provider) for any change in condition. On [DATE] at 11:37 AM, V8 (Infectious Disease Nurse Practitioner) said she recalled R1. V8 said she saw R1 when he was admitted to the facility and had noted he was running a temperature of 100.4 degrees. V8 said at the time she saw R1 his labs were normal and R1's fever had subsided before she left the facility that day. V8 said she ordered a PCR test (COVID19 Test) and some more labs for the next day just to be sure. V8 said when R1's elevated temperatures should have been reported to her. When asked about R1's temperatures on [DATE] being greater than 104 degrees, V8 said Nobody told me about that. One, they didn't call me about it and two, if they didn't call me about it, they should have called the primary and sent him out immediately. 104 degrees is too much, it's too high no matter what. Even if it was coming down with Tylenol, they should still have called somebody because he needed to be evaluated. No matter what they should have told somebody. He has a [CONDITION(S)] ([CONDITION(S)]). The fever could have been coming from anywhere. They know to call me. If they had called me when his temperature went up to 104, I would have had them send him right away. I've told them before people on traches can change quickly. A fever of 104 degrees could absolutely cause respiratory distress especially in someone like him with a [CONDITION(S)]. On [DATE] at 2:24 PM, V7 (R1's Primary Care Physician) said, [R1] was admitted to the facility with a low-grade fever. We always get infectious disease involved with low grade fevers and infectious disease takes care of antibiotics. I will tell you when I got a call on [DATE]) that he spiked to 104 degrees, I immediately gave them the orders to send to emergency room . During those 3 to 4 days, he was in the facility there was nothing communicated to me, there were no calls until I got the call that his temperature was 104 degrees. They should have called me or the infectious disease doctor when he spiked the high temperature. When there is a temperature of 104 degrees, the PCP (Primary Care Physician) needs to be contacted. I was not made aware on [DATE] that he was running a temperature of 104 degrees or I would have had them send him to the hospital then. There's no excuse for not contacting me with something like that. I answer my calls within minutes. On [DATE] at 10:47AM, V10 said R1 was doing ok on that morning except he had a fever but around 3PM when he did his rounds, he noticed R1 was breathing shallow, and his heart rate was higher. V10 said he suctioned R1, but he was still breathing shallow. V10 said R1 was taking maybe one breath every 20 seconds. V10 said he called the nurse and started giving R1 breaths with an ambu bag. V10 said the nurse called 911 and when the paramedics arrived, they started CPR. V10 said after some compressions the paramedics found a pulse and took the patient to the hospital. On [DATE] at 2:52 PM, V2 (Regional Nurse Consultant) said the nursing staff is expected to update the resident's physician with any change of condition, an elevated temperature is considered a change of condition. V2 said the nursing staff should have notified R1's physician when his temperature was elevated to 104.5 on [DATE] and document notification in the nursing progress notes. V2 said on [DATE] when V9 paged the physician to notify him of R1's change of condition he should have waited only 30 minutes to an hour before trying again. V2 stated if a physician is not getting back to nurses, they should contact the medical director of the facility for guidance. They should have kept calling the doctor or called the medical director. V2 said she is unsure why the nurse did not contact the medical director. V2 said depending on the effectiveness of nursing interventions such as giving medications she does not know if they should have notified R1's physician for his temperature of 104.5. V2 said the nurses probably notified the doctor but forgot to document. V2 said the nurse attempted to notify the doctor on [DATE] right away. The facility's policy titled Notification of Change of Condition with revision date of [DATE] showed, . The facility will provide care to residents and provide notification of resident change in status . Procedures . The facility must immediately inform the resident; consult with the resident's physician; 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) . The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1) R1 was discharged to the hospital via 911 on [DATE] 3:15pm. 2) Staff were re-educated by Interim ADON and/or designee on [DATE], [DATE], [DATE], and will continue and complete on [DATE] on but not limited to the facility policy and procedure on change in resident condition, and notification to physicians. The re-education emphasized to call the medical director if a physician is not returning the call timely (timely defined as within 30 minutes and/or using nursing professional judgement based on the clinical condition) and to send declining residents to the emergency room via 911 using professional assessment and judgement. Re-education provided with return demonstration of understanding. Staff will be re-educated prior to their next shift. 3) Quality assurance audit will be conducted by the interim ADON and/or designee daily to ensure staff are identifying change in condition appropriately, notifying physicians timely, carrying out orders related to the change in condition timely (timely defined as within 30 minutes of attempting to contact the physician)and/or using nursing professional judgement based on the clinical condition carrying out timely orders defined as if a physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This will continue for the first month. All identified trends will be reviewed by the monthly QAPI committee and a plan will be discussed and implemented until resolution. 4) The incident and abatement plan has been discussed and reviewed with the facility medical director on [DATE] at 11:35am. 5) Emergency QAPI meeting has been scheduled for [DATE] 2:00pm.

