Every finding on record at Hallmark Healthcare of Pekin

Based on record review and interview, the facility failed to ensure call lights were answered promptly for two of three residents (R1 and R2) reviewed for call lights in the sample of three.Findings include:1.R1's MDS (Minimum Data Assessment) dated 6/29/26 documents R1is cognitively intact and requires staff assistance for ADLs (Activities of Daily Living).On 7/24/26 at 9:25 AM R1 stated, There has been a continual problem with my call light getting answered. My call light is generally on around half an hour before someone answers it. It happens every shift. I have been reporting this in resident council every month and I have told (V1/Administrator).2. R2's MDS dated [DATE] documents R2 is cognitively intact and requires staff assistance for ADLs.On 7/24/26 at 9:30 AM R2 stated, Yesterday my call light was on for over an hour and a half before staff helped me get to the toilet. Most days my call light is on for over a half hour. Some staff are better than others about answering my call light.On 7/24/26 at 9:20 AM V8 (CNA/Certified Nursing Assistant) stated, (R1 and R2) frequently complain that their call lights are not answered quickly.On 7/24/25 at 12:50 PM V2 (Director of Nursing) stated, Call lights should be answered within 15 minutes.The Call Light Guidance Policy dated 8/20/22 documents, Staff shall respond to call lights with a reasonable about of time.

Based on record review and interview, the facility failed to ensure a resident's fall prevention safety alarm was maintained in proper working order for one of three residents (R3) reviewed for falls in the sample of three.Findings include:R3's Nursing Note dated 7/18/26 and signed by V4 (RN/Registered Nurse) documents R3 was found on the floor in the bathroom, in front of her wheelchair. This same note documents R3's bed alarm was blinking but was not sounding and needs to be replaced.R3's current Care Plan documents R3 is at risk for falls and had a bed alarm applied on 5/7/26 as a fall prevention intervention.R3's Electronic Health Record dated 5/7/26 (date of bed alarm application) through 7/24/26 does not include documentation of staff monitoring of R3's bed alarm for proper functioning/working order.On 7/24/26 at 12:37 PM V4 (RN/Registered Nurse) stated R3's bed alarm was not sounding when R3 was found on the floor in the bathroom on 7/18/26 at 4:05 AM.On 7/24/26 at 12:55 PM V5 (MDS Coordinator) stated, All alarms are supposed to have physician's orders and be recorded on the residents' medication administration record or treatment administration record to be checked for proper functioning every shift. After (R3) fell on 7/18/26 and (R3's) alarm was not working properly, we (facility staff) noticed that (R3) did not have an order and the nurses were not checking (R3's) alarm every shift to ensure the alarm was working properly.On 7/24/26 at 1:02 PM V2 (Director of Nursing) stated, (R3's) alarm should have been checked every shift to ensure the alarm was functioning appropriately.The facility's Fall Prevention Program policy dated 9/15/19 documents, Purpose: To provide guidelines on preventing resident falls or injury. Action Steps: Provide ongoing reducing interventions. Provide ongoing evaluations of resident response to interventions.

Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions for one of three residents (R1) reviewed for infection control in a sample of three. Findings Include:R1's current Physician Order Sheet documents, Enhanced Barrier Precautions related to indwelling (urinary) drainage catheter.On 9/16/25 at 1:40pm, R1 was in bed, with a urinary drainage bag hanging on the lower aspect of his bed frame. R1's urinary drainage bag contained approximately 400 milliliters of clear yellow urine. R1's door did not have a sign indicating EBP. On 9/17/25 at 10:00am, V4, Hospice Certified Nursing Assistant, was performing morning personal hygiene for R1. V4 then pushed R1 back to the main dining room. On 9/17/25 at 10:20am, V4 was unable to speak of the facility's Enhanced Barrier Precautions. V4 stated that she only wears gloves while performing personal care, unless the resident is on contact or droplet isolation. V4 verified that she only had gloves and a mask on while performing R1's personal care. On 9/17/25 at 11:00am, V3, Assistant Director of Nursing/Licensed Practical Nurse, stated that signs are to be outside of the resident's room indicating the type of isolation the resident is on. V3 verified that any resident with an indwelling urinary catheter is to be on EBP. V3 also stated that there should be an isolation cart outside of the room. V3 verified that R1 did not have an EBP sign on his door. The facility's Enhanced Barrier Precautions policy, revised 12/10/24, documents that EBP (Enhanced Barrier Precautions) are used in conjunction with standard precautions and expand the use of PPE (personal protective equipment) to donning of gowns and gloves during high contact resident care activities that provide opportunities for transfer of MDROs (multidrug resistant organisms) to staff hands and clothing. EHB are indicated for residents with any of the following has a wound or indwelling medical device and secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube or tracheostomy, ventilator. wound care: any skin opening requiring a dressing.

