Every finding on record at Hillsboro Rehab & HCC

Based on record review and interview, the facility failed to prevent abuse for 3 of 3 residents (R1, R12, and R17) reviewed for abuse in the sample of 17. This past non-compliance occurred from 5/3/2026-5/5/2026.Findings include; 1. The facility State report dated 5/4/2026 final report documents date and location of incident 5/4/2026 in dining room. The report documents brief description of incident: On 5/4/2026 staff witnessed a resident-to-resident interaction between R17, R10 and R1. The report documents type of injuries: none. The report document R1, R17 and R10 were interviewed, statements as follows: R1 was interviewed and did not recall anything happening. R17 denied the allegation. R10 was interviewed and stated, What are you talking about? I did not do anything wrong, I just kissed my wife. The report documents staff walked out of resident room from doing a bed check and observed R10 kissing R1. The report documents staff separated R1 and R10 and redirected to his room. The report documents staff went to the administrator's office to inform of the event she witnessed. The state report documents V21, Certified Nursing Assistant/CNA stated, I observed (R10) coming in the dining area and touched (R17's) hand and started to kiss (R17). The report documents R10 kissed R17 before staff could separate them.R10's undated face sheet documents a diagnosis in part of encephalopathy, hypertensive heart disease with heart failure, cognitive communication deficit R10's care plan, dated 11/17/2025, documents R10 has impaired cognitive function/dementia, Care plan, dated 4/24/2026, documents R10 has confusional episode with interventions dated 4/24/2026 has difficulty with remembering where he is room or bathroom is needs verbally cueing to find the rooms. R10's care plan, dated revised 5/7/2026, documents R10 has a behavioral problem the following interventions, dated 5/4, document R10 sent to hospital for evaluation and treatment. R10's care plan documents behavior #5 R10 mistakes females to be his wife redirect, separate resident; assist resident to sit with malesR10's Minimum Data Set (MDS), dated [DATE], documents a Behavioral Interview of Mental Status (BIMS) of 3, indicating cognitive impairment.R1's current undated face sheet documents a diagnosis in part of: Alzheimer's Disease unspecified, heart failure, dementia in other diseases classified elsewhere, moderate without behavioral disturbance, Psychotic disturbance, mood disturbance and anxiety, cerebrovascular disease unspecified, Atherosclerotic heart disease, angina pectoris R1's Minimum Data Set (MDS), dated [DATE], documents unable to score Behavioral Interview of Mental Status (BIMS)R1's Care Plan, dated 7/28/2025, documents R1 has been identified as being a vulnerable person related to her diagnosis of dementia. R1's care plan documents intervention dated 7/28/2025 frequent rounding by staff to maintain safety and ensure resident needs are met. R1's Care Plan, dated 10/15/2025, documents R1 has impaired cognitive function/dementia or impaired thought processes Alzheimer's disease, Dementia, Impaired decision making. R1's care plan documents R1 has an Activity Daily Living (ADL) self-care performance deficit dementia. R1's care plan documents R1 requires staff assistance time 1 for bathing, bed mobility, dressing, standby supervision for ambulation, personal hygiene, transfers and toileting. R17's undated face sheet documents diagnosis in part of unspecified Dementia, traumatic subdural hemorrhage without loss of consciousness and anxiety disorderR17's Care plan documents R17 has been identified as being a vulnerable person related to dementia R17's care plan documents the following interventions; frequent rounding by staff provided to maintain safety and ensure resident needs are met, resident resides on a closely supervised unit, social services will follow closely as need after each incident, trauma assessment will be completed for each incident. R17's Care plan documents has and ADL self-care deficit and R17 has unsteady balance and unsteady gait, requires staff assistance x1 for bathing bed mobility, dressing, personal hygiene, toileting and transfers.R17's MDS, dated [DATE], documents a BIMS of 4 indicating cognitive impairment. 2. The facility State Report, dated 5/3/2026, documents brief description of incident; resident to resident altercation, no injury noted. The report documents R12 entered R8's room and started talking to the staff. The report documents R8 walked into room and yelled 'don't touch my purse.' R8 then pushed R12. R12 fell into staff. The staff and R12 both landed-on bed. R8's undated face sheet documents a diagnosis in part of major depressive disorder, recurrent, severe with psychotic symptoms, unspecified dementia, and bipolar disorder.R8's MDS, dated [DATE], documents a BIMS of indicating R8 is cognitively intact.R8's Care plan, dated 4/30/2026, documents R8 has a behavior problem related to anxiety with behaviors identified, or attention seeking behaviors, sadness, aggression toward others and more frequent allegations.R12's undated face sheet documents in part a diagnosis of bipolar disorder, Alzheimer's disease, and cognitive communication deficit.R12's MDS, dated [DATE], documents R12 is severely cognitively impaired with a BIMS of 3. R12's care plan, dated 4/13/2026, documents R12 has impaired cognitive function related to dementia.On 7/23/2026 at 8:56AM, V1, Administrator, stated she would expect the facility to follow the abuse policy.The facility ABUSE, PREVENTION AND PROHIBITION POLICY, dated 11/25, documents each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The policy documents the facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The residents must not be subjected to abuse by anyone. The policy documents the resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse; corporal punishment and involuntary seclusion. Prior to the survey date of 7/20/2026, the Facility took the following steps to correct the non-compliance: 1. staff education regarding the abuse policy, with emphasis on separating residents involved and initiating supervision to avoid further concerns.2. Monitoring for compliance; the administrator and/or designee will conduct 5 audits weekly for 60 days regarding the abuse policy, with emphasis on separating resident involved and initiating supervision to avoid further concerns. Monitoring for compliance: The administrator/and or designee will conduct 5 audits weekly for 60 days to avoid further concerns, The DON and/or designee will review documentation during the QA clinical meeting regarding change in conditions and/or behaviors. any concerns will be addressed immediately during the QAPI.The facility documents dated of compliance as 5/5/2026. The facility in-service record dated 5/5/2026 documents all staff re-trained. Records document audits were completed as ordered.The Facility's Past-Noncompliance was confirmed through interviews with V1,V22, V23. and V24. Review of in-service sign in sheets, and review of all Facility audits.