Based on interview and record review the facility neglected to follow policies and procedures for notifying the physician and seeking medical intervention for a resident with a change in condition. R1 developed fevers some over 104 F and the facility failed to communicate with R1's physician for medical evaluation and intervention for a period of 30 hours after R1's condition had changed. R1 continued to deteriorate until he had cardiac/respiratory arrest. R1 expired on [DATE]. This applies to 1 of 3 residents reviewed for neglect. This resulted in R1 experiencing respiratory distress and contributed to R1's death on [DATE]. The Immediate Jeopardy began on [DATE] at 7:35 AM when the facility neglected to coordinate a higher level of care for R1 who was experiencing a declining condition. The Immediate Jeopardy was identified on [DATE]. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 11:17AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's face sheet showed he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's facility admission assessment dated [DATE] showed he was in a comatose state and was dependent upon staff for all cares. On [DATE], R1's temperature readings were as follows: 7:33 AM-104.5, 7:45 AM-104.5, 11:09 AM-102.6, 11:47 AM-104.7, 3:18 PM-101.3, 6:36 PM-104.0, and 10:51 PM-100.9. R1's medical record did not show any evidence of notification to R1's primary care Physician or Infectious Disease Nurse Practitioner regarding these elevated temperatures. On [DATE] the temperature log showed 6:30 AM-102, 8:53 AM-99.9, 10:57 AM-104.5 and 1:18 PM-101.4. R1's general progress note dated [DATE] showed, 10:45 AM, Vitals checked and recorded. Temp 104.5 . HR (heart rate) 112. PRN (as needed) Tylenol and cold packs applied. Paged [V7 R1's Primary Care Provider] for resident's status (Over 30 hours after R1 started running temperatures exceeding 104 degrees). Waiting for call back . The same note showed at 12:35 PM the Respiratory Therapist informed the nurse that resident's heart rate was ,d+[DATE] after suction. At 1255 Paged [V7 R1's Primary Care Provider] 1315 (1:15 PM) NOD (Nurse on Duty) checked resident and noted temp of 101.4 and HR (heart rate) 118 . 3 PM Paged [V7] and answering service transferred the call to [V7] and he answered (over 4 hours after the first call was made). Informed [V7] about resident's condition and doctor ordered transfer the resident to the ER. 3:05 PM Called [ambulance service] for transportation and [ambulance service] gave ETA (estimated time of arrival) of 90 minutes. 3:10 PM . RT noticed resident's breathing is shallow . NOD assessed noted breathing is shallow called for help . HR 134 . RT started ambu bagging with 100% oxygen. 3:15 PM Called 911, 3:23 PM 911 arrived . Paramedics started CPR (Cardiopulmonary Resuscitation) . R1's death certificate showed he expired on [DATE] at 4:20 PM. From the time of R1's first 104-degree fever until someone at the facility spoke with a physician over 30 hours had elapsed and 4 separate shifts of staff had been assigned to care for R1. R1's [DATE] acute care hospital documentation showed R1 arrived to the emergency department at 4:02PM. The Emergency Department Provider note from [DATE] showed, . Patient presents to the ED (Emergency Department) from the [Long Term Care Facility] in Cardiopulmonary arrest. EMS (Emergency Medical Services) was called for respiratory distress and found the patient without spontaneous respirations, CODE BLUE called on their arrival . EMS states that patient had no respirations or pulses on their arrival. Pulses were regained twice during transfer after 2 rounds of CPR (Cardiopulmonary Resuscitation) . ED Course: Patient present to the ED after arresting at his care facility. Suspect Respiratory arrest, possibly due to Pneumonia . Patient pronounced dead at 1620 . On [DATE] at 2:24 PM, V7 (R1's Primary Care Physician) said, [R1] was admitted to the facility with a low-grade fever. They should have called me or the infectious disease doctor when he spiked the high temperature. When there is a temperature of 104 degrees, the PCP (Primary Care Physician) needs to be contacted. I was not made aware on [DATE] that he was running a temperature of 104 degrees or I would have had them send him to the hospital then. The facility's Abuse and Neglect Policy with review date of [DATE] showed, . It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect or mistreatment . Types of Abuse . 