Based on interview and record review the facility neglected to notify the physician and seek medical treatment after a significant decline in condition for one of three residents (R1) reviewed for neglect in the sample of nine. These failures resulted in R1 significantly declining in condition for two weeks before the facility sought medical treatment and sent R1 to the hospital on 5/10/25 for evaluation where R1 was admitted to the ICU (Intensive Care Unit) and remains in the hospital currently for treatment of Medical Neglect, Severe Dehydration, Acute Encephalopathy, Hypernatremia, Bladder Obstruction, Lactic Acidosis, Complicated Urinary Tract Infection, Sepsis, Metabolic Acidosis, Contractures to the Lower Extremities, and Bacterial Pneumonia. These failures resulted in an Immediate Jeopardy. The immediate jeopardy started on 4/29/25 when R1 started declining and the physician wasn't notified and treatment wasn't obtained, resulting in R1 going two weeks without medical treatment and R1 being admitted to the to the ICU and remains in the hospital currently for treatment of Medical Neglect, Severe Dehydration, Acute Encephalopathy, Hypernatremia, Bladder Obstruction, Lactic Acidosis, Complicated Urinary Tract Infection, Sepsis, Metabolic Acidosis, Contractures to the Lower Extremities, and Bacterial Pneumonia.' V1/Administrator and V2/Director of Nursing were notified of the Immediate Jeopardy on 6/3/25 at 3:08 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed, and the deficient practice was corrected, on 5/13/25, prior to the start of the survey and was therefore Past Noncompliance. Findings include: The facility's Acute Change of Condition Policy, dated 1/23/23, documents Purpose: To provide facility guidance when a change of condition occurs with a resident. Policy: This facility shall identify and treat residents with acute change of conditions. Policy Interpretation and Implementation: 2. Direct care staff, including nursing assistants, will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the Nurse. 6. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician, for example, the history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status, history, current medications and SBAR (Situation, Background, Assessment, and Recommendation) in Point Click Care). 7. The nursing staff will contact the physician based on the urgency of the situation. For emergencies they will call or page the physician and request a prompt response. 8. The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. a. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. 9. The nurse and physician will discuss and evaluate the situation. a. the physician should request information to clarify the situation. 10. The staff and physician will discuss possible causes of the condition change based on factors including resident/patient history, current symptoms, medication regimen, and diagnostic test results. 13. The physician and staff will identify relevant resident/patient wishes, including advance directives and POLST (Physician Orders for Life-Sustaining Treatment) orders related to life-sustaining treatments. 14. If it is decided, after sufficient review, that care or observation cannot reasonable be provided in the facility, the physician will authorize transfer to an acute hospital, Emergency Room, or another appropriate setting. The facility's Abuse Policy, dated 1/9/24, documents Purpose: To provide guidance and Procedures to the facility and staff to assure the residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse Policy: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Definitions: Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, or mental anguish. Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, person care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident including deprivation of goods and services. On 5/28/25 at 12:21 PM V4/Director of Rehab stated, (R1) was able to straighten both legs out and he was able to bend both legs by the time he finished physical therapy (2/14/25). (R1) was a little resistant, but with dementia techniques we were able to get him to participate. (R1) was 25% (percent) weight bearing due to his right hip fracture at that time. He could stand up straight but did not know his limitations with weight bearing limitations. On 5/29/25 at 9:22 AM V10/SSD stated, I had tried to contact (V8/R1's Family Member) a week or so prior to the call on 5/8/25 and 5/9/25 regarding (R1's) major decline. I was trying to reach out to (V8) regarding hospice. I left (V8) a message asking if he could call me back. When I finally spoke to (V8) and let him know that (R1) has been getting worse, has lost weight, not eating, and possibly (R1) needing a gastrostomy tube, (V8) would not give me an answer on Hospice and kept telling me he would have to speak to (V16/R1's Family Member). I did let (V8) know how bad (R1) was and told him he didn't have much time to decide about hospice. I did not call (V14/R1's Physician) regarding (R1's) condition and I am not aware if nursing notified (V14) of (R1's) condition. The nursing staff just tell me what to call the families over and they wanted me to consult with (V8) regarding (R1's) decline in condition. On 5/29/25 at 9:44AM V11/CNA (Certified Nursing Assistant) stated around two weeks prior to R1 being sent out to the hospital R1 started not being as active as he normally was. V11 stated, Usually I could talk to (R1) and (R1) would talk back. (R1) started sleeping all the time and wasn't eating as much. I did notice (R1's) urine was darker than usual with a little less output. I believe I reported (R1's) urine color and output to (V12/Licensed Practical Nurse). (R1's) pain was also getting worse prior to being sent out to the hospital. (R1) just started moaning in pain all the time. (R1's) lower legs were bent at the knees and (R1) was unable to straighten them out. (R1) use to be able to straighten his legs. On 5/29/25 at 9:55AM V12/LPN stated, At least a week (maybe two weeks) before (R1) went to hospital (R1) was having a decline in his condition. (R1) stopped eating and wouldn't let us get him out of bed. I don't remember anyone reporting (R1's) urine color or output to me, I don't typically monitor that the CNA's usually do. I was at least (R1's) nurse two to three times a week. I reported to (V10/SSD) about (R1's) decline in condition. I did not notify the doctor however and should have. I did not document on (R1's) decline because I was communicating with (V10) regarding hospice, I should have documented. If we notice a change in condition, we should notify the physician immediately. On 5/29/25 at 10:15 AM V13/LPN stated I went to (V10/SSD) regarding a hospice consult around a week or so prior to (R1) being sent to the local hospital. I noticed (R1) was not eating and was having failure to thrive. I did not notify (V7/Dietitian or V14/R1's Physician) of my concerns with (R1) not eating and should have. Typically, we would fill out an SBAR (Situation, Background, Assessment, and Recommendation) and would send it to the doctor. I just assumed (V14) had already seen (R1) recently. On 5/28/25 at 1:54 PM V6/Hospital Registered Nurse stated I was the admitting nurse when (R1) got admitted to the ICU (Intensive Care Unit) on 5/10/25. (R1) could not straighten his legs, they were incredibly contracted. (R1's) legs were both completely bent at the knees where (R1) could not straighten either leg out. I doubt (R1) will ever be able to walk again. (R1's) mouth and teeth were caked with black sludge that took me ten minutes and 12 different swabs to even try to get it out of his mouth. (R1) had a lack of oral care like no one ever cleaned his mouth. (R1) had a horrible smell, (R1's) private area was excoriated and had an (indwelling urinary catheter) and a lack of it being cleaned. (R1's) groin was very red everywhere. The head of (R1's) penis, from the catheter rubbing and not cared for was actually split. (R1) was in severe pain and all he could do was cry out. It was one of the worst things I have seen, I felt completely horrible for (R1). (R1) had to have been completely neglected for a while. I was able to give him a bath here and treat him without (R1) refusing any care. (R1) remains in the hospital at this time and is still being treated. On 5/29/25 at 11:27 AM V14/R1's Physician stated that the last time he had visited R1 was on 4/8/25. V14 verified he was not made aware of R1 repetitive refusals of eating and drinking his med pass, refusing weekly weights, R1's significant weight loss, or R1's decline. V14 stated, It's not right if the (local hospital) had emptied two liters of urine from (R1's) bladder when (R1) arrived at the hospital. I am not sure what orders the facility had to change the urinary catheter, but if the facility staff would have notified me, I would have referred (R1) to a Urologist to assist in caring for (R1's) urinary catheter. Not changing (R1's) urinary catheter since January 2025 could have contributed to (R1's) infection and being hospitalized . I was not made aware of (R1's) declining condition. I last saw (R1) on 4/8/25 and I do not have any record of the facility notifying me of (R1's) change in condition. I would have sent (R1) right to the hospital and not messed with doing anything in house if the facility would have notified me of his condition. On 5/29/25 at 2:54 PM V7/Dietitian verified the lack of R1 eating and drinking would have led to hypernatremia. On 5/31/25 at 11:36 AM V8/R1's Family Member stated, I would call and speak to (R1) a couple of times a week from the time of (R1's) admission until he was admitted to the hospital. (R1) wasn't all the way cognitively there, but he could hold a conversation. I would call the facility and speak with the nurses, and they would always tell me (R1) was doing good, and that some Nurse Practitioner would see (R1) every Tuesday and monitor his labs, vital signs, and condition. A few days after (R1) being sent to the hospital I received a call from (V10/SSD) suggesting that (R1) receive hospice care due to (R1) not eating, having a significant weight loss, and (R1's) decline. (V10) stated (R1) started to really decline around a few weeks prior to this where he was becoming super weak. I told (V10) I wanted to speak with (V16/R1's Family Member) before making any decisions because (R1) always wanted to be a full code. I was waiting for a call back from (V16) when I then received a call from (V2/Director of Nursing/DON). (V2) told that we really need to get (R1) on hospice. I asked (V2) if (R1) was going to die and (V2) stated Oh no, no, no (R1) is just declining food at this point. I told (V2) I wanted (R1) sent out to the hospital to be evaluated and (V2) told me if they would send (R1) out to the hospital, the hospital would just send him right back because there is nothing the hospital can do. The next day I received a call from (V15/Registered Nurse/RN) that (R1) was lethargic and barely moving so (V15) sent (R1) to the local hospital. (V15) told me she could not take it anymore with (R1's) condition and that her conscious got the best of her, so (V15) decided she needed to send (R1) to the emergency room. The hospital then reached out to me and told me what (R1's) condition was and told me that my dad was severely dehydrated, malnourished, and was neglected. (R1) was in critical condition and they didn't know if he was going to make it. (R1) remains in the hospital as of today still being treated for his medical conditions. On 6/2/25 at 9:59 AM V18/Hospital Physician stated, I was the admitting physician that admitted (R1) to the hospital on 5/10/25. I did (R1's) assessment. (R1) had an indwelling catheter. (R1's) urine looked very, very dirty and had a lot of sediment in the urine. (R1) appeared very dry looking, he was dehydrated, and his oral cavity had tons of sludge like material with crusting in his mouth. (R1) came in with Acute Kidney Injury and his creatine lab was five times over his baseline number of one, implying that (R1) was very dehydrated and had been dehydrated for a while. His creatine lab was 4.94 which indicates someone has been dehydrated for at least more than two days. (R1) appeared very malnourished. (R1) did not get like that in just one day. I felt (R1) should have been hospitalized well before he was sent to us. On 6/2/25 at 11:51 AM V2/Director of Nursing verified R1's Electronic Health Record does not include documentation of V14 (R1's Physician) or V7 (Dietician) being notified of R1's 13.9 % weight loss within six months as of 5-7-25, R1's decrease in meal consumption and refusal of meals between 4/29/25 through 5/9/25, R1's decreased consumption of med pass between 5/1/25 through 5/9/25, or R1's nutritional care plan not being revised until 5-8-25. V2 stated, I know I spoke to (V8) on 5/9/25 to go over (R1's) decline again and possibly needing hospice services. (V10/SSD) had called (V8) regarding (R1) possibly needing a gastrostomy tube. (V8) had questions regarding that. (V8) did ask if (R1) needed to be sent out to the hospital and I did tell (V8) that if we did send him out, the hospital probably would not do anything and send him right back. I have no documentation of a physician being notified of (R1's) significant decline in condition from 4/29/25 through 5/10/25. (V14/R1's Physician) should have been notified right away when (R1) started not eating/drinking and started having his significant decline. R1's admission Record, dated 5/28/25, documents R1 is a [AGE] year-old male admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Type Two Diabetes Mellitus, Unspecified severe Protein-Calorie Malnutrition, Depression, Poly Osteoarthritis, Chronic Kidney Disease, Obstructive and Reflux Uropathy, Celiac Disease, and Hypertension. R1's Order Summary Report, dated 5/28/25, documents R1 is a full code, has an indwelling urinary catheter, and an order for weekly weights. R1's MDS (Minimum Data Set) Assessment, dated 1/17/25, documents R1 had no behaviors. R1's MDS Assessment, dated 4/18/25, documents R1 had other behavioral symptoms not directed towards others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). R1's MDS Assessments, dated 1/17/25 and 4/18/25, did not document R1 had rejected cares, had a weight loss, or had any upper or lower impairments. R1's MDS Assessment, dated 5/10/25, documents R1 rejected cares and had a weight loss of five % (percent) or more in the last month or loss of ten % or more in the last six months. R1's Progress Note, dated 3/29/25 and signed by V7/Dietitian documents R1's oral intake is typically 75 to 100% of meals per chart. R1's Nutritional Assessment, dated 4/21/25 and signed by V7/Dietitian documents R1 had no decrease in food intake. R1's Nutritional Risk Assessment, dated 4/29/25 and signed by V7/Dietitian documents R1 had a decrease in oral food intake and eats zero to 75% of meals. R1's Percentage of Meal, dated 4/29/25 through 5/9/25 does not document consistent meal percentages consumed. This forms documents in eleven days R1 consumed 26 to 50% of a meal four times and in eleven days consumed zero to 25% of a meal 15 times. This same form documents in eleven days R1 refused or did not receive a meal three times. R1's Medication Administration Record (MAR) does not document R1's Physician ordered weekly weights were completed from 3/1/25 through 5/10/25. R1's Contracture Risk Assessments, dated 1/1/25 and 4/14/25, document R1 does not have any contractures. These same assessments document R1 was at moderate to severe risk for contractures related to (R1's) diagnoses. R1's Physical Therapy Evaluation and Plan of Treatment, dated 12/23/25 and signed by V17/Physical Therapist, documents Initial Assessment/Current Level of Function and Underlying Impairments: Musculoskeletal System Assessment- Contracture: Functional Limitations Present due to Contracture= No. R1's Physical Therapy Evaluation and Plan of Treatment, dated 1/14/25 and signed by V17/Physical Therapist, documents Initial Assessment/Current Level of Function and Underlying Impairments: Musculoskeletal System Assessment- Contracture: Functional Limitations Present due to Contracture= No. R1's emergency room Summary, dated 5/10/25, documents Musculoskeletal: Comments: Chronically contracture (to the) lower extremities. R1's Behavior Log, dated March 2025, documents R1 refused care twice out of 31 days. R1's Behavior Log, dated April 2025, documents R1 refused care zero times out of 30 days. R1's Behavior Log, dated 5/1/25 through 5/10/25, documents R1 refused care one time out of ten days. R1's Electronic Health Record does not include documentation of V14 (R1's Physician) or V7 (Dietitian) being notified of R1's 13.9 % weight loss within six months as of 5/7/25, R1's decrease in meal consumption and refusal of meals between 4/29/25 through 5/9/25, and R1's decreased consumption of med pass between 5/1/25 through 5/9/25. R1's Electronic Health Record dated 4/28/25 through 5/10/25 (date of hospitalization) does not include documentation of the facility contacting V14 (R1's Physician) or seeking medical treatment for two weeks once R1 started to have a decrease in appetite, decrease in fluid consumption, increase in weakness, increase in behaviors, and rejecting cares. R1's Electronic Medical Record from admission [DATE]) through R1's discharge to the hospital (5/10/25) does not include evidence of the facility monitoring R1's fluid intake. R1's care plan, dated 5/20/25, documents (R1) is at high risk for urinary tract infection due to catheter use, related to indwelling catheter secondary to diagnosis of Obstructive Uropathy. Goal: (R1) will not experience any decline in mental status related UTI (Urinary Tract Infection) through review date. Interventions: Change catheter and drainage bag per medical doctor orders, empty catheter drainage collection bag every shift, ensure catheter tubing and drainage bag are properly positioned to prevent urinary backflow or contamination, observe for and notify doctor for fever, abdominal tenderness, flank pain, altered mental status, malodor (odor), hematuria (blood in urine) or abnormal urine clarity/consistency, provide catheter irrigation as ordered. This same care plan documents Date Initiated 12/23/2024: (R1) has potential for altered nutrition and hydration related to diagnoses of Type Two Diabetes Mellitus, Dementia, and Cancer. (R1) also limits himself on foods he eats. Gluten free, no red meat or pork. Goal: (R1) will have no signs or symptoms of altered nutrition/hydration through review date. Interventions dated 12/23/24: Monitor weights as ordered and notify Physician of significant Weight Change. R1's Care Plan does not include any revisions or nutritional interventions to address R1's seven pound weight loss within one week on 4/23/25, R1's 13.9 % weight loss within six months as of 5-7-25, R1's decrease in meal consumption and refusal of meals between 4/29/25 through 5/9/25, or R1's decreased consumption of med pass between 5/1/25 through 5/9/25, until 5-8-25 (two days before R1 was admitted to the hospital). On 5-8-25 R1's Nutritional Care Plan documents, 5-8-25 Encourage (R1) to eat all meals in the dining room and chart any refusals. Notify physician of any further increase in oral intake for appropriate intervention. Provide supplements as ordered-refer to MAR. Staff to provide supervision with cueing during mealtimes. R1's Electronic Medical Record, including R1's Progress Notes, Care Plan, and Treatment Administration Records from admission [DATE]) through R1's discharge to the hospital (5/10/25) does not include documentation of R1's urinary catheter being changed. R1's Treatment Administration Record (TAR), dated 4/1/25-4/30/25, does not document R1's urinary output on 4/20, 4/21, 4/24, 4/25, 4/30/25 dayshift amounts and on 4/18, 4/19, 4/23, 4/25 and 4/27/25 evening shift amounts, for a total of ten undocumented urine output recordings in the month of April. R1's TAR, dated 5/1/25-5/31/25, documents a total day shift urine output for R1 on 5/9/25 of 100 milliliters (ml) and a total evening shift urine output of 600 ml (for a total of 700 ml). This TAR does not document R1's urinary output on 5/3/25 dayshift or 5/7/25 evening shift. R1's Progress Note, dated 5/8/25 and signed by V10/SSD, documents (V10) left a message for (V8/R1's family Member) regarding the decline in (R1) and hospice services and new POLST (Physician Orders for Life-Sustaining Treatment). (V10) will follow up. R1's Progress Note, dated 5/9/25 and signed by V10/SSD documents (V10) contacted (V8/R1's Family Member) regarding the decline in (R1). (V10) talked about (R1's) significant weight loss, refusing to eat, and wounds. (V10) explained hospice care or gastrostomy for nutrition. (V8) stated he wanted to talk with (V16/R1's Family Member) first before deciding what to do. (V8) stated that the earliest he would be able to come from out of town would be around 6/1/25. (V10) told (V8) that he needs to make a decision before then. (V8) is going to call back once he speaks with (V16). (V10) will follow up. R1's Progress Note, dated 5/10/25 and signed by V15/RN (Registered Nurse), documents (R1) lethargic with involuntary jerking, very slow to respond, increased weakness and fatigue noted, slow to responds and slurred speech, hypotension noted, Blood Pressure 66 systolic/44 diastolic. Emergency Contact (V16/R1's Family Member) notified and request (R1) be evaluated at Emergency Room. 911 called and Emergency Medical Transport arrived, paramedics placed on IV (Intravenous Fluids) at facility and administered EKG (Electrocardiogram). (R1) in route to (local hospital) at this time. R1's Local Hospital emergency room Note, dated 5/10/25, documents Chief Complaint: Dysuria- Per SNF (skilled nursing facility). (R1) has had a UTI (Urinary Tract Infection) for several days. Had antibiotic and has been completed. (R1) presents with purulent (thick, milky white, yellow, green, or brown discharge) drainage in (R1's) indwelling urinary catheter bag. (R1) alert to self per baseline. HPI (History of Present Illness): (R1) is a [AGE] year-old male presenting to the emergency department for sepsis. (R1) presents to the emergency department by ambulance from nursing home. (R1) has a history of dementia and is alert to self only at baseline. (R1) has a chronic indwelling urinary catheter. Staff reports that (R1) has been treated for UTI for the past several weeks. (R1) has been appearing to have lower abdominal pain. (R1's) catheter isn't having significant urine output but has been noted to have purulent appearing content in urinary catheter bag. (R1) has had blood around his urethra. Review of systems by age: Genitourinary: Positive for dysuria (painful urination). Constitutional: Appearance: (R1) is ill-appearing. Genitourinary: Hypospadias (urethra opening on the posterior of the penile shaft) with blood around urethra. Purulent drainage noted in indwelling bag without significant blood clots or gross blood. Medical Decision Making: (R1) presents to emergency department for concern of Sepsis/Urinary Infection. Nursing home staff reports that (R1) appeared to have lower abdominal discomfort as well as purulent drainage from his chronic indwelling catheter. (R1) had blood around the urethra and had hypospadias noted. Nursing staff replaced (R1's) urinary catheter and had immediate return of two liters (2,000 milliliters) of purulent appearing urine. (R1) has acute renal failure with creatinine greater than four as well as metabolic acidosis with lactic acidosis. (R1's) urinalysis appears significantly concerning for infection. Urine culture was sent. CT (computed tomography) scan showed right-sided hydroureteronephrosis (ureters and kidneys are dilated due to a blockage or obstruction in the urinary tract) without obstructing stone. This same summary notes also documents Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Sepsis, Renal failure, and Cardiac failure. Clinical Impression: 1. Acute Renal Failure, Bladder Obstruction, Complicated UTI, Lactic Acidosis, Metabolic Acidosis, and Bacterial Pneumonia. R1's Hospital Progress Note, dated 5/10/25 and signed by V6/Hospital Registered Nurse documents (R1)'s mouth was caked with crusty sludge like material. It took over ten swabs to perform oral care. Was able to move the sludge from his mouth. (R1) was also noted to have a very crusty indwelling catheter at the penis. (R1) is very thin and dehydrated. Nose is crusty with dried mucous. (R1) has a very unwashed smell about him. This same note documents R1 is contracted and difficult to straighten legs. R1's Hospital Progress Note, dated 5/11/25 and signed by V18/Hospital Physician, documents Physical Exam: General- 78-years-old male poorly built, poorly nourished. Assessment and Plan: Acute Cystitis: (R1's) Urinalysis showed 3+ (three plus) blood, positive leukocyte esterase. Urine looked dirty in foley bag with sediment and cloudy urine. On Intravenous antibiotics currently. Acute Kidney Injury, Dehydration, and Chronic Kidney Disease Stage 2: (R1's) baseline creatine is around 1. Current creatinine is around 3.83 which improved from 4.9 with Intravenous fluids. (R1) severely dehydrated on arrival. (R1's) foley catheter was exchanged upon arrival. Concern with Osteomyelitis Pressure Wound on Right Thigh: Ordered x-ray right femur but (R1) has contracture and is not able to extend the right lower extremity due to ongoing pain. Medical Neglect: (R1) arrived at the hospital showing signs of neglect including severe dehydration with poor oral care, and poor foley catheter care. R1's Hospital History and Physical, dated 5/10/25 and signed by V18/Hospital Physician, documents Physical Exam: General- [AGE] year-old male poorly built, poorly nourished, appears to be in moderate distress. Lungs- rhonchi noted on the right lung. Assessment/Plan: Acute Metabolic Encephalopathy: (R1) is alert, not oriented to time, place or person. Not able to follow commands. Ordered computed tomography of brain as well. Encephalopathy is multifactorial likely from infection, dehydration, hypernatremia. Severe malnutrition: Concern for Refeeding Syndrome: (R1) appeared malnourished. BMI (Body Mass Index) is 18.4. Will consult dietitian once (R1) mentation improves. (R1) is at high risk for refeeding syndrome. Will monitor and replete electrolytes closely. The Immediate Jeopardy that began on 4/29/25 was removed and the deficient practice corrected on 5/13/25 when the facility took the following actions to remove the Immediacy and correct the noncompliance. 1. R1 still remains in the hospital and will not be returning to the facility (as per family.) 2. On 5/13/25 resident chart reviews were conducted for the following areas: Change in condition, Significant Weight Change, Resident Exhibiting Signs/Symptoms of Dehydration, Hydration Status, and Foley Catheter Status by the clinical team and consulting team. 3. On 5/12/25 V30/Chief Executive Officer in-serviced the facility's interdisciplinary team on the Change in Condition Policy, Assessments/Identification/Hydration Policy, Signs of Symptoms of Dehydration, Foley Catheter Policy, Facility Weight and Nutrition Policy, and Physician and Interested Party Notification. 4. On 5/13/25 V2/Director of Nursing in-serviced all licensed nursing staff on the Change in Condition Policy, Assessments/Identification/Hydration Policy, Signs of Symptoms of Dehydration, Foley Catheter Policy, Facility Weight and Nutrition Policy, and Physician and Interested Party Notification. 5. On 5/13/25 V2/Director of Nursing in-serviced all CNA's on Foley Catheter Policy and Hydration Policy. 6. On 5/14/25, 5/18/25, 5/27/25, and 6/3/25 V2/Director of Nursing audited three residents on each date for any changes in condition. 7. On 5/14/25, 5/18/25, 5/27/25, and 6/3/25 V2/Director of Nursing audited three residents on each date to ensure they are receiving catheter care, physician orders to change catheters are in place, care plans are updated, and catheter output is documented. 8. On 5/15/25, 5/22/25, 5/29/25, and 6/5/25 the V1/Administrator held a quality assurance meeting where the results from the quality assurance audits were reviewed, and additional interventions were implemented. Completion Date: 5/13/25.