Based on interview and record review, the facility failed to prevent theft from occurring for 2 of 3 residents (R4, R5); reviewed for Misappropriation in a sample of 17. This Past Non-Compliance occurred from 6/15/26 through 6/25/26.Findings include: 1. R4's Facesheet, with a print date of 7/20/26, documented he was admitted to the facility on [DATE] with diagnosis of, in part, Alzheimer's disease, heart failure, and cirrhosis of the liver.R4's Minimum Data Set (MDS), dated [DATE], documented he was cognitively intact.R4's Care Plan, dated 5/27/25, documented he had impaired cognitive function/dementia or impaired thought processes dementia with an intervention added on 6/20/26 that he was offered a lock box for cards and money and educated on resident trust account.R4's Bank Letter, dated 7/6/26, documented, Based on the facts of the investigation for transaction(s) listed immediately below, it was determined that the claims are valid. As of July 6, 2026, the claims listed in the table directly below are considered closed and the provisional credit you received in the amount of $44.68 is permanently credited to your account. (R4) was interviewed and stated, I can't find my debit card. I thought I had it at the snack machine yesterday. Room search complete with resident approval and unable to locate card. Guardian was notified and activity checked on the card. There were two unauthorized transactions noted on his card. Smoke shop for $30.44 and ice cream shop in surrounding town $14.24. Guardian had the card put on hold. it is believed V26 (CNA/certified nursing assistant) took R4's card and made purchases.On 7/20/26 at 9:38 AM, R4 stated he had an issue a while back with one of his cards and the facility took it from him as requested by his son to do. R4 stated his son told him that there were two unauthorized charges made on the card and had the card canceled but does not know what happened after that; his son has full control over all his finances and care.2. R5's Facesheet, with a print date of 6/16/26, documented she was admitted to the facility on [DATE] with diagnosis of, in part, chronic respiratory failure, type two diabetes mellitus, and hypertension.R5's Care Plan, dated 5/30/25, documented she had a potential for psychosocial well-being problem with interventions of, in part, educating her on resident trust accounts and encouragement to use lock box for personal belongings and items dated 6/23/26.R5's State Report, dated 6/16/26, documented she was cognitively intact. R5's State Report continued to document the police were able to contact businesses and obtain security footage that revealed V26 using R5's debit card to make purchases. It was believed that the same staff member took the R5's cash as well. The police spoke to V26 regarding the allegations, and he admitted to taking the card and money. V26 had worked at the facility for only one day and on one hall.On 7/20/26 at 10:01 AM, R5 stated one of her cards got stolen a while back. R5 stated she reported it missing to one of the CNAs and they immediately started investigating. R5 stated a cop came in and followed up on everything and mentioned they think an agency CNA was responsible for it. R5 stated she's pretty sure charges were made. R5 stated V10 (SSD/Social Services Director) was very helpful, including V1 (Administrator) in following up on everything and tracking the charges. R5 stated they did end up finding a few different charges that were unauthorized, and we contacted the bank to have it canceled. R5 stated, The facility paid me back.On 7/23/26 at 1:40 PM, V10 (Social Services Director/SSD) stated she was notified R5's money and card were missing so she immediately started working with V1, V2, and V18 on figuring out what had happened. V25 stated they reported to the police everything they found. V25 stated they were able to pretty much figure out who would have been the likely person responsible by going through the schedule and location of the charges being placed to the agency CNA who had worked on R5 and R4's hall. V25 stated the money was refunded to both R4 and R5 she believes. V25 stated now they provide lock boxes for all the residents and have not had any further concerns.On 7/23/26 at 1:46 PM, V18 (Assistant Director of Nursing/ADON) stated when she came in they had already been looking into R4's theft. V18 stated she started looking at the schedule and looked up where the agency CNA was from, then correlated the location of the transactions to him. V18 stated they reported all their findings to law enforcement and were able to track the person down pretty fast. V18 stated the money was reimbursed to her knowledge. V18 stated now they have lock boxes for the residents and spoke with all of them as an extra safety measure and have had no concerns since. On 7/22/26 at 