5. Neglect, (Including medical neglect) . Neglect is the failure to provide necessary and adequate (medical, personal, or psychological) care. Neglect is the failure to care for a person in a manner which would avoid harm and pain, or the failure to react to a situation which may be harmful. Staff may be aware or should have been aware of the service the resident requires, but fails to provide that service . The facility's policy titled Notification of Change of Condition with revision date of [DATE] showed, . The facility will provide care to residents and provide notification of resident change in status . Procedures . The facility must immediately inform the resident; consult with the resident's physician; 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) . The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1) R1 was discharged to the hospital via 911 on [DATE] at 3:15pm. 2) Staff were re-educated on the facility Abuse and Neglect policy by the Administrator and/or designee on [DATE] and will continue and complete by [DATE]. Return demonstration of understanding provided. Re-education emphasis on identifying immediate care needs for a resident and ensuring immediate care is provided for declining residents. Staff will be re-educated prior to their next shift. 3) Quality assurance audit will be conducted daily by the Interim ADON and/or designee to ensure staff are identifying a change in condition and when a higher level of care is needed and providing necessary care to declining residents immediately. 4) The incident and abatement plan has been discussed and reviewed with the facility medical director on [DATE] at 11:35am. 5) Emergency QAPI meeting has been scheduled for [DATE] 2:00pm.

Based on interviews and record reviews the facility failed to supervise one resident (R1) identified at high risk for falls and with known impulsive behaviors of removing alarm and attempting to ambulate without assistance. This resulted in R1 sustaining multiple facial fractures and cervical fractures. The finding includes: R1's most recent CAA (Care Area Assessment) dated 7/18/13, in the area of Cognitive loss/Assessment states R1 " triggers for cognition due to his [DIAGNOSES REDACTED]. This is also why he triggers for behaviors because resident will try to stand while sitting or tends to lean forward while seated. The Psychotropic Drug Use CAA states R1 is [AGE] years old admitted to facility with [DIAGNOSES REDACTED]. Has periods of agitation and restlessness. Currently on psychotropic medications Seroquel 200mg at bedtime and Seroquel 50 mg twice a day. Haldol and Ativan prn. The BIMS (Brief Interview for Mental Status) section of the MDS (minimum data set) shows R1 scored a 0, indicating severe cognitive impairment. The MDS dated [DATE] shows R1 scored a 3 in this section, still indicating severe cognitive impairment. The ADL (activities of daily living) section of the MDS (minimum data set) dated 7/18/13 shows that R1 requires extensive physical assist of one person with bed mobility, transfers, dressing, toilet use and personal hygiene. This MDS also shows R1 does not walk in room or out on the unit but does use a wheelchair for locomotion with staff assistance. The section on " Balance During Transitions and Walking " from the MDS dated [DATE] shows that R1 is " not steady, only able to stabilize with staff assistance " in the areas of moving from seated to standing position, walking, turning around, moving on and off toilet and surface-to-surface transfer. E3 (director of nursing ) stated on 10/9/13 at 11:55am that R1 was admitted about a year ago and was assessed as a high fall risk upon admission and a personal safety alarm was put into place at that time, which R1 would remove often. E3 said that R1 had diagnosis ' including dementia with agitation, schizophrenia and psychosis. R3 said that R1 has a colostomy which he often removes, is very weak from chronically low hemoglobin levels. Incident/Occurrence Reports and Investigations involving R1 show the following: 1/30/13 9:30am fell in bathroom at dialysis center, trying to empty colostomy bag. Fractured 11th rib 7/12/13 7:55am Found on floor mat next to bed. No injuries. 7/18/13 9:30am Observed kneeling on floor in dining room. No injuries 8/28/13 10:15am fell at dialysis center. No injury 9/25/13 3:30pm Having episytaxis. Abrasion to bridge of nose. Stated he bumped his nose on bed. Nasal xrays were negative. 10/6/13 2:30am Observed walking 'fast' back to his bed. Lost balance and fell , hitting face on floor. ER report dated 10/6/13 shows R1 sustained right orbital floor fracture with associated fractures of the anterior and posterior walls of the right maxillary sinus. Nondisplaced buckle type nasal septum fracture. Fracture of the base of the dens compatible with type II lens fracture. Retrolisthesis of C1 and C2 at the level of the fracture. Bilateral fractures involving the posterior C1 arch. On the back of each of these occurrence reports staff has identified probable cause as R1s impulsive behavior of attempting to transfer without assistance, decreased strength and unaware of his safety issues. E2 (director of nursing) and E3 stated on 10/9/13 that R1 