Based on Interview and Record review, the facility failed to ensure a resident with diagnoses of Chronic Kidney Disease and Obstructive and Reflux Uropathy (urine flow obstruction) was monitored for urinary catheter obstruction, failed to document physician ordered urinary output, and provide indwelling urinary catheter changes every 30 days or as needed for one of three residents (R1) reviewed for urinary tract infections in a sample of nine. This failure resulted in R1 experiencing a significant change in condition and being sent to the local emergency room with a subsequent admission to the hospital's critical care unit for diagnoses including Acute Renal Failure, Bladder Obstruction, Complicated urinary Tract Infection, Lactic Acidosis and Metabolic Acidosis. This past noncompliance occurred from 4/29/25 through 5/13/25. Findings include: The facility's Catheter Insertion/Maintenance Policy, dated 5/7/25, documents Purpose: To provide staff with guidelines for the proper insertion of an indwelling urinary catheter. Policy: An indwelling urinary catheter is to be inserted only by order of the physician. Replacement of (indwelling urinary) catheters will be done every thirty days or as needed when clogged/dislodged/accidental removal or ordered by the physician. The indwelling urinary bag shall be changed every week. Indwelling urinary catheters may be flushed as needed for maintenance/to clear clogs or slow drainage. The facility's Indwelling Catheter Care Policy, dated 10/7/22, documents Purpose: To provide guidance to facility staff on the care of residents with an indwelling foley catheter within the facility to prevent catheter-associated urinary tract infections. Policy: The facility shall maintain and care for foley catheters per the facility, following physician orders and adhering to facility infection control and best nursing practice standards. Policy Interpretation and Implementation: c. Empty the collection bag and perform indwelling catheter care at least every shift. R1's MDS (Minimum Data Set), dated 4/18/25 documents R1 has an indwelling urinary catheter. R1's current Care Plan, dated 5/20/25, documents R1 has diagnoses including Chronic Kidney Disease, Obstructive and Reflux Uropathy and Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms. This same care plan documents R1 has Impaired urinary elimination related to obstruction of urethra related to BPH. Interventions: (Indwelling urinary) catheter as ordered, notify doctor of any complaints of problems with voiding. This same care plan documents R1 is High risk for urinary tract infection due to catheter use, related to indwelling catheter secondary to diagnosis of Obstructive Uropathy. Goal: (R1) will not experience any decline in mental status related UTI (urinary tract infection) through review date. Interventions: Change catheter and drainage bag per medical doctor orders, empty catheter drainage collection bag every shift, ensure catheter tubing and drainage bag are properly positioned to prevent urinary backflow or contamination, observe for, and notify doctor for fever, abdominal tenderness, flank pain, altered mental status, malodor (odor), hematuria (blood in urine) or abnormal urine clarity/consistency, provide catheter irrigation as ordered. This care plan also contains a plan of care, dated 4/29/25, that (R1) has a urinary tract infection as evidence by burning at catheter site and abnormal urinalysis. Interventions: Monitor intake and output, monitor/document/report to medical doctor as needed for signs and symptoms of urinary tract infection: frequency, urgency, malaise (feeling unwell), foul smelling urine, dysuria, fever, nausea, and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes, obtain and monitor laboratory/diagnostic work as ordered. Report results to medical doctor and follow up as indicated. R1's Physician Order Sheet, dated 5/1/25, documents R1 has physician orders of (Indwelling urinary) catheter output every shift, start date 4/15/25. This same order sheet documents the following physician orders with a start date of 2/6/25, (Indwelling urinary) catheter 16 French balloon to gravity drainage for Obstructive Uropathy. (Indwelling urinary) catheter may irrigate with 100cc (cubic centimeters) normal saline as needed if tube clogging. May re-insert (indwelling urinary) catheter as needed for malfunction or dislodgement as needed. R1's Treatment Administration Record (TAR), dated 5/1-5/31/25, documents a treatment order dated 5/7/25 to (Indwelling urinary): 16 French 10 ml (milliliter) balloon to gravity drainage for obstructive uropathy, every night shift every 30 days. This TAR does not document that R1's (indwelling urinary) catheter was changed in May 2025. This same administration record documents (Indwelling urinary) catheter output every shift. This TAR documents a total day shift urine output for R1 on 5/9/25 of 100 milliliters (ml) and a total evening shift urine output of 600 ml (for a total of 700 ml). This TAR does not document R1's urinary output on 5/3/25 dayshift or 5/7/25 evening shift. R1's TAR, dated 4/1-4/30/25, documents (Indwelling urinary) catheter output every shift. This TAR does not document R1's urinary output on 4/20, 4/21, 4/24, 4/25, and 4/30/25 dayshift amounts. This same TAR does not document R1's urinary output on 4/18, 4/19, 4/23, 4/25 and 4/27/25 evening shift amounts, for a total of ten undocumented urine output recordings in the month of April. This same TAR does not document R1's (indwelling urinary) catheter was changed for the month of April 2025. R1's Nursing progress notes, dated 1/1/25-5/10/25, do not document R1's (indwelling urinary) catheter has ever been changed. R1's Nursing Progress notes, dated 4/1/2025 at 11:29 PM, document (R1) is having increased confusion, agitation, and burning at (indwelling urinary) catheter site, urine is concentrated and amber in color. Fluids encouraged, resident is afebrile, urine collected for testing. Urinalysis (UA) and Culture and Sensitivity ordered. Urine placed in refrigerator and will go out with lab in AM. R1's Nursing Progress notes, dated 4/6/2025 at 4:07 PM, document (R1's) (indwelling urinary) catheter is patent and draining cloudy yellow urine. UA results are pending. R1's Provider visit summary, dated 4/8/25 and signed by V14 (R1's Physician), documents Diagnosis and all orders for this visit: Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present. Assessment and Plan: Patient (R1) with recurrent urinary tract infection with UA results demonstrating enterococcus faecalis (bacteria) growth greater than 100,000 colonies per high powered field. I (V14) do not recall this, nor do staff. Do not recall seeing this, nor being treated. R1's Nursing Progress Notes, dated 5/5/25-5/10/25, does not document the consistency/color of R1's urine or the patency of R1's (indwelling urinary) catheter. R1's Nursing Progress notes, dated 5/10/25 at 3:45 AM documents (R1) lethargic with involuntary jerking, very slow to respond, increased weakness and fatigue noted, slow to respond and slurred speech, hypotension (low blood pressure) noted, BP (blood pressure) 66/44. Emergency contact (V16, R1's family) notified and (V16) requested resident be evaluated at ER (Emergency Room) 911 (emergency) called and Emergency Medical Transport's arrived, paramedics placed (Intravenous peripheral line) at facility and administered EKG (electrocardiogram), (R1) in route to (local hospital) at this time. R1's Local Hospital emergency room Note, dated 5/10/25, documents Chief Complaint: Dysuria (painful urination)- Per SNF (skilled nursing facility). (R1) has had a UTI (urinary tract infection) for several days. Had antibiotic and has been completed. (R1) presents with purulent (thick, milky white, yellow, green, or brown discharge) drainage in (R1's) indwelling urinary catheter bag. (R1) alert to self per baseline. HPI (History of Present Illness): (R1) is a [AGE] year-old male presenting to the emergency department for sepsis. (R1) presents to the emergency department by ambulance from (facility). (R1) has a history of dementia and is alert to self only at baseline. (R1) has a chronic (indwelling urinary) catheter. Staff reports that (R1) has been treated for UTI for the past several weeks. (R1) has been appearing to have lower abdominal pain. (R1's) catheter isn't having significant urine output but has been noted to have purulent appearing content in urinary catheter bag. (R1) has had blood around his urethra. Review of systems by age: Genitourinary: Positive for dysuria (painful urination). Constitutional: Appearance: (R1) is ill-appearing. Genitourinary: Hypospadias (urethra opening on the posterior of the penile shaft) with blood around urethra. Purulent drainage noted in indwelling bag without significant blood clots or gross blood. Medical Decision Making: (R1) presents to emergency department for concern of sepsis/urinary infection. (Facility) staff reports that (R1) appeared to have lower abdominal discomfort as well as purulent drainage from his chronic (indwelling) catheter. (R1) had blood around the urethra and had hypospadias noted. Nursing staff replaced (R1's) urinary catheter and had immediate return of two liters (2,000 milliliters) of purulent appearing urine. (R1) has acute renal failure with creatinine greater than four as well as metabolic acidosis with lactic acidosis. (R1's) urinalysis appears significantly concerning for infection. Urine culture was sent. CT (computed tomography) scan showed right-sided hydroureteronephrosis (ureters and kidneys are dilated due to a blockage or obstruction in the urinary tract) without obstructing stone. This same summary notes also documents Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Sepsis, Renal failure, and Cardiac failure. Clinical Impression: 1. Acute renal failure, Bladder Obstruction, Complicated UTI, Lactic Acidosis, Metabolic Acidosis, and Bacterial Pneumonia. R1's Hospital Progress Note, dated 5/10/25 and signed by V6 (Hospital Registered Nurse), documents (R1) was also noted to have a very crusty (indwelling urinary) tube at the penis. (R1) is very thin and dehydrated. R1's Hospital Progress Note, dated 5/11/25 and signed by V18 (Hospital Physician), documents Physical Exam: General- 78-years-old male poorly built, poorly nourished. Assessment and Plan: Acute Cystitis: (R1's) Urinalysis showed 3+ blood, positive leukocyte esterase. Urine looked dirty in foley bag with sediment and cloudy urine. On Intravenous antibiotics currently. Acute Kidney Injury, Dehydration, and Chronic Kidney Disease Stage 2: (R1's) baseline creatine is around 1. Current creatinine is around 3.83 which improved from 4.9 with Intravenous fluids. (R1) severely dehydrated on arrive. (R1's) (indwelling urinary) catheter was exchanged upon arrive. Medical Neglect: (R1) arrived at the hospital showing signs of neglect including severe dehydration with poor oral care, and poor (indwelling urinary) catheter care. On 5/28/25 at 1:54 PM V6 (Hospital Registered Nurse) stated I was the admitting nurse when (R1) got admitted to the ICU (Intensive Care Unit). (R1's) private area was excoriated and had a (indwelling urinary) catheter and a lack of it being cleaned. (R1's) groin was very red everywhere. The head of (R1's) penis, from the catheter rubbing and not cared for was actually split. On 5/28/25 at 3:10 PM V2/DON (Director of Nursing) stated that they notified R1's physician via fax on 4/6/25. V2 stated that they never received a response from the physician regarding R1's urinalysis results. V2 confirmed they did not try to get ahold of R1's physician again on 4/6 or 4/7/25 and R1's physician did not provide orders until 4/8/25 for an antibiotic to start on 4/9/25 (three days after facility received urinalysis results). On 5/29/25 at 9:44AM V11/CNA (Certified Nursing Assistant) stated that around two weeks prior to R1 being sent out to the hospital R1 started not being as active as he normally was. V11 stated, Usually I could talk to (R1) and (R1) would talk back. (R1) started sleeping all the time and wasn't eating as much. I did notice (R1's) urine was darker than usual with a little less output. I believe I reported (R1's) urine color and output to (V12/Licensed Practical Nurse/LPN). I usually go to (V12) for most things. We (CNA's) were responsible for catheter care. I noticed (R1's) tip of penis was getting slimy and then would start to crust over. I am not sure what was causing it. On 5/29/25 at 9:55AM V12/LPN stated, At least a week (maybe two weeks) before (R1) went to hospital (R1) was having a decline in his condition. (R1) stopped eating and wouldn't let us get him out of bed. I don't remember anyone reporting (R1's) urine color or output to me, I don't typically monitor that the CNA's usually do. I was at least (R1's) nurse two to three times a week. I reported to (V10/Social Service Director) about (R1's) decline in condition. I did not notify the doctor however and should have. I did not document on (R1's) decline because I was communicating with (V10) regarding hospice, I should have documented. If we notice a change in condition, we should notify the physician immediately. V12 stated that when the nursing staff receives lab results and they are abnormal, they would expect the physician to respond that day. If they don't the next nurse that would come on shift should follow up and if they cannot get ahold of the physician there is an on-call number to call after hours. On 5/29/25 at 11:27 AM (V14/R1's Physician) confirmed he did not receive R1's urinalysis results, dated 4/6/25, until he was at the facility on 4/8/25 and stated he would have started R1 on an antibiotic for a UTI prior to 4/8/25 if he would have received R1's urinalysis results. V14 stated, It's not right if the (local hospital) had emptied two liters of urine from (R1's) bladder when (R1) arrived at the hospital. I am not sure what orders the facility had to change the urinary catheter, but if the facility staff would have notified me, I would have referred (R1) to a Urologist to assist in caring for (R1's) urinary catheter. Not changing (R1's) (indwelling urinary) catheter since January 2025 could have contributed to (R1's) infection and being hospitalized . I was not made aware of (R1's) declining condition. I last saw (R1) on 4/8/25 and I do not have any record of the facility notifying me of (R1's) change in condition. I would have sent (R1) right to the hospital and not messed with doing anything in house if the facility would have notified me of his condition. V14 verified the facility should have monitored R1's urine color and output every shift. On 6/2/25 at 9:59 AM V18/Hospital Physician stated, I was the admitting physician that admitted (R1) to the hospital on 5/10/25. I did (R1's) assessment. (R1) had an (urinary indwelling) catheter. (R1's) urine looked very, very, dirty and had a lot of sediment in the urine. On 6/2/25 at 11:51 AM V2/DON verified R1's urinary catheter outputs should have been documented every shift. Prior to this survey date, the facility had taken the following action to correct the noncompliance: 1. R1 still remains in the hospital and will not be returning to the facility (as per family.) 2. On 5/13/25 resident chart reviews were conducted for Residents Exhibiting Signs/Symptoms of Dehydration, Hydration Status, and Foley Catheter Status by the clinical team and consulting team. 3. On 5/12/25 V30/Chief Executive Officer in-serviced the facility's interdisciplinary team on Assessments/Identification/Hydration Policy, Signs of Symptoms of Dehydration, and Foley Catheter Policy. 4. On 5/13/25 V2/Director of Nursing in-serviced all licensed nursing staff on Assessments/Identification/Hydration Policy, Signs of Symptoms of Dehydration, and Foley Catheter Policy. 5. On 5/13/25 V2/Director of Nursing in-serviced all CNA's on Foley Catheter Policy and Hydration Policy. 6. On 5/14/25, 5/18/25, 5/27/25, and 6/3/25 V2/Director of Nursing audited three residents on each date to ensure they are receiving catheter care, physician orders to change catheters are in place, care plans are updated, and catheter output is documented. 8. On 5/15/25, 5/22/25, 5/29/25, and 6/5/25 the V1/Administrator held a quality assurance meeting where the results from the quality assurance audits were reviewed, and additional interventions were implemented.

Based on interview and record review the facility failed to obtain physician ordered weekly weights and notify the Physician and Registered Dietitian of a resident's repetitive nutritional supplement refusals, decreased meal consumption, and significant weight loss for a resident with a diagnosis of Severe Protein-Calorie Malnutrition for one of three residents (R1) reviewed for weight loss in a sample of nine. These failures resulted in R1 experiencing a severe significant weight loss of 13.9 percent in less than six months and requiring admission to a local hospital critical care unit for treatment of the diagnoses of Hypernatremia, Acute Metabolic Encephalopathy, and Severe Malnutrition/concern for refeeding syndrome (Fatal Metabolic Response). This past noncompliance occurred from 4/29/25 through 5/13/25. Findings include: The facility's Weight Assessment and Intervention Policy, dated 11/22/24, documents Policy Statement: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. 2. Weights will be recorded in (Electronic Computer System) under the resident's Weight/Vitals tab. 7. The threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight equals (usual weight minus actual weight) / (usual weight) times 100): c. 6 months- 10% (percent) weight loss is significant; greater than 10% is severe. 9. If this is an undesirable weight change, resident will be referred to Dietitian, Doctor and family will be notified. Care Planning: 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment. The facility's Hydration Policy, dated 5/8/24, documents Policy: This facility will strive to provide adequate hydration and to prevent and treat deyhdration. 1. Policy interpretation and Implementation. b. The Physician will be notified of any nutritional or hydration changes. R1's admission Record documents R1 is a [AGE] year-old male who admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Unspecified Severe Protein-Calorie Malnutrition, Dementia, and Type Two Diabetes Mellitus with Diabetic Chronic Kidney Disease. R1's Physician's Order dated 1/16/25 documents, Med Pass (Medication) Pass 2.0 Calorie (nutrition supplement) TID (Three Times Daily). R1's Order Summary Report, printed 5/28/25, documents Order date: 1/30/25. Start date: 2/5/25. Weekly weights one time a day every Wednesday for weekly weights. R1's Progress Note, dated 3/29/25 and signed by V7/Dietitian, documents R1's current weight of 151 pounds. This same progress notes documents R1's oral intake typically is 75 - 100% (percent) of meals per day. R1's MAR (Medication Administration Record) dated, March 2025, documents R1 has an order for weekly weights one time a day every Wednesday for weekly weights and does not document weekly weights on 3/5, 3/12, 3/19, and 3/26/25. R1's MAR dated, April 2025, documents R1 has an order for weekly weights one time a day every Wednesday for weekly weights and does not document weekly weights on 4/2, 4/9, 4/16, and 4/30/25. This same MAR documents a physician order for Med (Medication) Pass 2.0 Calorie (nutrition supplement) three times a day related to unspecified severe protein-calorie intake administer 90 ml (milliliters). From 4/1 through 4/30/25 this same MAR does not document milliliters consumed of the Med Pass. R1's MAR, dated May 2025, documents R1 has a physician order for Med Pass. This same MAR documents on 5/1, 5/3, and 5/4/25 at 9:00 AM R1 consumed zero milliliters of med pass, on 5/1, 5/4, and 5/9/25 at 2:00 PM R1 consumed zero milliliters of med pass, and on 5/1, 5/2, and 5/3/25 at 8:00 PM R1 consumed zero milliliters of med pass. R1's Nutritional Risk assessment dated [DATE] and signed by V7 (Dietitian) documents R1's weight on 4/18/25 was 150.5 pounds and within one-week R1 lost seven pounds, weighing 143.5 pounds on 04/23/25. This same Nutritional Risk Assessment documents R1's seven-pound weight loss was undesirable and V7 ordered an increase in R1's med pass to 60 ml three times daily, even though R1 has been receiving med pass 60 ml three times daily since 1/16/25. R1's MDS (Minimum Data Set) Assessment, dated 5/10/25, documents R1 had a weight loss of five % or more in the last month or loss of ten % or more in the last six months and was not on a physician-prescribed weight loss regimen. R1's Percentage of Meal, dated 4/29/25 through 5/9/25 does not document consistent meal percentages consumed. This forms documents in eleven days R1 consumed 26 to 50% of a meal four times and in eleven days consumed zero to 25% of a meal 15 times. This same form documents in eleven days R1 refused or did not receive a meal three times. R1's Weights and Vital Summary, dated 5/29/25, documents R1's weights on 12/22/24 was 157lbs (pounds), on 4/18/25 was 150.5lbs and on 5/7/25 was 135.2lbs, reflecting a 13.9% (percent) weight loss in less than six months and a 10.2% weight loss from 4/18/25 to 5/7/25 (less than three weeks). R1's Progress Note, dated 5/8/25 and signed by V3/ADON (Assistant Director of Nursing), documents Weight Warning: (R1) continues to lose weight due to poor appetite. (R1) is on med pass during the day. Remeron may need to be increased due to poor appetite. (R1) refuses to eat even when fed. Message sent to (family members) about a possible hospice evaluation. R1's Electronic Health Record does not include documentation of V14 (R1's Physician) or V7 (Dietitian) being notified of R1's 13.9 % weight loss within six months as of 5-7-25, R1's decrease in meal consumption and refusal of meals between 4/29/25 through 5/9/25, and R1's decreased consumption of med pass between 5/1/25 through 5/9/25. R1's Care Plan dated 5/20/25, documents Date Initiated 12/23/2024: (R1) has potential for altered nutrition and hydration related to diagnoses of Type Two Diabetes Mellitus, Dementia, and Cancer. (R1) also limits himself on foods he eats. Gluten free, no red meat or pork. Goal: (R1) will have no signs or symptoms of altered nutrition/hydration through review date. Interventions dated 12/23/24: Monitor weights as ordered and notify Physician of significant Weight Change. R1's Care Plan does not include any revisions or nutritional interventions to address R1's seven pound weight loss within one week on 4/23/25, R1's 13.9 % weight loss within six months as of 5-7-25, R1's decrease in meal consumption and refusal of meals between 4/29/25 through 5/9/25, or R1's decreased consumption of med pass between 5/1/25 through 5/9/25, until 5-8-25 (two days before (R1) was admitted to the hospital). On 5-8-25 R1's Nutritional Care Plan documents, 5-8-25 Encourage (R1) to eat all meals in the dining room and chart any refusals. Notify physician of any further increase in oral intake for appropriate intervention. Provide supplements as ordered-refer to MAR. Staff to provide supervision with cueing during mealtimes. R1's Progress Note, dated 5/9/25 and signed by V10/SSD (Social Service Director/SSD), documents (V10) contacted (V8/R1's Family Member) regarding the decline in (R1). (V10) talked about (R1's) significant weight loss, refusing to eat, and wounds. (V10) explained hospice care or gastrostomy for nutrition. (V8) stated he wanted to talk with (V16/R1's Family Member) first before deciding what to do. (V8) stated that the earliest he would be able to come from out of town would be around 6/1/25. (V10) told (V8) that he needs to make a decision before then. (V8) is going to call back once he speaks with (V16). (V10) will follow up. R1's Progress Note, dated 5/10/25 and signed by V15/RN (Registered Nurse), documents (R1) lethargic with involuntary jerking, very slow to respond, increased weakness and fatigue noted, slow to responds and slurred speech, hypotension noted, Blood Pressure 66 systolic/44 diastolic. Emergency Contact (V16/R1's Family Member) notified and request (R1) be evaluated at Emergency Room. 911 called and Emergency Medical Transport arrived, paramedics placed on IV (Intravenous Fluids) at facility and administered EKG (Electrocardiogram). (R1) in route to (local hospital) at this time. R1's Hospital History and Physical, dated 5/10/25 and signed by V18/Hospital Physician, documents Physical Exam: General- [AGE] year-old male poorly built, poorly nourished, appears to be in moderate distress. Assessment/Plan: Dehydration: (R1's) baseline creatinine is around 1. Current creatinine is around 3.3, which improved from 4.9 with intravenous fluids. (R1) is severely dehydrated on arrival. Hypernatremia: Likely from poor oral intake. Switch intravenous fluids to D5W (dextrose and water) after reviewing labs. Acute Metabolic Encephalopathy: (R1) is alert, not oriented to time, place or person. Not able to follow commands. Ordered computed tomography brain as well. Encephalopathy is multifactorial likely from infection, dehydration, hypernatremia. Severe malnutrition: Concern for Refeeding Syndrome: (R1) appeared malnourished. BMI (Body Mass Index) is 18.4. Will consult dietitian once (R1) mentation improves. (R1) is at high risk for refeeding syndrome. Will monitor and replete electrolytes closely. On 5/28/25 at 1:54 PM V6 (Hospital Registered Nurse) stated that she was the admitting nurse when R1 got admitted to the ICU (Intensive Care Unit) on 5/10/25 and R1 appeared severely malnourished, thin, and dehydrated. V6 stated, (R1) had to of not been eating or drinking anything or very little for days. It was one of the worst things I have seen, I felt completely horrible for (R1). On 5/29/25 at 9:44 AM V11/CNA (Certified Nursing Assistant) stated around two weeks prior to R1 being sent out to the hospital R1 started not being as active as he normally was. V11 stated, Usually I could talk to (R1) and (R1) would talk back. (R1) started sleeping all the time and wasn't eating as much. On 5/29/25 at 9:55AM V12/LPN (Licensed Practical Nurse) stated, At least a week (maybe two weeks) before (R1) went to hospital (R1) was having a decline in his condition. (R1) stopped eating and wouldn't let us get him out of bed. I was at least (R1's) nurse two to three times a week. On 5/29/25 at 10:15 AM V13/LPN stated I went to (V10/Social Service Director) regarding a hospice consult around a week or so prior to (R1) being sent to the local hospital. I noticed (R1) was not eating and was having failure to thrive. I did not notify (V7/Dietitian) or (V14/R1's Physician) of my concerns with (R1) not eating and should have. Typically, we would fill out an SBAR (Situation, Background, Assessment, and Recommendation) and would send it to the doctor. I just assumed (V14) had already seen (R1) recently. On 5/29/25 at 3:43 PM V15/LPN stated I know (R1) hadn't been eating or drinking very well for a while. (R1) would just lay there. On 4/26/25 I received an order from (V14/R1's Physician) to start (R1) on Mirtazapine, but I did not notify (V14/R1's Physician) of R1 refusing any meals or drinks and/or losing weight after that. I know the week prior to (R1) being sent to the hospital (R1) was not wanting to eat or drink anything when I was there. On 5/29/25 at 11:27 AM V14/R1's Physician stated the last time he had visited R1 was on 4/8/25. V14 verified he was not made aware of R1 repetitive refusals of eating and drinking his med pass, refusing weekly weights, R1's significant weight loss, or R1's decline. V14 stated, I was not aware of R1's condition after 4/8/25. I last saw (R1) on 4/8/25 and I do not have any record the facility notified me of any major changes in (R1's) condition. On 5/29/25 at 2:54 PM V7/Dietitian verified the lack of R1 eating and drinking would have led to hypernatremia. The last time I reviewed (R1) was on 4/29/25. I was not aware of the significant weight loss that triggered on 5/7/25. I was aware that (R1's) oral intake had decreased when I reviewed him on 4/29/25. I was not aware that (R1) had not been drinking his Med Pass 2.0 or I wouldn't have suggested to increase his Med Pass from 60 ml (milliliters) to 90 ml. If (R1) was having a significant decline with eating and drinking that is a pattern, then they should be letting me know right away as well as documenting it every shift so I can review it. On 6/2/25 at 9:59 AM V18/Hospital Physician stated, I was the admitting physician that admitted (R1) to the hospital on 5/10/25. I did (R1's) assessment. (R1) appeared very malnourished and thin. (R1) did not get like that in just one day. I felt (R1) should have been hospitalized well before he was sent to us. On 6/2/25 at 11:51 AM V2/Director of Nursing verified R1's Electronic Health Record does not include documentation of V14 (R1's Physician) or V7 (Dietitian) being notified of R1's 13.9 % weight loss within six months as of 5-7-25, R1's decrease in meal consumption and refusal of meals between 4/29/25 through 5/9/25, and R1's decreased consumption of med pass between 5/1/25 through 5/9/25, or R1's nutritional care plan not being revised until 5-8-25. V2 also stated, If (R1) was refusing weights or his meals/drinks the physician should have been notified at that time. Prior to the survey date, the facility had taken the following action to correct the noncompliance: 1. R1 still remains in the hospital and will not be returning to the facility (as per family.) 2. On 5/13/25 resident chart reviews were conducted for the following areas: Significant Weight Change, Resident Exhibiting Signs/Symptoms of Dehydration, and Hydration Status. 3. On 5/12/25 V30/Chief Executive Officer in-serviced the facility's interdisciplinary team on the Assessment/Identification/Hydration Policy, Signs of Symptoms of Dehydration, Facility Weight and Nutrition Policy, and Physician and Interested Party Notification. 4. On 5/13/25 V2/Director of Nursing in-serviced all licensed nursing staff on the Assessments/Identification/Hydration Policy, Signs of Symptoms of Dehydration, Facility Weight and Nutrition Policy, and Physician and Interested Party Notification. 5. On 5/13/25 V2/Director of Nursing in-serviced all CNA's on Facility Weight and Nutrition Policy. 6. On 5/14/25, 5/18/25, 5/27/25, and 6/3/25 V2/Director of Nursing audited three residents on each date to ensure weekly weights are being done for a resident with physician ordered weekly weights, significant weight losses are being identified, physician and dietician notification is being done regarding the significant weight loss and any nutritional refusals. 7. On 5/15/25, 5/22/25, 5/29/25, and 6/5/25 the V1/Administrator held a quality assurance meeting where the results from the quality assurance audits were reviewed, and additional interventions were implemented.

Based on Interview and Record review the facility failed to report an allegation of Injury of Unknown Origin to the facility's Abuse Coordinator and the State Agency for one of three residents (R4) reviewed for Injury of Unknown Origin in the sample of nine. Findings include: R4's Nursing progress note, dated 5/16/25 at 2:40 PM and signed by V13 (Licensed Practical Nurse), documents (R4) continues increased confusion, lethargy (weakness) and not at baseline with ADLS (Activities of Daily Living) order received to send to Emergency Department for evaluation and treatment. Family aware and (Emergency services) called. R4's Nursing progress note, dated 5/16/2025 at 8:40 PM and signed by V22 (Licensed Practical Nurse), documents Nurse (V22) received call from (V20, R4's family member). (V20) told nurse that (R4) would not be coming to the facility tonight due to transfer to a (tertiary) hospital. (R4) was given a CT (Computed Tomography) of the head scan which showed internal bleeding. (V20) asked if his (R4) had a fall within the last 24 hours, because the hospital informed (V20) the internal bleeding could be from a possible unwitnessed fall. (V22) informed (V20) that no falls were documented or reported within the last 24 hours. (V20) informed (V22) that he will be keeping in touch if anything else comes up. R4's electronic medical record, dated May 2025, documents the last recorded fall for R4 occurred on 5/13/25 without R4 striking his head or suffering any injury. On 5/31/25 at 8:59 AM, V2 (Director of Nursing) stated We (the facility) do not have any injuries of unknown origin, or bruises of unknown origin in past six months. On 6/3/25 at 2:53 PM, V22 (Licensed Practical Nurse) stated I was the nurse working the evening after (R4) was transferred to the hospital. I took a call from the resident's family (V20) and wrote a nursing note regarding it. I notified the DON (Director of Nursing, V2) of this information because (R4) was sent out prior to my shift and then family called to let me know the emergency room had identified a new head bleed injury that happened in the last 24 hours. I was not able to find any falls or incidents so I felt like the DON should be aware of this information. On 6/3/25 at 2:40 PM, V2 (Director of Nursing) confirmed it was reported to her that R4's family member (V20) called and updated the facility on R4's transfer to a tertiary hospital for a fresh brain bleed that was believed to have occurred in the prior 24 hours. V2 stated We did not do a written investigation or report to (the state agency). We didn't know how he got the injury, and we didn't have any documented falls in the prior 24 hours. On 6/3/25 at 3:34 PM, V1 (Administrator) confirmed she is the facility's Abuse Coordinator. V1 stated I do know that (R4) transferred out and that he had a brain bleed. I was not informed of the injury being reported after he left, to have happened in the prior 24 hours. Reading the nursing note, I do see how it should have been identified and investigated because we don't know what happened and there aren't any recent incidents to show what the bleed was caused from. I did not report the incident (to the state agency) or document an investigation to solve an injury of unknown origin. The facility's Accidents and Incidents policy, dated 9/7/23, documents Purpose: To provide staff with guidelines for investigating, reporting, and recording accidents and incidents. Policy: All accidents/incidents involving a resident shall require an incident report. Accidents and incidents, including injuries of an unknown origin, must be reported to the department supervisor, and an incident report should be completed on the shift that the accident or incident occurred. The facility's Abuse policy, dated 1/9/24, documents To provide guidance and procedures to the facility and staff to assure the residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The administrator and/or designee is the facility abuse coordinator for the facility. It is the responsibility of all facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. It is all staff responsibility report any allegation or witnessed abuse immediately to the Administrator (Abuse Coordinator). This policy also documents The facility will report all allegations of abuse immediately to the Administrator and timely to the proper authorities to include (the state agency), ombudsman, local police department, power of attorney, and medical doctor in a timely manner. The facility will timely report all allegations of abuse initial/final to (the state agency) according to the state and federal guidelines. This same policy documents Injuries of unknown source is defined as such when all of the following criteria is met: the source of the injury was not observed by any person and the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (the location of the injury is not generally vulnerable to trauma) or the number of injuries noted at a particular point of time or the incident of injuries over time.