had a behavior of removing his alarm prior to getting up. E4 (nurse's aide) stated on 10/9/13 at 1:40pm and E5 (nurse's aides) on 10/11/13 at 3:45pm that R1 would always remove his alarm. E4 said that R1 was ' pretty confused. We would encourage him to eat and he would place his face in the plate of food without using utensils. Staff would tell (R1) to sit down and he would be trying to get up 2 or 3 minutes later. " Nurse's notes repeatedly document R1's impulsiveness and non-compliance: 9/11/13 R1 "kept getting out of bed all night long. Non-compliant with care and does not listen to care staff. Very non-compliant with body alarm and kept throwing it on floor...has severe behavioral issues and needs extreme attention from staff...." 9/25/13 (11-7 shift) R1 "is very impulsive-removes colostomy bag and tries to get out of bed or wheelchair. Reminded constantly not to get up by staff." 10/4/13 Noted attempting to get up and ambulate without assist. Alarm in place but he is able to remove it, very difficult to redirect. E5 stated on 10/11/13 at 3:45pm that the night R1 fell (10/6/13), only 2 aides were working that night. Ideally, there are 4 aides on the night shift for 50 residents. But that night there were only 3 scheduled and one of them called in, leaving 2 nurse's aides for 50 residents. E5 heard R1 talking and went to his room. R1 turned and quickly walked to his bed but fell to the floor, hitting his face. E5 said R1 " tried to get up about half the nights and he takes off his alarm most of the time. " R1's room was observed to be halfway down the hall from the nursing station, approxiametly 50 feet away. Moving R1 closer to the nursing station for better supervision was not an intervention listed on R1 ' s fall care plan dated 4/26/13 or 7/12/13. These care plans also did not re-evaluate for more appropriate safety devices to replace the personal alarm which R1 was known to remove frequently. The current interventions have not been re-evaluated for their effectiveness as indicated on R1's fall plan of care dated 7/12/13 nor are they specific to R1's fall risk factors. The facility has not taken measures to modify R1's risk factors in an attempt to decrease R1's falls. There is no root cause analysis of R1's falls.

Based on observation, interview and record review the facility failed to provide close monitoring and supervision per plan of care, failed to provide device/s to notify staff of attempts to self transfer, for a resident identified with behavior of transferring without staff assistance, failed to supervise a resident with cognitive impairment and failed to respond to an alarm for a resident with history of hip fracture. This applies to 3 of 14 residents (R17, R20, R21) reviewed for falls with injury in the sample of 24, and 3 residents (R34, R36, R55) in the supplemental sample. This failure resulted in R17 sustaining a left ankle fracture on 3/28/13, that required surgery and hospitalization . Findings include: 1. R17 has Polymyalgia Rheumatica, DM (Diabetes Mellitus), Osteoporosis, Kyphosis, Scoliosis and legally blind. R17's annual MDS (Minimum Data Set) dated 3/14/13 was coded to reflect that the resident has problem with orientation and recall. The same MDS also reflected that R17 required extensive assistance times one person physical assist for transfers and toilet use. R17's fall risk assessment dated [DATE], reflected a score of 16 which indicates that the resident is at high risk for fall. R17's at risk for fall care plan related to unsteady gait, generalized weakness, poor safety awareness and attempts to transfer self unassisted initially dated 3/8/12 and last updated 3/28/13 reflected multiple approaches which includes, close monitoring/supervision and to instruct resident to always use call light for assistance. R17's at risk for fall care plan related to use of medications, unsteady gait, poor safety awareness, generalized weakness and attempts to transfer without assistance initially dated 3/15/13 and last updated 3/28/13 reflected multiple approaches which includes, instructing the resident to ask for assistance prior to attempting to transfer or walk. R17's incident investigation report indicated that on 3/28/13 at 5:40 PM, the resident was found on the floor inside the bathroom on a sitting position, leaning on the wall. R17 was unable to move her left ankle with pain and swelling. R17 was sent to the hospital emergency room per physician order [REDACTED]. In an interview held on 5/7/13 at 3:40 PM, E22 (LPN/Licensed Practical Nurse) stated that, on 3/28/13 at 5:40 PM she heard R17 calling for help. When she went to R17's bathroom, she saw the resident sitting on the floor, complaining of left ankle pain. Upon assessment, R17's left ankle was swollen and slightly reddened. Per E22, R17 stated that after using the bathroom, she