Based on Interview and Record Review, the facility failed to investigate an injury of unknown origin for one of three residents (R4) reviewed for Injuries of Unknown Origin in the sample of 9. Findings include: R4's Nursing progress note, dated 5/16/25 at 2:40 PM and signed by V13 (Licensed Practical Nurse), documents R4 was transferred to the local Emergency Department for evaluation and treatment. R4's Nursing progress note, dated 5/16/2025 at 8:40 PM and signed by V22 (Licensed Practical Nurse), documents Nurse (V22) received call from (V20, R4's family member). (V20) told nurse that (R4) would not be coming to the facility tonight due to transfer to a (tertiary) hospital. (R4) was given a CT (Computed Tomography) of the head scan which showed internal bleeding. (V20) asked if his (R4) had a fall within the last 24 hours, because the hospital informed (V20) the internal bleeding could be from a possible unwitnessed fall. (V22) informed (V20) that no falls were documented or reported within the last 24 hours. R4's electronic medical record, dated May 2025, documents the last recorded fall for R4 occurred on 5/13/25 without R4 striking his head or suffering any injury. On 5/31/25 at 8:59 AM, V2 (Director of Nursing) stated We (the facility) do not have any injuries of unknown origin, or bruises of unknown origin in past six months. V2 confirmed there are no abuse investigations to review related to injuries of unknown origin. On 6/3/25 at 2:53 PM, V22 (Licensed Practical Nurse) stated I was the nurse working the evening after (R4) was transferred to the hospital. I took a call from the resident's family (V20) and wrote a nursing note regarding it. I notified the DON (Director of Nursing, V2) of this information because (R4) was sent out prior to my shift and then family called to let me know the emergency room had identified a new head bleed injury that happened in the last 24 hours. I was not able to find any falls or incidents so I felt like the DON (V2) should be aware of this information. V22 confirmed he did not complete an incident report or have any other communications (related to R4's injury) with V2 or R4's family after the phone call on 5/16/25. On 6/3/25 at 2:40 PM, V2 (Director of Nursing) stated We did not do a written investigation or report to (the state agency). We didn't know how (R4) got the injury and we didn't have any documented falls (for R4) in the prior 24 hours. On 6/3/25 at 3:34 PM, V1 (Administrator) confirmed she is the facility's Abuse Coordinator. V1 stated I do know that (R4) transferred out and that he had a brain bleed. I was not informed of the injury being reported after he left, to have happened in the prior 24 hours. Reading the nursing note, I do see how it should have been identified and investigated because we don't know what happened and there aren't any recent incidents to show what the bleed was caused from. I did not report the incident (to the state agency) or document an investigation to solve an injury of unknown origin. The facility's Accidents and Incidents policy, dated 9/7/23, documents Purpose: To provide staff with guidelines for investigating, reporting, and recording accidents and incidents. Policy: All accidents/incidents involving a resident shall require an incident report. The interdisciplinary team (IDT) will complete an investigation to determine root cause and implement appropriate interventions. Accidents and incidents, including injuries of an unknown origin, must be reported to the department supervisor, and an incident report should be completed on the shift that the accident or incident occurred. The Interdisciplinary Team (IDT) will conduct a thorough investigation of the accident/incident. Findings of the investigation, including root cause of the accident/incident and appropriate interventions will be in the incident report and implemented. The facility's Abuse policy, dated 1/9/24, documents To provide guidance and procedures to the facility and staff to assure the residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The administrator and/or designee is the facility abuse coordinator for the facility. It is the responsibility of all facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This policy also documents The facility immediately and thoroughly investigates all allegations of abuse to include but not limited to interviews of residents and staff, visitors, and vendors. This same policy documents Injuries of unknown source is defined as such when all of the following criteria is met: the source of the injury was not observed by any person and the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (the location of the injury is not generally vulnerable to trauma) or the number of injuries noted at a particular point of time or the incident of injuries over time.

Based on Interview and Record review, the facility failed to ensure a resident was provided nursing assessments, vital signs, and timely provider notifications to ensure medical intervention was received with an acute change of condition for one of four residents (R4) reviewed for change of condition in the sample of nine. Findings include: R4's care plan, dated 4/14/25, documents R4 has diagnoses including but not limited to Atrial Fibrillation, Hypertension, Type II Diabetes Mellitus, Parkinson's Disease, Congestive Heart Failure, Cardiac Pacemaker, and Neurocognitive Disorder with Lewy Bodies. This care plan documents (R4) is at risk for potential falls with injury related to a history of falls prior to admission, weakness, diagnosis of Lewy Body Dementia with confusion, poor balance, gait instability, diagnosis of Diabetes, and daily use of Psychotropic medication. This same care plan documents R4 requires physical assistance of one staff member for transferring and ambulating, and setup help only/ cuing is required with eating. On 6/2/25 at 12:15 PM, V19 (R4's Family Member) stated (R4) was sent out to the hospital on 5/16/25. I was there visiting him just the day before (Thursday 5/15) and he wasn't having confusion. I got a call on 5/16 at 10:47 AM and the nurse (V13, Licensed Practical Nurse) said that (R4) was confused and she thought maybe he had a UTI (Urinary Tract Infection). (V13) said the doctor (V29, R4's Physician) was on his way and would see (R4) today. At 1:10 PM I called back to see what they found out and (V13) said (V29) was on vacation and they (nursing staff) didn't realize it. (V13) said they may send him out for a urinalysis to the hospital. At 2:33 PM, (V13) called me back and said (R4) was going to the hospital. I asked what the (prompt care doctors office) said and (V13) said they didn't get a response back, but that (R4) could not feed himself. I agreed he needed to go out to the hospital because that is a huge change. (R4) would need to be seen right away. (V20, R4's Family) was able to get to the hospital to be with him. (R4) got to the hospital according to the chart records around 3:30 PM. The emergency room told (V20) that (R4) had a fresh brain bleed from hitting his head hard. We (family) had no knowledge of a fall. If (R4) was unable to feed himself that is a big change, not subtle, because he's always been fine with his own meals. On 6/2/25 at 1:58 PM, R9 stated (R4) ate at my table for meals a lot. On the day he went to the hospital (R4) couldn't pick up his fork. He was confused and wasn't making any sense. I think maybe (R4) wasn't at my table for breakfast, but I know at lunch (R4) had a lot of confusion and could not eat on his own which was a big change for him. He had dementia but this was way more, (R4) just was not making any sense. R4's Nursing progress note, dated 5/16/25 at 11:20 AM and signed by V13 (Licensed Practical Nurse), documents Change in condition, increased confusion, increased lethargy, SBAR (Situation, Background, Assessment, Recommendation) sent to (prompt care physician's office), (V19, R4's Family) notified. R4's Nursing progress note, dated 5/16/25 at 2:40 PM and signed by V13, documents (R4) continues increased confusion, lethargy (weakness) and not at baseline with ADLS (Activities of Daily Living), order received to send to Emergency Department for evaluation and treatment. Family aware and (Emergency services) called. R4's electronic medical record, dated May 2025, does not document a nursing assessment was provided to R4 on 5/16/25 and documents the last neurological assessment for R4 was completed on 5/15/25 at 3:32 AM. This record also documents the last set of vital signs including blood pressure, pulse and oxygen saturation was completed for R4 on 5/15/25 at 3:29 AM. On 6/3/25 at 11:35 AM, V13 (Licensed Practical Nurse) confirmed that R4 was her assigned resident on 5/16/25 when he went to the hospital. V13 stated On 5/16 my shift started at 6:00 AM but I don't think I was R4's nurse right away. V13 stated she first assumed care of R4 at around 11:00 AM and noticed he wasn't acting right. V13 stated I noticed he had a change from his baseline, and he wasn't acting normal. I called the family (V19) and I tried to contact the provider (V29) via fax. R4 was lethargic, not acting normal and was mumbling his words, which was all new behavior. I never got a response back from (V29) and at 2:40 PM (over three and a half hours from the first recognized change in R4's cognition), I sent (R4) to the Emergency Room. I believe when I first saw (R4) he was in his room and then he was taken to lunch and wasn't able to eat or do anything. That would have been around noon. I would assume I took vital signs and if I did, they would be in the computer. (R4's) increased confusion was not normal for him, nor was the mumbled speech. (R4) had a change in condition, was off and needed evaluated which is why I ultimately sent him to the hospital. From the first recognition of his change around 11:00 AM until EMS (Emergency Medical Services) was called (2:40 PM) his condition remained about the same, no better and no worse. V13 confirmed her method of reaching out to providers was all by fax and she did not call the provider (V29) or an on-call provider when no response was received from the fax. R4's local emergency room record, dated 5/16/25, documents R4 admitted to the local emergency room at 3:17 PM with symptoms of left side facial drooping, blurred vision, altered mental status and slurred speech. This record documents R4 was transferred to a higher level of care hospital (tertiary) for a neurosurgical evaluation and admission. R4's Tertiary hospital Discharge summary, dated [DATE], documents R4 was admitted to the tertiary hospital's Intensive Care Unit on 5/16/25 and started on medication (Nicardipine, calcium channel blocker) to keep (R4's) systolic blood pressure below 140 (millimeters of mercury). On 6/3/24 at 3:20 PM, V2 (Director of Nursing) confirmed R4's medical record does not document vital signs, nursing assessments, neurological checks, or a successful provider notification with response, throughout the morning and afternoon of 5/16/25 when R4 was exhibiting a change in baseline and new onset of significant deficits. V2 stated she would expect nurses to complete these nursing assessments when a resident is showing significant changes like R4 was on 5/16/25. The facility's Acute Change of Condition policy, dated 1/23/23, documents Purpose: To provide facility guidance when a change of condition occurs with a resident. Policy: The facility shall identify and treat residents with acute change of conditions. This policy also documents Direct care staff, including nursing assistants, will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the nurse. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician, for example, the history of present illness and previous and recent test results for comparison. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the residents/patient's current symptoms and status, history, current medications, etc. (etcetera). The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response. The attending physician (or practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response.

Based on interview and record review, the facility failed to fully assess and complete a skin inspection assessment upon admission, obtain initial treatment orders upon admission, perform daily skin checks, and provide weekly documentation assessments for one (R1) of three residents reviewed for pressure ulcer/skin conditions in a sample of three. Findings include: R1's medical record documents he was admitted to the facility on [DATE] and discharged from the facility on 4/11/25. R1's medical record documents the following diagnoses: Gangrene of right leg with right above the knee amputation, Rhabdomyolysis (breakdown of muscle tissue), Diabetes, and Muscle Wasting. R1's Braden Score, dated 3/25/25, documents R1 is at high risk for pressure ulcers. R1's Admission note, dated 3/25/25, documents Sacrum open area noted upon admission. R1's current care plan for the facility documents (R1) admitted to the facility with an open area to his sacrum. admitted with a Stage three pressure injury to the coccyx. R1's Minimum Data Set/MDS, dated [DATE], documents R1 is not cognitively intact, requires substantial/maximum assistance of two people for activities of daily living, uses a wheelchair, is frequently incontinent of bowels, at risk for pressure ulcers, and has a surgical wound. R1's Skin Inspection/Nursing Weekly Assessment ordered every Tuesday in the afternoon, with an order date of 3/25/2025, documents on 4/1/25 and 4/8/25 the skin inspection/nursing weekly assessment was signed off by the nurses on R1's TAR/Treatment Administration Record, but R1's medical record has no documentation on R1's pressure ulcer to his coccyx. R1's skin and wound note, dated 4/8/25 at 3:05PM by V10 NP/Nurse Practitioner, documents the following: Reason for visit: New admission to the facility, skin/wound assessment. His medical history includes the following: Type 2 Diabetes Mellitus/DM, Chronic Anemia, Smoking, Peripheral Artery Disease/PAD, and Atrial Fibrillation/Afib where these co-morbidities could delay wound healing. Patient also seen today for a stage three pressure ulcer to his coccyx that was present on admission. SKIN: History of a chronic wound to coccyx; Primary Etiology: Pressure Ulcer/Injury; Stage/Severity: Stage 3; Wound Status: Present on Admission; Size: 3 cm/centimeters x 2 cm x 0.2 cm. Calculated area is 6 sq/square cm. Wound Base: 0% epithelial, 100% granulation, 0% slough; Exposed Tissues: Epithelium, Dermis, Subcutaneous; Wound Edges: Attached; Peri-wound: Intact; Treatment Recommendations: 1. Cleanse with wound cleanser, 2. apply Hydrocolloid to base of the wound, 3. change PRN/as needed, and three times per week. R1's medical record has an order, dated 4/9/25, for the following: Wound. Coccyx. Cleanse with wound cleanser. Pat dry. Apply Hydrocolloid three times a week and PRN/as needed every night shift on Tuesday, Thursday, and Saturday. On 4/30/25 at 1:16PM, V2 DON/Director of Nursing verified R1's medical record documents R1 has an open area to his coccyx upon admission (3/25/25), and on 4/9/25 (14 days after admission) the facility obtained orders for R1's stage three pressure ulcer to his coccyx. V2 also verified there was no further documentation or orders in R1's medical record regarding any treatment to R1's pressure ulcer to his coccyx prior to 4/9/25; no completed skin inspection assessment upon admission (3/25/25); no daily skin checks; and no weekly documentation on R1's pressure ulcer was in his medical record. On 4/30/25 at 2:30PM, V1 Administrator stated, We missed it (R1's pressure ulcer) upon admission, (R1) did not have wound orders when he admitted , and we did not get wound orders until 4/9/25 when (V10 NP) saw (R1). Facility Pressure Ulcer policy, revised 8/31/23, documents When a pressure ulcer is identified, whether in-house or upon a resident's admission, the area will be assessed, a skin inspection assessment shall be completed, and initial treatment orders started per physician orders. Daily skin checks shall be initiated on residents with a pressure wound to provide increased monitoring from nursing staff. Resident may be referred to wound physician for evaluation and treatment. Physician order for treatment will include: Specific site, Type of treatment, and how often treatment is to be completed. Documentation of the pressure ulcer must occur upon identification and at least once a week and as needed until healed. Assessment is to include: Characteristics: (size, depth, color, drainage); presence of granulation tissue, necrotic tissue; treatment; prevention (turning and repositioning, skin care, protective devices); and update physician and resident/Power of Attorney.

Based on observation, interview, and record review the facility failed to ensure resident dignity was maintained by failing to ensure call lights were answered in a timely manner for four residents (R1, R2, R3 and R4) of four residents reviewed for call light response time in a sample list of four. Findings Include: 1.) R1's Admission Record printed on 11/1/24 at 9:57 AM documents R1 was admitted to the facility 10/1/24 with diagnoses of Sepsis, Asthma, Obesity, Class 3, Essential (Primary) Hypertension, Chronic Kidney Disease, Stage 3, Localized Edema, Pneumonia, Chronic Right Heart Failure, Low Back Pain, Polycystic Kidney, Adult Type, Hypothyroidism, Irritable Bowel Syndrome, Pressure Ulcer of Other Site, Stage 2, and Neuromuscular Dysfunction Of Bladder. On 11/1/24 at 11:00 AM R1 stated on 10/26/24 at 1:00PM R1 pushed the call light as R1 had been incontinent of bowel at that time. R1 stated R1 knows it was 1:00PM as R1 stated she looked at the time due to having to wait a long time for her call light to be answered previously. R1 stated it was 3:00PM before staff came to change/clean her up. R1's Minimum Data Set completed on [DATE], documents a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicates R1 is cognitively intact. R1's Care Plan dated 10/1/24 documents- Toilet Use: Two person physical assistance required. The same Care Plan documents R1 has a Self-Care Deficit as Evidenced by a recent hospitalization for weakness secondary to a diagnosis of Sepsis. The Care Plan documents R1 currently requires staff assistance for the completion of her ADL's (Activities of Daily Living). 2.) R2's Admission Record printed on 11/1/24 at 12:14 PM documents R2 was admitted on [DATE] with a diagnoses of Multiple Sclerosis, Chronic Obstructive Pulmonary Disease, Mild Protein-Calorie Malnutrition, Idiopathic Pulmonary Fibrosis, Spastic Hemiplegia, Panlobular Emphysema, Mild Intermittent Asthma With (Acute) Exacerbation, Irritant Contact Dermatitis Due To Fecal, Urinary or Dual, Incontinence, Laceration Without Foreign Body of Left Buttock, Bariatric Surgery Status, Zoster with other Complications, Hypothyroidism, Hyperlipidemia, Major Depressive Disorder, Anxiety Disorder, Insomnia, Obstructive Sleep Apnea, Disorders of Acoustic Nerve, Essential (Primary) Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery, Angina Pectoris, Atrial Fibrillation, Diastolic (Congestive) Heart Failure, Allergic Rhinitis, Eosinophilic Esophagitis, Gastro-Esophageal Reflux Disease, Gout, Pain In Thoracic Spine, Chronic Kidney Disease, Stage 2, Flaccid Neuropathic Bladder, Benign Prostatic Hyperplasia without Lower Urinary Tract, Tachycardia, Localized Edema, and Cachexia. On 11/1/24 at 10:45AM R2 was laying in his bed, R2 stated there are extended call light wait times, sometimes exceeding 30 minutes and he will call his wife for help who calls the facility to get someone to come help him. R2's Minimum Data Set completed on [DATE], documents a Brief Interview for Mental Status (BIMS) score of 13. A score of 13 indicates R2 is cognitively intact. R2's Care Plan dated 4/1/2024 documents Self-Care Deficit as evidenced by recent hospitalization for diagnoses of urinary tract infection and Sepsis. The Care Plan documents R2 currently requires staff assistance for the completion of his ADL's (Activities of Daily Living). The same care plan dated 4/1/24 documents Toilet Use - One-person physical assist required. 3.) R3's Admission Record printed on 11/1/24 at 12:43 PM documents R3 was admitted to the facility 2/28/2024 with diagnoses of Secondary Malignant Neoplasm, Spastic Hemiplegia Affecting Left Nondominant Side, Personal History of Transient Ischemic Attack (Tia), and Cerebral Infarction without Residual Deficits, Malignant Neoplasm of Lower Lobe, Right Bronchus or Lung, Mixed Hyperlipidemia, Dysphagia, Long Term (Current) use of Anticoagulants, Hypersomnia, Unilateral Primary Osteoarthritis, Right Hip, Sleep Apnea, personal history of Pulmonary Embolism, Basal Cell Carcinoma of Skin, Anxiety Disorder, Mild Protein-Calorie Malnutrition, Contracture, Left Hand, Major Depressive Disorder, and Local Infection of the Skin and Subcutaneous Tissue. On 11/1/24 at 1:00 PM R3 was escorted to the conference room and agreed to be interviewed. R3 stated call light times can be a very long wait sometimes greater than 30 minutes. R3's Minimum Data Set completed on Sep 25, 2024, documents a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicates R3 is cognitively intact. R3 Care Plan dated 3/1/2024 documents R3 has a Self-Care Deficit as evidenced by left sided spastic Hemiplegia secondary to a history of cerebral vascular accident, Osteoarthritis of the right hip, and weakness. The Care Plan documents R3 currently requires staff assistance for the completion of his ADL's (Activities of Daily Living). The same dated care plan documents Toilet Use: Two-person physical assistance required. 4.) R4's Admission Record printed on 11/1/24 at 2:35 PM documents R4 was admitted to the facility 5/12/2023 with diagnoses of Essential (Primary) Hypertension, Allergic Rhinitis, Dependence on other enabling machines and devices, Allergy Status, Venous Insufficiency (Chronic), Sleep Apnea, Ventral Hernia without obstruction or Gangrene, Anxiety Disorder, Major Depressive Disorder, Glaucoma, Anemia, Vitamin D Deficiency, Body Mass Index [BMI]40.0-44.9, Morbid (Severe) Obesity, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Polyneuropathy, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Atrioventricular Block, Hyperlipidemia, Atrial Fibrillation, Pleural Effusion, Hypotension, Presence of Cardiac Pacemaker, Pulmonary Fibrosis, Chronic Venous Hypertension (Idiopathic) with Ulcer of Left Lower Extremity, Insomnia, Type 2 Diabetes Mellitus with other Skin Complications, Bariatric Surgery Status, Gastro-Esophageal Reflux Disease without Esophagitis, Intestinal Adhesions [Bands], with Partial Obstruction, and Pressure Ulcer of Right Heel, Stage 4. On 11/1/24 at 2:15 PM R4 was sitting in the wheelchair at the bedside, R4 stated that it can take up to and over 30 minutes for his call light to be answered. R4's Minimum Data Set completed on [DATE], documents a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicates R4 is cognitively intact. R4's Care Plan dated 8/22/2024 documents Self-Care Deficit as evidenced by: Needs (extensive) assistance with ADLs related to pain, weakness, lack of coordination, reduced mobility and abnormalities of gait and mobility. The Care Plan documents R4 currently requires staff assistance for the completion of his ADL's (Activities of Daily Living). On 11/1/24 at 10:30 AM V1 Administrator acknowledged the facility has extended call light wait times. On 11/1/24 at 11:13 AM V4 stated she is the SSD (Social Service Director) and one of her jobs is to talk to the residents. V4 stated she has received complaints from multiple residents about extended or long call light wait times. On 11/1/24 at 2:30 PM V2 Assistant Director of Nurses acknowledged the facility has extended call light times. V2 states they are working on it. Resident Council Minutes dated 10/7/24 document residents would like a quicker response time to call lights. The Call Light Guidance Policy: Issued Date: 9/22/20 Revised: 8/20/22 documents that resident call lights shall be responded to within a reasonable amount of time.

Based on interview and record review, the facility failed to educate residents on what a grievance is, have grievance forms readily available in a public area in the facility, and allow a resident to file a grievance anonymously if desired. This has the potential to affect all 59 residents living in the facility. Findings: On 9/30/24 at 10 AM, during the Group Meeting, Residents, R9, R10, R50, R211, all stated that they did not know what a grievance was, where forms were kept, how to file a grievance and it could be done anonymously. All four stated that they were interested in having this available to them for future use. R10 stated, it would be nice to let (the administration) know if something was going on without giving your name. On 10/01/24 at 10:15 AM, V1, Administrator, stated, Residents are welcome to tell staff if they have an issue. We don't actually call them grievances, more like concerns. V10, Social Services Director, will record the concern and look into the issue. We do not have grievance forms displayed anywhere for residents or family to fill out. I never thought about the possibility that they would want to do so anonymously. The document, Grievance Policy, and Procedure, dated 9/17/19, states, (The purpose of this policy) is to offer guidance to the facility in identifying, investigating, and resolving grievances reported by residents, visitors, family members or staff. In accordance with federal law, the facility shall post a sign or signs notifying individuals of the right to file a grievance or complaint, including the right to file this action anonymously. The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 9/29/24 and signed by V1, Administrator, documents 59 residents currently reside within the facility.

Based on record review and interview the facility failed to implement their Abuse Policy to remove an alleged perpetrator from direct care of residents once an allegation of abuse was made by R7. This failure has the potential to affect all 59 residents residing within the facility. Findings include: V6's (CNA's) Attendance Card dated 9-28-24 documents V6 worked on 9-28-24 from 6:09 AM through 2:17 PM. R7's MDS (Minimum Data Set) assessment dated [DATE] documents R7 is cognitively intact. On 9-29-24 at 9:20 AM V5 (Registered Nurse/RN) stated, (V6/CNA/Certified Nursing Assistant) reported to me on 9-28-24 around 12:30 PM that (R7) was saying that (V6) yanked on her arm (R7's arm) rough and hurt (R7's) shoulder. I did not remove (V6) from resident care or have (V6) leave the facility. I have only worked here three weeks and was not trained on the abuse policy. On 9-29-24 at 9:18 AM V1 stated, (V5) should have reported to me immediately when (R7) reported her concerns about (V6) to (V5). (V6) should have been suspended immediately once (R7) made an allegation. On 9-30-24 at 10:45 AM V6 (CNA) stated, On 9-28-24 around 12:00 PM (R7) started yelling at me to get out of her room and said I hurt her shoulder when moving her. I immediately let (V5) know that (R7) was upset and said I moved her too hard or too fast and I hurt her. I went back in her room around 1:00 PM and (R7) told me to get out of there again. I think I was moving (R7) too fast. (V5) did not suspend me when I informed (V5) around 12:00 PM that (R7) said I hurt her and (R7) was upset with me. I continued to work until a little after 2:00 PM and tried to take care of (R7) again around 1:00 PM. All the residents are on the same hallway at the facility, so I take care of all the residents whenever they need something. The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 9/29/24 and signed by V1/Administrator documents 59 residents currently reside within the facility. The facility's Abuse Policy dated 1-9-24 documents, The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law: or have a disciplinary action against their license by a state licensing body as the result of a finding of abuse, neglect, exploitation, misappropriation of property, or mistreatment. Procedure: Any staff member or person suspected of abuse will be escorted by staff out of the facility and will be notified that they are not permitted back into the facility until the investigation has been complete.

Based on record review and interview the facility failed to ensure direct care staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to affect all 59 residents residing within the facility. Findings include: The facility's Annual Training Logs were reviewed and do not include evidence of the facility providing employees with QAPI training. On 10-01-24 at 10:27 AM V1 (Administrator) stated, We (the facility) do not do QAPI training with any of the staff. The facility does not have a policy on providing QAPI training. The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 9/29/24 and signed by V1, Administrator, documents 59 residents currently reside within the facility.

Based on observation, interview and record review, the facility failed to ensure nebulizer masks and nebulizer tubing were dated and stored in a bag between uses for two resident (R41 and R161), failed to ensure a resident had a physician order for oxygen for one resident (R2) and failed to ensure nasal cannula tubing were dated for two of six residents (R26 and R161) reviewed for respiratory care in a sample of 32. Findings include: 1. On 9/29/24 at 10:55 AM R26 was sitting in her wheelchair in her room wearing oxygen. There was no date on the oxygen tubing. R26 stated I don't know how often they change the tubing, but I know it is not once a week. On 9/29/24 at 10:56 AM V8/CNA/Certified Nursing Assistant verified there was no date on the oxygen tubing. On 10/1/24 at 1:34 PM, V2/Director of Nursing stated that oxygen tubing should be changed at least once a week and labeled with the date. R26's Admission Record printed 9/29/24 at 10:32 AM documents that R26 was admitted to the facility 5/18/23 with diagnoses that include Chronic Obstructive Pulmonary Disease/COPD, Chronic Respiratory Failure with Hypercapnia, and Emphysema. R26's Minimum Data Set assessment dated [DATE], documents R26 has a BIMs (Brief Interview for Mental Status) of 14 (cognition intact). R26's Physician Order Summary dated 10/1/24 at 10:55 AM, documents Oxygen at 6 (six) liters via nasal cannula continuous every shift related to COPD. Change oxygen tubing weekly on Sunday night shift and as needed for infection control. R26's Care Plan documents that R26 has altered respiratory status and difficulty breathing related to diagnosis of COPD. Oxygen via nasal cannula as ordered. 2. On 9/29/24 11:00 AM R161 was lying in bed wearing oxygen. There was no date on the oxygen tubing. R161 also had a nebulizer machine in his room on the bedside table. The nebulizer mask was still attached to the tubing and machine. There was no date on the mask or tubing and no bag to store the mask in. R161 stated I don't know when the tubing was last changed. On 9/29/24 at 11:03 AM V8/CNA verified there was no date on the oxygen tubing or nebulizer tubing. On 10/1/24 at 1:34 PM, V2/Director of Nursing stated that oxygen tubing should be changed at least once a week and labeled with the date. V2 also stated that nebulizer tubing should also be labeled, and the mask should be stored in a plastic bag when not in use. R161's Admission Record printed 10/1/24 at 10:40 AM documents that R161 was admitted to the facility on [DATE] with diagnoses that include Acute Respiratory Failure with Hypoxia, Centrilobular Emphysema, and Chronic Obstructive Pulmonary Disease. R161's Minimum Data Set assessment dated [DATE], documents R161 has a BIMs (Brief Interview for Mental Status) of 15 (cognition intact). R161's Physician Order Summary dated 10/1/24 at 10:42 AM, documents Oxygen at 5 (five) to 7 (seven) liters via nasal cannula continuous every shift. Change oxygen tubing every Sunday on night shift and place date on tubing. R161's Care Plan documents that R161 has altered respiratory status and difficulty breathing related to diagnosis of Respiratory Failure, Emphysema, and COPD. Oxygen via nasal cannula as ordered. The facility's Nebulizer Therapy policy, dated 4/1/20, documents Purpose: To provide guidelines to Licensed nursing staff for the proper administration of nebulizers per physician order. Nebulizer treatments are given to liquefy and moisten secretions or instill medications. Procedure: 8. Rinse all parts of nebulizer under warm water after each treatment. Wash all parts under warm soapy water daily. Store in plastic bag when not in use. Change mouthpiece, tubing and nebulizer monthly. The facility's Oxygen Administration policy, dated 3/17/22, documents Procedure: 16. Care and Use of Prefilled Disposable Humidifiers: I. Label humidifier with date opened. Tubing will be changed and dated weekly. 17. Care and Use of Reusable Humidifiers: G. Label humidifier with date opened. Tubing will be changed and dated weekly. 22. When Oxygen cannula/Mask is not in use it should be stored in a zip lock or like bag attached to the oxygen concentrator. 49187 3. R41's current POS (Physician Order Sheet) documents a Physician order for Ipratropium-Albuterol Solution 0.5-2.5 (3) mg(milligram)/3ml (milliliter) inhale orally two times a day and every 4 hours as needed. On 9/29/24 at 8:50 AM R41's nebulizer tubing and nebulizer mask were lying on R41's bedside table un-dated and unbagged. On 9/29/24 at 8:53AM V9/Licensed Practical Nurse verified R41's nebulizer tubing and nebulizer mask were undated and un-bagged. V9 stated, The nebulizer tubing and mask should be changed at least once a week and placed in a bag when not in use. 4 R2's POS, dated 9/29/24, does not document a physician order for the use of oxygen. On 9/29/24 at 8:45 AM R2 was sitting in her wheelchair in her room. R2 had oxygen flowing at 3.5 liters via nasal cannula. R2's nasal cannula was un-dated. V9/Licensed Practical Nurse verified that R2's nasal cannula tubing was undated. V9 stated, Oxygen tubing should be changed weekly and dated. On 9/30/24 at 2:00 PM V2/Director of Nursing verified R2 did not have a current order for oxygen. V2 stated, I am unsure why there is not an order for (R2) to wear oxygen, (R2) always has oxygen on.