tried to pull her pants up and fell . According to E22, R17 has a history of going to the bathroom and transferring to the toilet unassisted. E22 stated that R17 has been educated not to go to the bathroom and not to transfer unassisted, but the resident kept on doing it. In an interview held on 5/7/13 at 3:45 PM, E23 (CNA) stated that she was the assigned staff to take care of R17 on 3/28/13 during the 3 - 11 shift. Per E23, R17 used the bathroom unassisted on 3/28/13 and was found by E22 on the floor. E23 stated that she is not aware of R17's toileting schedule. According to E23, R17 was told to call and wait for the staff to assist with transfers and toileting but most of the time, R17 goes to the bathroom by herself (unassisted) and would only pull the call light for assistance when finished. On 5/8/13 at 11:30 AM, R17 was inside her room sitting in her wheelchair, alert and verbally responsive. R17 stated that she fell in her bathroom and sustained a fracture on her left ankle. According to R17, she uses the toilet without assistance every time. R17 has been identified with poor safety awareness and attempts to transfer without assistance. However, no assessment and documentation for the use of any device to notify the staff of attempt to get up, ambulate or transfer unassisted was found in R17's clinical record. 2. R20's [DIAGNOSES REDACTED]. Review of facility reportable incident report dated 12/6/12 that R20 was found on floor at 8:20 PM after staff heard bed alarm sounding. R20 was sent to hospital and admitted for right hip fracture. R20 was readmitted to facility on 12/13/12. R20's fall risk assessment dated [DATE] assessed R20 at high risk for falls. R20's fall care plan dated 12/26/12, denotes R20 was at risk for falls due to use of psychotropics, cognitive deficits, poor safety awareness, generalized weakness, impaired mobility and does not used call light or ask for assistance despite reminders. Interventions included Provide close monitoring/supervision. Incident reports and nurses notes dated 4/6/13 documents R20 was found with discoloration of bluish color measuring 9 centimeters (cm) x 6 cm. Incident report and nurses notes dated 4/24/13 denotes R20 was found sitting on the floor with bilateral legs in extended position. R20 was assessed by staff, physician was notified with no new orders. On 5/6/13 at 12:55 PM, R20 was in her room in bed with her clip alarm sounding. R20 was holding her ears and head and saying "I'm so confused." R20's wheelchair was next to her bed. R20 grabbed the handle of her wheelchair and began shaking it as she continued to voice that she was confused. At 1:00 PM E30 (Activity Aide) walked past R20's room but did not respond to the alarm. At 1:01, E31 (Nurse) responded to the alarm. E31 stated that she was in the bathroom. 3. On 5/6/13 at 2:00 PM, 11 residents were in the small dining room on the 3rd floor dementia unit. No staff were present in the dining room. R34 was standing and his alarm was sounding. At 2:01 PM, E7 responded to the alarm. R21, R36, and R55 also had clip alarms, indicating that they were also at risk for falls.

Based on record review and interview, the facility failed to have wheelchair leg/foot rests while transporting one resident in her wheelchair. The resident dropped down both legs and the left leg was caught underneath the wheelchair which caused fracture of the left femur (thigh). This applies to 1 of 3 residents (R1) reviewed for transfer in the sample of 3. Findings include: The Incident/Occurrence Report dated 4/11/13 at 2:00 PM documented that at 1:50 PM, a staff was pushing R1 via wheelchair when the resident complained of left knee pain. R1 placed both feet down while the wheelchair was moving. Interventions were as follow: Assess for ROM(Range of Motion), PRN (as needed) Norco given, MD (Physician) paged, ice pack applied. The Nurse's Notes dated 4/11/13 at 2:30 PM indicated that R1 was being pushed in the wheelchair to a new room by a facility staff. R1 dropped both feet down and dragged the left leg underneath the wheelchair. R1 complained of pain to the left knee. POA (Power of Attorney) was notified and MD was paged. At 4:00 PM, the physician called back and ordered Xray of the left knee, tibia & fibula. At 9:30 PM, MD was informed of the Xray results. Ordered to send R1 to the local hospital for further evaluation. On 4/12/13 at 12:00 AM, follow up call to the hospital indicated that R1 was being admitted for Left Femur Fracture. The Left Knee Oblique and Lateral Views Xray report dated 4/11/13 showed the following: There is an acute fracture of the distal femur just proximal to the femoral prosthetic component. E3 (Medical Supply Staff) said on 4/22/13 at 1:00 PM that he was making rounds to put away supplies in the 1st floor when he passed by R1 ' s room. R1 was