Based on observation, interview, and record review the facility failed to ensure the call light was in reach for one resident (R26) out of 15 residents reviewed for call lights in the sample 32. Findings include: R26's Current Medical Record documents that R26 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease/COPD, Chronic Respiratory Failure with Hypercapnia, Emphysema, Essential (Primary) Hypertension, Chronic Kidney Disease, and Type 2 Diabetes Mellitus with Hyperglycemia. R26's Minimum Data Set assessment dated [DATE] documents R26 has a BIMs (Brief Interview of Mental Status) of 14 (cognition intact). R26 requires partial assistance for activities of daily living, transfers and is dependent on staff for toileting. On 9/29/24 at 10:55 AM, R26 was sitting in her wheelchair in her room wearing oxygen. R26 did not have the call light in reach. R26 stated that she did not have the call light since staff got her out of bed. On 9/29/24 at 10:57 AM, V8/Certified Nursing Assistant/CNA came into R26's room and found R26's call light near the head of R26's bed on the floor. V8 verified that R26 should have had the call light in reach. On 10/1/24 at 1:28 PM, V2/Director of Nursing stated that the call light should always be in reach of the resident. The Call Light Guidance policy dated 8/20/24, documents 2. A call light activation device shall be kept within resident reach while in resident rooms and bathrooms.

Based on record review and interview the facility failed to implement their Abuse Policy to report staff-to-resident abuse to the administrator immediately for one of one resident (R7) reviewed for abuse reporting in the sample of 32. Findings include: R7's MDS (Minimum Data Set) assessment dated [DATE] documents R7 is cognitively intact. On 9-29-24 at 9:20 AM V5 (Registered Nurse/RN) stated, (V6/CNA/Certified Nursing Assistant) reported to me on 9-28-24 around 12:30 PM that (R7) was saying that (V6) yanked on her arm (R7's arm) rough and hurt (R7's) shoulder. I have only worked here three weeks and was not trained on the abuse policy. I did not report (R7's) allegations to (V1/Administrator). I just thought it was a racist issue. On 9-29-24 at 9:30 AM V4 (CNA) stated on 9-28-24 around 12:15 PM R7 was refusing care from V6 (CNA). V4 stated R7 reported to her that V6 was rough during cares and was rude to R7. V4 stated she did not report R7's allegation to V1. On 9-29-24 at 9:18 AM V1 stated, (V5) should have reported to me immediately when (R7) reported her concerns about (V6) to (V5). (V5) has received abuse training on the facility's abuse policy on 9-3-24. The facility's Abuse Policy dated 1-9-24 documents, It is all staff responsibility to report any allegation or witnessed abuse immediately to the Administrator (Abuse Coordinator). The facility will report all allegations of abuse immediately to the Administrator.

Based on observation, interview, and record review the facility failed to implement physician ordered pressure relieving interventions for a resident identified as being a high risk for pressure ulcer development for one of three residents (R13) reviewed for pressure ulcers in the sample of 32. This failure resulted in R13 developing a painful, facility acquired stage four pressure ulcer to the left heel that became infected with MRSA (Methicillin Resistant Staphylococcus Aureus) and Proteus Mirabilis and required surgical debridement on multiple occasions. Findings include: R13's MDS (Minimum Data Set) Assessments dated 3-8-24 and 9-6-24 documents R13 is cognitively intact. R13's Braden Scale for Predicting Pressure Sore Risk dated 6-12-24 documents R13 is at high risk for developing pressure sores, is chairfast and her ability to walk is severely limited or non-existent, is completely immobile and does not make even slight changes in body or extremity position without assistance, has adequate nutrition, and requires moderate to maximum assistance in moving. R13's Current Care Plan documents R13 has a pressure injury to the left posterior heel with interventions to apply a heel floating device while R13 is in bed, provide off-loading of ulcer site, and reposition every two hours. This same Care Plan documents R13 has the potential for impaired skin integrity with interventions to ensure bilateral heel protectors are in place while in bed or chair as she will allow. R13's Wound Evaluation and Management Summary dated 4-9-24 and signed by V18 (Wound Physician) documents, Chief complaint: (R13) has wounds on her left posterior heel full thickness. Stage four pressure wound of the left posterior heel full thickness. Etiology: Pressure. Stage four. Duration less than one day. Wound size: 1.7 cm (centimeters) length by 1.5 cm width by 0.7 cm depth. Exudate moderate serosanguinous (pinkish-yellowish drainage). Slough (dead tissue) 40 percent. Recommendations: (pressure relieving heel boots). Reposition per facility protocol. Float heels in bed. Off-load wound. Management and prognosis presented; importance of wound off-load and wearing the boots while in wheelchair emphasized. Surgical excisional debridement procedure to remove necrotic tissue and establish the margins of viable tissue. R13's Wound Evaluation and Management Summary dated 9-3-24 and signed by V18 (Wound Physician) documents, Chief complaint: Stage four pressure wound of the left posterior heel full thickness. Etiology: Pressure. Stage four. Duration over 148 days. Wound size: 1.7 cm length by 0.6 cm width by 0.2 cm depth. Exudate light serosanguinous. Slough 20 percent. Recommendations: (pressure relieving boots). Reposition per facility protocol. Float heels in bed. Off-load wound. Surgical excisional debridement procedure to remove necrotic tissue and establish the margins of viable tissue. Dressing treatment plan: Silver Sulfadiazine apply once daily for 16 days. Gauze island with border apply once daily as needed. R13's Left Heel Wound Culture dated 7-9-24 documents, Heavy growth of Proteus Mirabilis. Heavy growth of (MRSA). R13's Physician's Order dated 7-9-24 documents, Tetracycline Hydrochloride 500 mg (milligrams) one tablet two times daily for MRSA of left heel wound for 14 days. On 9-30-24 from 9:10 AM through 12:05 PM R13 was lying in bed on her back with a four-inch raised mat under her knees. R13 had a four-by-four dressing to the left heel. R13's heels were lying directly on the mattress with no pressure relief or off-loading. R13 did not have pressure relieving boots on during this time. On 9-30-24 at 9:10 AM R13 stated, I was told I got the sores on my heels from rubbing my heels on the mattress. That sore is painful, especially when the doctor looks at it. They do not put heel boots on me. My heel boots are in the closet, and no one has been putting them on me. I need them because I have blisters on my heels, and I know I should wear them. On 9-30-24 at 12:08 PM V15 (CNA/Certified Nursing Assistant) entered R13's room and stated, I have not tried to turn (R13) since this morning around 7:00 AM. I do not know if (R13) has heel protector boots or not. I have worked here since August 1, 2024, and I have only seen (R13) wear heel boots one time. I know the boots were green. I have not tried to put heel boots on (R13) ever before. V15 also confirmed R13's heels were laying directly on the bed without pressure relief. V15 then exited R13's room and did not off-load R13's heels off the bed or apply heel pressure relieving boots before exiting the room. On 9-30-24 from 12:08 PM through 2:05 PM R13 was in lying bed on her back with a four-inch raised mat under her knees. R13 had a four-by-four dressing to the left heel. R13's heels were lying directly on the mattress with no pressure relief or off-loading. R13 did not have pressure relieving boots on during this time. On 10-1-24 from 9:30 AM through 10:35 AM R13 was in lying bed on her back with four inch raised mat under her knees. R13 had a four-by-four dressing to the left heel. R13's heels were lying directly on the mattress with no pressure relief or off-loading. R13 did not have on pressure relieving boots at these times. On 10-1-24 at 10:40 AM V14 (Assistant Director of Nursing) stated, I did not know (V18/Wound Physician) had ordered pressure relieving heel boots and off-loading. I thought we (the facility) were just supposed to off-load (R13's) heels. (R13's) heels are not off-loaded off the mattress. I will have to educate the staff on proper positioning of the off-loading device to ensure (R13's) heels are always off the bed. The staff did not have the off-loading device positioned correctly. On 10-1-24 at 10:50 AM V9 (LPN/Licensed Practical Nurse) stated, I did not see on (V18's) recommendations that (R13) needs heel boots on. I rounded with (V18). I know (R13) has pressure relieving boots in her closet and the staff have not put them on. On 10-1-24 at 11:00 AM V14 (Assistant Director of Nursing/ADON) removed R13's dressing to the left heel pressure ulcer. V21 (Wound Nurse Practitioner) cleansed the wound with normal saline and measured the wound at 1.7 cm by 0.9 cm by 0.2 cm with 10 percent slough covering the wound. The wound bed was dark red with a small amount of serosanguinous drainage. V21 applied honey alginate to the wound bed and covered with a four-by-four gauze and tape. On 10-1-24 at 11:00 AM V21 (Wound Nurse Practitioner) stated, (R13's) heels should be always off-loaded. The wound on (R13's) left heel was caused by pressure and was facility acquired. I prefer (R13) to have pressure relieving boots on always. The facility's Pressure Ulcer Prevention, Identification and Treatment policy dated 4-1-2020 documents Purpose: To provide guidelines that will assist nursing staff in prevention, identification, and appropriate treatment of pressure ulcers. Policy: Prevention program including Turning and Positioning, will be utilized for all residents who have been identified of being at risk for developing pressure ulcers. The facility will initiate an aggressive treatment program for those residents who have pressure ulcers. Responsibility: A pressure ulcer is defined as any lesion caused by unrelieved pressure those results in damage to underlying tissue. Pressure ulcers usually occur over bony prominence and are graded or staged to classify the degree of tissue damage observed. The staging method is one method of describing the extent of the tissue damage in the pressure sore. Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often including undermining and tunneling. Pressure Sore Prevention Guidelines and Suggested Interventions: Positioning device should be used to keep bony prominence from direct contact with each other. Residents who are completely immobile should have pressure reducing devices to totally relieve pressure on heels and raise the heels completely off bed.

Based on observation, interview, and record review the facility failed to obtain physician ordered scheduled medication from the pharmacy for one of fifteen residents (R2) reviewed for pharmacy services in the sample of 32. Findings include: R2's Physician Orders, dated 9/29/24, documents Order date: 9/12/24: Cyclobenzaprine hydrochloride 10 mg (milligrams) one tablet by mouth three times a day for muscle spasms. On 9/29/24 at 8:23 AM V9/LPN (Licensed Practical Nurse) was administering R2's scheduled medications. R2's Cyclobenzaprine Hydrochloride 10 mg was not available in the medication cart. V9 stated, We (the facility) have been having trouble getting this medication in from pharmacy and I am not sure why. On 9/30/24 at 2:10 PM V9/LPN stated, R2 was still out of her Cyclobenzaprine 10 mg tab. V9 stated, I did not notify the (R2's) doctor yesterday or today that R2 was out of her Cyclobenzaprine. I did just call the pharmacy and it is something to do with insurance coverage for that medication. On 9/30/24 at 2:30 PM V2/DON verified R2's Cyclobenzaprine was not given yesterday or today. V2 stated, The nurses should notify the resident and the resident's doctor right away when a resident is out a medication. R2's Medication Administration Record, dated 9/2024, documents R2 missed six scheduled doses of Cyclobenzaprine on 9/29/24 and 9/30/24. The facility's Unavailable Medications policy, dated 8/2020, documents Policy: Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This may be due to pharmacy being temporarily out of stock of a particular product, a drug recall, or manufacturer's shortage of an ingredient, or may be a permanent situation due to the medication no longer being produced. The facility must make every effort to ensure that medications are available to meet the needs of each resident. Procedures: The pharmacy staff shall: 1. Notify nursing staff that the order (products) is/are unavailable. 2. Notify nursing staff of when it is anticipated that the drug(s) that is/are available. The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy(ies) available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility medical Director for orders and/or direction. 2. Obtain a new order and cancel/discontinue the order for the non-available medication. 3. Notify the pharmacy of the replacement order.

Based on observation, interview, and record review the facility failed to perform anti-psychotic drug assessments, failed to perform gradual dose reductions, and failed to document behaviors and diagnosis to justify the use of an anti-psychotic medication for one of five residents (R38) reviewed for the use of anti-psychotic medication with the diagnosis of Dementia in the sample of 32. Findings include: R38's current Physician's Order document R38 was admitted to the facility on [DATE]. R38's OBRA (Omnibus Budget Reconciliation Act) Initial Screen dated 1-16-22 documents R38 does not have a mental illness. R38's MDS (Minimum Data Set) Assessments dated 4-26-24 and 7-24-24 document R38 receives an anti-psychotic medication on a routine basis, has had no gradual dose reduction attempts, and has no physician documentation as to why a gradual dose reduction is clinically contraindicated. R38's Initial Psychiatric Evaluation dated 2-3-23 and signed by V22 (Psychiatric Nursing Practitioner) documents, Assessment: Dementia with psychotic disturbance, unspecified dementia severity, unspecified dementia type. Recommendations: Start Seroquel (anti-psychotic medication) 12.5 mg (milligrams) every night. R38's Order Summary Report dated 10-1-24 documents R38 has been receiving Seroquel 50 mg two times daily since 9-23-23. R38's current Care Plan documents R38 receives an anti-psychotic medication for the diagnosis of Dementia with agitation. R38's Medical Record does not include evidence or documentation of a gradual dose reduction attempt of R38's Seroquel since 9-23-23. R38's Medical Record does not include evidence or documentation of an anti-psychotic medication assessment since the start of R38's Seroquel on 2-3-23. R38's Behavior Tracking Report dated 4-1-24 through 9-30-24 documents R38 has had no behaviors. On 9-29-24 at 10:00 AM R38 was in bed. R38 was well-groomed and pleasant. R38 was alert and orientated and had no behaviors. R38 stated I do not want all my medications. The medications make me tired. On 9-30-24 at 12:08 PM V15 (CNA/Certified Nursing Assistant) stated, I have not noticed (R38) to have any behaviors. On 10-1-24 at 11:00 AM V2 (Director of Nursing) stated, (R38) has not had any behaviors in the last six months for the use of Seroquel and has never had a gradual dose reduction of the Seroquel. We (the facility) have not done any anti-psychotic medication assessments for (R38's) Seroquel use. The Psychotropic Medication Protocol (not dated) documents Purpose: To provide guidance to facility staff in the implementation, monitoring and gradual dose reductions of psychotropic medications. Initiating a Psychotropic Medication: Appropriate diagnosis/justification must be obtained. Initial Psychotropic Assessment shall be completed. Behavior tracking shall be initiated, specific to the medication and the targeted behaviors in POC (Plan of Care). Quarterly - Initiate potential GDR/Gradual Dose Reduction.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for one resident (R8) out of three residents reviewed for abuse in a sample of eight. This failure resulted in R8 having feelings of being intimidated for prolonged periods of time. Findings include: The facility's Abuse policy dated 10/24/22 documents The administrator and/or designee is the facility abuse coordinator for the facility. It is the responsibility of all facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. R8s minimum data set (MDS) documents a brief interview of mental status (BIMS) of 15. A BIMS of 12 -15 indicates a resident is cognitively intact with 15 being the highest score. On 12/7/23 at 9:35 AM, V6, Certified Nursing Assistant, observed entering R8's room. Upon entry of R8's room, R8 stated I want to get up. V6 replied in a stern tone I said 10:30. R8 stated But I want to get up now. V6 replied raising her voice You think you're above everyone else? It'll be 10:30 like I said! You want to play games? Then that's what we'll do we'll start playing games! At this point R8 started crying and stated, Every time you're my CNA, you do this to me. V6 replied in an even louder tone stating I'm down here working hard to be here (raising voice) on time (yelling) for you! While still crying R8 started talking and V6 interrupted her started stating that she was going to (V1, Administrator) to be taken off of R8's group. As R8 was still trying to speak, V6 started yelling I'm not going back and forth with you! I'm not going to let you disrespect me! At that point, while still crying, R8 pointed to this surveyor and stated, He's from the state and just heard everything you said. V6 turned looked at this surveyor and stated, I don't care. On 12/7/23 at 9:40 AM, V1 Administrator, was informed of the incident. V1 stated That's not how we do things here. (R8) can be a very difficult person to work with, but that's still no excuse. (V6, CNA) should have walked out of the room and taken a moment instead of arguing with (R8). On 12/7/23 at 9:55 AM, V1 Administrator, stated I went down to talk with (R8) about the situation, but she didn't say much. I think she's still upset about the situation. (V6, CNA) has taken off the floor and sent home. On 12/7/23 at 10:45 AM, R8 stated No I'm not OK. It's not the first time (V6, CNA) has yelled at me. (R8's voice started cracking and her eyes became watery) Every time (V6) works with me, she makes me feel belittled. Like I'm not good enough. She treats me as though she's the boss and has power over me. Every time she's here I feel intimidated. I feel this way the entire time (V6) is here. It's the whole shift until she goes home. I didn't tell anyone because it won't do any good.

Based on observation, interview, and record review, the facility failed to provide supervision to a cognitively impaired resident with a history of falling, for one of one resident reviewed (R55) for falls with major injury and failed to ensure a wandering resident did not enter other residents rooms for one of one resident (R29) in a sample of 56. This failure resulted in R55 falling from her wheelchair as she was unsupervised, on 8/06/23 and sustaining a left hip fracture. Findings include: 1. On 8/21/23 at 11:54 am, R55 was sitting in a high back reclining wheelchair with a lap tray. R55 was non-verbal and leaning forward with her head resting on the lap tray. On 8/22/23 at 10:23 am, R55 was sleeping in bed with a staff member sitting in the doorway providing 1:1 supervision. The Electronic Record Face Sheet documents R55 was admitted to the facility on [DATE] with the diagnoses of Non-displaced Fracture of the Second Cervical Vertebra with Subsequent Encounter for Fracture with Routine Healing, Aftercare Following Surgery on the Nervous System, Encephalopathy, History of Falling and Major Depressive Disorder. A Fall Risk Assessment completed 6/16/23 determined R55 to be high risk for falls. Nursing Notes, dated 6/17/23, document R55 was transferred to the local Hospital for chest pain, was admitted for Pneumonia, Urinary Tract Infection and Acute Metabolic Encephalopathy and did not return to the facility until 7/10/23. R55's 7/10/23 Hospital Transfer/Readmission documentation indicates R55 was started on Seroquel (Anti-psychotic) 25 mg (milligrams) daily during that hospitalization and orders were given for R55 to continue the Seroquel 25 mg daily. A repeat Fall Risk Assessment on 7/10/23 documents R55 continued to be high risk for falling. R55's Plan of Care, which was revised on 7/13/23 documents (R55) is at risk for falls and injuries (related to) a (history) of falls prior to admission, use of narcotics for pain control, poor safety awareness secondary to (a diagnosis) of Dementia, daily use of Psychotropic medication, daily use of Antipsychotic medication and age. (R55) gets agitated when staff try to redirect her. Nursing Progress Notes document R55 fell a total of eight times between 7/14/23 and 8/03/23. Physician's Orders document R55's Anti-psychotic medication, Seroquel was doubled in dose to 25 mg twice per day (on 7/19/23), an additional Anti-psychotic, Zyprexa 2.5 mg daily was added on 7/28/23. Physician's orders document R55's Seroquel was doubled again on 7/29/23, to 50 mg twice per day. Manufacture's Prescribing Information cites patients on Seroquel are at an increased risk of sedation, somnolence and dizziness, which could lead to falling. Fall Investigations indicate R55 experienced her first fall at the facility on 7/14/23, when R55 was witnessed by staff to stand from her wheelchair, land on her buttocks when she went to sit down, sustaining no injury. The next Fall Investigation, dated 7/15/23, documents R55 was observed by staff to stand from the dining room table, lose her balance and fall to the ground, without injury. The 7/15/23 Fall Investigation determined R55 was barefoot when she fell and needed to always have proper footwear on. A Fall Investigation, dated 7/17/23, documented R55 experienced an unwitnessed fall and was found, uninjured, by staff sitting on the floor in front of her wheelchair in the dining room. Documentation indicates the facility put a Dycem (non-slip pad) in the seat and added an anti-roll back devices to R55's wheelchair. A 7/18/23 Fall Investigation documented R55 was found lying on her side in the hallway and the fall was unwitnessed. The 7/18/23 Fall Investigation determined R55 was uninjured and had likely wandered into the hallway looking for a bathroom, so a nightlight was placed in R55's room and she was to be encouraged to toilet prior to bedtime. Another Fall Investigation, dated 7/23/23, documents staff observed R55 stand from her wheelchair and then kneel onto the floor before staff could assist her. The 7/23/23 Fall Investigation determined R55 was restless in the dining room, stood independently and was uninjured, with instructions for staff to offer R55 to lay down in bed between meals. A Fall Investigation, dated 7/30/23, documents staff observed R55 standing next to her wheelchair, turn and fall onto her right side, sustaining a skin tear to her right wrist and a bump to the left side of her head. The 7/30/23 Fall Investigation determined Resident has Dementia and is confused. Attempted to stand from chair without assistance, with an intervention of a pressure alarm to be placed in R55's wheelchair. Another Fall Investigation, dated 8/02/23, documents staff observed R55 get up out of her wheelchair and fall to the floor, without sustaining an injury. The 8/02/23 Fall Investigation determined R55 attempted to stand unassisted and lost her balance, with an intervention of Supervision will be increased by way of sitting at the nurse's station and management offices with staff and engaging in meaningful conversation. A Fall Investigation, dated 8/03/23, documents staff witnessed R55 standing in the hallway with her wheelchair behind her as she fell backwards onto her buttocks. The 8/03/23 Fall Investigation concluded that R55 was uninjured, has poor safety awareness due to Dementia and recommended applying a soft lap restraint to keep (R55) safe from falls. Lastly, a Fall Investigation, dated 8/06/23 at 11:20 am, documents, This nurse was notified by (resident's Certified Nursing Assistant) that this resident had a fall out in the hallway. This nurse witnessed resident on the ground next to wheelchair with (Certified Nursing Assistant) and staff present at the scene. (R55) unable to state what happen(ed) and if she is experiencing any pain. (R55) unable to give description. Vitals (within normal limits). No injuries noted. (R55) unable to state any pain. No visible sign of trauma noted. Skin intact. Oriented to self. (R55) is now being (placed) on 1:1 supervision by staff. Nursing Notes from 8/06/23 document R55 had displayed signs of discomfort during transfer to bed at 9:00 pm, and at Around (11:00 pm) CNA (Certified Nursing Assistant) told nurse (R55) continued to display signs of pain during bed check. Resident held her left hip while lying down while grimacing, so nurse called to have resident sent to (local Hospital) to have her hip (x-rayed). Hospital Records, dated 8/07/23, document R55 was found to have an acute, displaced, overriding subcapital left femoral neck fracture with overriding at the fracture site. The Hospitalist Discharge Summary, dated 8/10/23, documents Family opted against surgery (of femoral neck fracture) and instead wanted her moved to palliative/comfort care, had agitation related to Dementia, being in new setting, etc. An Administrative Summary/Verification of Incident Investigation dated 8/06/23, documents (R55) had a fall in the hallway out of her wheelchair, not witnessed. Resident was unable to state what she was doing, due to her cognitive status. She was likely attempting to get out of (her) wheelchair to ambulate unassisted. The nurse immediately assessed resident, and vital signs (were) completed. (R55) had no noted abnormalities, edema, redness, and no open areas, so she was assisted back to (her) wheelchair per staff. (R55) continued with 1 on 1 supervision by (Certified Nursing Assistant). (R55) was being transferred to bed by staff later that night and she was noted to show signs of discomfort. The nurse completed assessment and sent resident to Hospital for an evaluation related to her signs and symptoms of pain during weight bearing activities. (R55) was diagnosed with a left hip fracture and returned to the facility. A witness statement, from V18 (Certified Nursing Assistant), dated 8/07/23, documents I don't remember exactly what time I actually toileted the resident that day, but when I take care of her, I normally attempt to take her to the bathroom every hour or hour and a half. That day, I went to break and let the nurse know I was leaving the unit. When I came back on the unit, I saw (R55) laying in the hallway. I was gone approximately 15 minutes. (R55) was a couple feet from her wheelchair, so it appeared she may have tried to ambulate without assistance. I immediately went and got the nurse. On 8/24/23 at 11:40 am, V2 (Director of Nursing) stated R55 had repeatedly fallen because she would stand from her chair and try to ambulate independently. V2 stated R55 could only ambulate with a gait belt and standby assistance of staff. V2 stated they tried using a soft lap restraint in R55's wheelchair to remind her she shouldn't stand independently, but R55 would just pull it off the wheelchair and throw it. V2 stated they tried using a pressure alarm in the seat of R55's wheelchair, but that agitated R55, and she would turn it off. V2 indicated, this was when they decided R55 should be at the Nurse's Station for increased supervision by staff when up in her wheelchair. V2 stated she would expect staff to have R55 within arm's reach, not just visual supervision. V2 stated her investigation into the 8/06/23 fall concluded that R55 was in the hallway by the Social Service office, and not at the Nurse's Station when she fell . According to V2, based on the location of where R55 was found on the floor and the location of her wheelchair, it appeared R55 had stood from her chair and taken a couple of steps and then fell . V2 stated, even if R55 had been left at the Nurse's Station, she needed to be monitored because she would propel away, so, someone had to watch her. V2 confirmed that V18 had left the unit for break at the time of R55 fall and there was no staff around to witness the incident. On 8/24/23 at 1:19 pm, V10 (Licensed Practical Nurse) stated she was R55's nurse on 8/06/23. V10 stated she gave R55 her medication around 11:00 am, and at that time R55 was sitting in her wheelchair in the hallway near the Social Service office. V10 didn't recall any additional staff in the area at that time. V10 then took her medication cart into the dining room to finish her medication pass. V10 indicated, several minutes later, she heard V18 (Certified Nursing Assistant) say R55 was on the floor. V10 stated she assessed R55 for injury and R55 did not express any verbal or non-verbal indicators of pain, so they assisted R55 back into her wheelchair. V10 stated she then took R55 into the dining room with her so she could monitor her more closely. V10 stated staff are to watch R55 closely, because she needs constant supervision, she likes to get up (on her own). V10 stated she was unaware that V18 had been out on break when R55 fell and indicated if she had known, she would have brought her (R55) with me on my med (medication) pass. V10 stated she was unaware that R55 had been care planned to be at the Nurse's Station for increased supervision, as well. 2. A Wandering/Elopement Policy dated 10/18/22 states, If identifies as at risk for wandering or elopement; the resident's care plan will include strategies and interventions that shall (be) implemented to maintain the resident's safety, including but not limited, to electronic monitoring device, room placement, frequent checks, etc. R29's Minimum Data Set assessment dated [DATE] documents R30 is severely cognitively impaired and requires supervision for locomotion on and off the unit and utilizes a wheelchair for mobility. R29's care plan dated 5/23/22 documents R29 is an elopement risk. This care plan instructs staff to, Provide re-direction and Diversion as needed. An additional intervention on R29's care plan dated 1/27/21 instructs staff to, keep within staff supervision when out of room. On 8/21/23 at 1:30p.m. while R10 was seated in a wheelchair in his room talking to visitors and with the privacy curtain closed, R29 self-propelled her wheelchair into R10's room around the privacy curtain and began to speak aggressively to R10 and the visitors. R29 seemed confused, disoriented, and was mumbling nonsensically but aggressively. V14 (Certified Nurse Aide) could be seen in the hallway walking towards R10's room. When V14 was just outside R10's room, V14 saw that R29 was in R10's room near R10 and R10's visitors, V14 shrugged her shoulders and turned to walk away. One of R10's visitors called out for V14 to come remove R29 from R10's room. V14 stated she did not know R29's name but that V14 knew which room belonged to R29 which was at the other end of the hallway. Once V14 had escorted R29 out of R10's room, R10 stated that R29 frequently wanders into his room without being invited. R10 stated he realizes R29 is confused and wanders, however, R10 stated he does not want R29 to wander into his room without permission. R10 stated that earlier that morning R29 wandered into his room while he was, On the pot, which made R10 uncomfortable. On 8/24/23 at approximately 2:39p.m. V1 (Administrator) was discussing R10's concerns including his concern with R29 wandering into R10's room and invading R10's privacy. V1 stated, V10's particular.

Based on interview and record review the facility failed to prevent a resident from falling off the bed during cares for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 sustaining a left intertrochanteric [CONDITION(S)]. Findings include: R1's Fall Risk assessment dated [DATE] documents that R1 is at high risk for falls because of being chairbound and/or requiring assist with elimination, legally blind, unable to stand, and is being administered three to four medications which put R1 at high risk for falls. R1's current care plan documents that R1 is at risk for falls related to weakness with a goal to limit or minimize R1's risk for falls and injuries, may require one or two person assist with repositioning in bed depending on the resident's condition. R1's care plan also documents that R1 has been exhibiting increased confusion. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 has highly impaired vision, requires extensive assistance of two people for bed mobility, is totally dependent on two staff for toileting which includes cleansing after elimination, changing incontinence pad, adjusting clothing. On 11/29/21 at 1:55p.m. V7 (R1's Power of Attorney/POA) stated that on 11/26/21 R1 fell off the bed while receiving incontinence care from a CNA (Certified Nurse Aide) at the facility. V7 stated that R1 sustained a fractured hip which required surgery as a result of this fall. R1's nurse's note dated 11/26/21 at 11:09p.m. and entered by V4 (Licensed Practical Nurse/LPN) documents, CNA was doing peri care on resident and when resident was rolling over to be changed her left leg went forward too far and she rolled out of bed onto the floor, resident landed on her left side. R1's nurse's note dated 11/27/21 at 1:43p.m. and entered by V5 (Registered Nurse/RN) documents that X-ray results showed that R1 had sustained a left [CONDITION(S)] and was transferred to the hospital for treatment. R1's X-ray report dated 11/27/21 documents that R1 sustained an acute left intertrochanteric [CONDITION(S)]. On 11/29/21 at 6:21p.m. V3 (CNA) stated she was R1's CNA the night she fell out of bed on 11/26/21. V3 stated on 11/26/21 sometime between 7:00p.m. and 8:00p.m. V3 entered R1's room to see if R1 had been incontinent and R1 needed changed. V3 stated that even though R1 was sound asleep, V3 told R1 that she was going to check to see if she needed changing. V3 stated that she pulled back R1's covers and saw that R1 had been incontinent of urine and needed a complete bed change and clothing change. V3 stated that she told R1 that she needed changing, but R1 was mostly asleep and didn't answer. V3 stated, I rolled (R1) toward her window. I noticed she can hold herself up on her side from when I have cared for her before. She had been on her side for a good five minutes when I turned away for a split second and when I turned back R1 had adjusted one leg and fell out of bed. V3 stated when the nurse assessed R1, R1 didn't complain of pain or have any signs that she had any broken bones but later during the night R1 began to complain of left leg pain. V3 stated that V4 (LPN) called R1's physician for orders for an X-ray which showed R1 had a fractured left hip. V3 stated, I think if I had had my hands on (R1) she may not have fallen out of bed. V3 stated that if she had kept her hands on R1 instead of turning away, she might have felt R1 shifting in the bed and prevented her from falling off the side. On 11/30/21 at 11:40a.m. V2 (Director of Nurses/DON) stated that R1's fall from the bed resulting in a left [CONDITION(S)] was avoidable because V3 turned away from R1 without maintaining physical contact despite knowing that R1 was very sleepy and not verbally responding when V3 turned R1 to her side in the bed.