asking for help to go to her new room. E3 stated that R1 needed help because she was losing her eyesight. E3 said that R1 was able to propel herself in the wheelchair mostly in her room. E3 stated that there were no footrests attached to the wheelchair. E3 instructed R1 to put both of her feet up and proceeded to push the wheelchair towards the new room. The resident suddenly dropped her feet to the ground while E3 was moving her. E3 heard the resident moaned and saw that left knee/leg was bent underneath the wheelchair. The resident informed E3 that her left knee was hurting. E3 stated that E4 (Staff Nurse) who was in the nursing station, came and assessed the resident. E3 also said that he was trained how to transport residents using the wheelchair since he was an Activity Aide prior to becoming the central supply staff. E4 (Staff Nurse) stated on 4/23/13 at 1:20 PM that on 4/11/13 at 2:00 PM, she saw E3 pushing R1 via wheelchair in the hallway. E4 was sitting in the nursing station and heard R1 complained of pain. E4 then went to assess R1. E4 did not see the leg/foot rests attached to the wheelchair. E4 observed that R1's left leg was underneath the wheelchair. E3 informed E4 that R1 dropped her feet to the ground while he was pushing the chair. E4 said that R1 was able to move her right extremity without discomfort. E4 heard R1 complaining of pain so E3 stopped. E4 then went assessed the both of the resident's legs. E4 stated that R1 was able to move her right leg without discomfort but was not able to lift her left leg independently. E4 called both the physician & POA. E4 endorsed to the incoming staff nurse to follow up with the physician and expect Xray to be taken. E4 acknowledged that leg/foot rests should be used when transporting residents. The facility policy titled, "Resident Transportation and Ambulation," dated 3/2012, required, "Residents must have leg rests on during transportation by staff."

Based on record review, observation and interview the facility failed to: ? Analyze data to identify trends, patterns, serious injuries and perform analysis of root causes for all residents sustaining incidents or accidents. This is for 3 (R1, R18 and R19) of 5 residents sampled for incidents/falls. ? Perform thorough investigations and tracking of serious resident injuries to rule out possible abuse or inappropriate care of resident by staff. This is for one (R1) of one resident sampled for serious injury in the sample of 24 but can affect any resident experiencing a fall or injury. ? Secure the main entrance to the facility from trespassers and resident elopement. ? Provide supervision to R 15 who was identified needing direct supervision during mealtimes & who has the potential for aspiration and failed to follow doctor's order to directly supervise R 15 during mealtime ? Provide safe water temperatures to 6 of 42 residents (R54, 55,59, 60, 61, 67) who reside on the 2nd floor. Findings include: ? Review of individual incident /accident reports for April 2011 through July 2011 tallied 24 instances of residents sliding out of wheel chairs or chairs on to floor. Eight residents fell more than one time in the month of July. Incident reports indicated 27 unwitnessed falls for April through June, mostly occurring in resident rooms. Specific resident examples include R18 who was found on the floor on 3/3/11 (in bathroom), on 3/30/11 and 4/20/11, 4/21/11 (in room), in bathroom 4/28/11/11, sustaining a laceration to back of head resulting in staples, and 5/9/11 (lowered to floor). This information was found during review of R18's medical record and incident reports Review of R18's care plan in the area of falls and dated 3/3/11 is not individualized in the approaches to prevent falls, the interventions are not revised after each fall, and the possible causes are not examined such as incontinence and medications. Review of medical record and incident accident reports show that R19 has sustained 3 unknown injuries: right elbow skin tear on 5/11/11, bilateral bruising to knees on 7/26/11, bruise to right hand/wrist on 8/3/11. The investigations into these are not thorough and consequently do not rule out the possibility of abuse. R19's care plan does not address approaches to prevent these types of incidents/injuries. Interview with E2 (Dir. of nurses) stated on 8/24/11 at the facility does not have a tracking system to identify trends and patterns surrounding incidents and accidents occurring in the facility. E2 stated that all falls/incidents are reviewed everyday. E2 was asked to provide survey team with documentation of an example of a resident who has sustained frequent falls and what steps/interventions the facility put into place. None was provided by end of survey. Review of R1's nursing notes documented that on 9/07/2010, R1 complained to E17 (CNA/certified nurses aide) that a CNA was rough in turning her, and hit her hand against the side rails. Later, R1 was assessed to have a fracture finger. E17 (CNA) was interviewed on 8/25/2011. E17 reported that R1 told her that a CNA was rough while turning her in bed and hit her finger. E17 said she told the nurse on duty of R1's allegation. But, E17 stated she did not know the outcome of the investigation. Review of the facility's investigation into R1's injury of 9/07/2010, failed to have any documentation of the CNA being identified in this incident, possible monitoring or retraining of staff. Because of the documented history of R1's serious injury and possible staff involvement, the survey team asked E2 (director of nursing) for the conclusion of this investigation and tracking of serious injuries of accident involving residents in the facility. E2 reported that she did not have any knowledge about the conclusion of the investigation into this allegation because it happened before she came. Since being in her current position for a few months, E2 still did not have a method in place to track serious resident's injuries/incidents occurring in the facility, which would help identify possible mistreatment/poor care by staff. ? Upon arrival to the facility on [DATE] at 6:20am, surveyors entered the main front entrance without difficulty: door was not secured, no alarm sounded nor was there staff monitoring the unlocked entrance. Interview with E1 stated on 8/22/11 at 10:20am that the system wasn't working at the time of entry but now it is functioning . On 08-22-11 at 8:35 AM, R 15 was observed in bed, head of bed at 45 degree angle eating in the room without supervision. Review of the dietary ticket found on R 15's ticket tray reads: General pureed/nectar thick liquids...chewing & swallowing problems...R 15 stated "sometimes I do choke, I did in the past." Review of R 15's plan of care showed:the following: PROBLEM: with poor P.O. intake related to: inability to feed self & poor cognition. Resident with chewing & swallowing problem, needs limited to extensive assistance with eating, with [DIAGNOSES REDACTED]. If the resident is bed bound , the head of the bed should be elevated to a high Fowler's position of 90 degrees. On 08-22-11 at 8:50 AM, the CNA (E 24) claimed "I'm suppose to get him up for breakfast but I didn't get the change. The Nurse in Charge (E 25) was notified about the observation, E 25 stated " he has a [DIAGNOSES REDACTED]." R 15's Physician reads: Direct supervision while feeding. The hot water exceeded 110 degrees arenheit. in 6 of 42 residents (R61, R77, R59, R60, R54 and R55) rooms on the second floor. Water temperatures ranged from 116 to 120 degrees F. at the hand washing sinks in the resident bathrooms. E1 said, "Those rooms are closest to the hot water heater. We have lowered the temperature on the hot water heater."

Based on observation, interview & record review, the facility failed to: comprehensively assess risk factors for pressure ulcers, develop and implement individualized interventions, and evaluate the effectiveness of the interventions for 2 of 5 residents (R1, R3) with facility acquired pressure ulcers in a sample of 5. These failures resulted in (1) R 3 acquiring multiple avoidable pressure ulcers & worsening of the acquired pressure ulcers on R 3's (a) left elbow from Stage II now an Unstageable due to the presence of necrotic tissue (b) Unstageable pressure ulcer on the right elbow and (3) a newly identified Deep Tissue Injury on the medio lateral aspect of the right foot. (2) R 1's acquiring avoidable facility acquired pressure ulcer on the right heel. Findings include: On 08-22-11 at 8:15 AM, R 3 observed in bed sleeping. R 3's observed with dressing on both elbows, no pressure relieving devices were noted. On 08-22-11 at 8:25 AM, the Rehab Aide (E 21) claimed "she doesn't talk, sometimes she moans, have contractures on both upper & lower extremities." E 21 confirmed R 3 has no order for elbow protector. On 08-24-11 at 10:50 AM, R 3 was observed in bed with oxygen on via nasal cannula, R 3's non verbal & unable to reposition self. R 3 was observed with wedge positioning device place on R 3's right & left side, from waist up to her shoulder. These positioning devices were observed to be restricting R 3's movement & R 3's elbows were noted directly resting on the bed. AT 11:00 AM, the Nurse in Charge stated "She doesn't really get up that much, she got multiple pressure sores, she's non verbal, she just open her eyes." Review of R 3's wound tracking sheets showed the following: (1) LEFT ELBOW - Stage II pressure ulcer - acquired on 06-27-11- measured at 1.4 cm X 1.3 cm X 0.1 cm- with 100% pink tissue. On 08-24-11 at 11:50 AM, during treatment observation with the Treatment Nurse (E 12), showed worsening and an increased in size. E 12 identified & described the wounds as: "the wound is fully covered with mixture of yellowish/brownish slough & necrotic with only 5% granulation. Measurement 3.0 cm X 3.1 cm. Current treatment sheet dated (08-01-11 to 08-31-11) showed an order from Aug. 25, 2011 to apply PolyMem foam dressing every 3 days & cover with dry dressing, there were no changes of treatment modalities since then. (2) RIGHT ELBOW-Unstageable pressure ulcer- acquired on 08-01-11- measured at 2.3 cm X 1.8 cm. On 08-22-11 this ulcer was described with large pink tissue with some eschar. On 08-24-11 at 12:05 PM, the Treatment Nurse (E 11) measured and described the wounds as follows: " a lot of brown slough/necrotic tissue covering the wound bed, with only 5 % granulating tissue. Measured at 2.5 cm X 1.8 cm. (3) New Deep tissue injury on the Medio- lateral aspect of the right foot that the facility was not aware of. On 08-24-11 at 12:30 PM, E 11 measured this wound at 2.7 cm X 1.5 cm - with purple discoloration. E 12 stated "she used to have pressure ulcer around that area & healed." There was no pressure ulcer care plan, no comprehensive assessment found in R 3's clinical record on 08-22-11. On 08-24-11 at 2:10 PM, E 11 stated "the pressure ulcer care plans are in a binder in the 3rd floor cabinet. We only do comprehensive assessment upon admission & re admission." The only & most current BRADEN Scale - for predicting pressure sore risk found in R 3's clinical record dated 04-11-11 showed that R 3's high risk (12) for developing pressure ulcer, no preventative plan was developed & implemented. E 11 presented R 3's pressure ulcer care plan for 3 different sites (1) right elbow (2) left elbow & (3) right lateral foot . These care plans have the same goals & same interventions. There were no revisions noted & interventions were not specific to the problem identified. On 08-25-11 at 10:50 AM, E 2 stated "we purchase elbow protector last night. We took the wedge (positioning device) away. I know it's restricting her movement. On 08-24-11 at 2:10 PM, E 11 stated "the CNA's is supposed to put R 3's elbows on top of the wedge but it's not being done." -R1 was observed several times (mornings and afternoons) on 8/23/2011 and 8/24/2011. Surveyor only observed R1 lying in one position, which was flat on her back. R1's dressing changed was observed on On 823/2011 and 8/24/2011. Surveyors accompanied the treatment nurses (E11 and E12) to R1's bedside to observe her wound care. On both days, surveyors observed R1's dressing was saturation with a moderate amount of dark bloody drainage prior to being removed. When, E12 removed the dressing, surveyor observed R1's wound bed as beefy red with small amount of dark (black) tissues surrounding the edge. R1's wound was also dripping a moderate amounts of dark blood. When asked E12 described R1's wound bed as 95% granulation with small narcotic border and moderate amount of drainage. E12 told surveyor that R1 had moderate amount of drainage because she was on blood thinner. E12 measured R1's right heel wound at 4.2 x 3.5 cm. When asked about the condition of her (R1's) wound, E11 reported she usually did the care and assessment of R1's wound. E11 told surveyor that she noticed an increase in the amount of drainage from R1's wound earlier in the week. But, E11 said that she had not informed R1's primary care physician. So, surveyors prompted E11 to inform R1's primary physician of the change in R1's wound condition. Review of R1's most recent assessment weekly skin report, dated 8/22/201, documented that R1 acquired a right heel wound at the facility. But, the 8/22/2011 skin assessment did not document the changes to R1's wound as stated above. Review of R1's care plan identified skin integrity as a focus in her care. However, review of the nursing interventions were general, and not specific in directing staff to care for the wound on R1's heel. Surveyor observed staff also failed to follow nursing approached such as: "Notify MD (Medical Director) of progression/regression of wound." Turn and position as needed." Surveyor reviewed R1's most recently Minimum Data Set (MDS) Assessment, done because of a significant change on 5/14/2011. Staff documented that R1 was at risk for the development of pressure ulcer. During the Daily Status Meeting conducted on 8/24/2011 with administrative staff (E1 and E2), the survey team expressed concerns that R1 was not receiving appropriate treatment and care to her right heel wound. The survey team also questioned if the facility was following an appropriate plan to turn and reposition R1. E2 told the survey team she would inservice nursing staff on repositioning residents. But up to date of exit on 8/25/2011, E1 nor E2 presented any evidence to support that R1's heel wound was receiving appropriate treatment.