2:20 PM, V1 stated she expects staff to do what is right (referring to abuse). V1 stated they banned the CNA from all the facility's buildings. V1 stated, We have started offering lock boxes and safe access for all new admissions and to all the residents now. V1 stated she did in-serving on the abuse policy. V1 stated they have had no further concerns with theft.The facility's Abuse, Prevention and Prohibition Policy, dated 11/2025, documented the facility prohibits misappropriation of resident property.Prior to the survey date of 7/20/26, the facility took the following steps to correct the non-compliance:IMMEDIATE ACTION TAKEN: Social Service and Administrator notified immediately. Called the banks to see if the card had been used. Police Department was notified of the incident. Investigation initiated Both cards are cancelled and will be reissued by the bank. Both residents offered a lock box for their cards and/cash. Administrator completed education with staff on misappropriation of funds (abuse). An AD HOC was completed. The medical director was made aware. V26 was made a do not return from the facility and shift key notified of the incident.Staff were educated regarding the abuse policy with the focus on misappropriationof resident property. All residents with cards/ or cash offered a lock box and educated on resident trustfunds. The administrator or designee to be conducting weekly audits for 30 days to ensure theresidents' cards are kept secure.The Facility's Past-Noncompliance was confirmed through interviews with V1, V2, V10 and V18, review of in-service sign in sheets, and review of all facility audits.

Based on interview, observation, and record review, the facility failed to provide timely and accurate wound care for 2 of 3 residents (R6, R11); reviewed for quality of care in a sample of 17. Findings include:1. R6's Facesheet, with a print date of 7/22/26, documented he was admitted to the facility on [DATE] with diagnosis of in part, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following unspecified cerebrovascular disease, and type two diabetes mellitus with other circulatory complications and foot ulcer. R6's Minimum Data Set (MDS), dated [DATE], documented he was moderately cognitively impaired.R6's Care Plan, revised on 7/16/26, documented he had an actual impairment to skin integrity with interventions of, in part, to complete treatments as ordered by physician, dated 5/13/26, keep cushion at end of bed to keep feet off of foot board, dated 5/13/26, wear heel protectors on both feet at all times as tolerated, dated 4/8/26.R6's Skin and Wound note, dated 3/4/26, documented left plantar surface wound larger and appears to have more moisture. The note continued to document V12 (Wound Nurse Practitioner/NP) recommended a wound culture of R6's left plantar foot wound.R6's Skin and Wound note, dated 3/11/26, documented V12 was awaiting culture of left plantar surface wound.R6's Skin and wound note, dated 3/18/26, documented V12 made recommendations to pad his foot board so he is not getting pressure on the bottom of his foot while in bed. The note continued to document V12 was still awaiting orders from PCP (primary care provider) for culture.R6's Skin and Wound note, dated 3/25/26, documented his culture will be obtained today and that R6 needs his footboard padded.R6's Skin and Wound note, dated 4/3/26, documented his left foot wound had ESBL (extended spectrum beta lactamase) and was on Bactrim. The note continued to document R6's footboard was padded now.R6's L Foot (left foot) Culture Results, dated 3/30/26, documented a collection date of 3/26/26 and a resulted date of 3/29/26 with confirmation the wound was positive for E. Coli ESBL (Escherichia coli Extended Spectrum Beta Lactamase) and Staphylococcus (staph) Aureus.R6's Active Orders, with a start date of 7/11/26, documented cleanse open area to right lateral foot with wound cleanser, apply collagen powder and calcium alginate with silver and cover with border gauze dressing daily and PRN (as needed).On 7/20/26 at 2:30 PM, R6's right lateral foot wound care was completed by V8 (wound nurse). V8 cleansed R6's right lateral foot wound with wound cleanser and dressed it with calcium alginate with silver and bordered gauze but did not apply collagen power. V8 stated she is not sure if R6 has any infections because hospice does not continue to test. R6's feet were pressed up against the foot board with no padding. V8 stated, That is the long bed hospice got for R6, they had one for him with padded cushion on the foot board for him, but the padding wouldn't fit with the hospice bed. V8 stated they added the cushion shortly after R6 developed the wounds on his feet. V8 stated R6's foot wounds have been deemed arterial from diabetes.On 7/22/26 at 11:35 AM, V8 (wound nurse) stated R6's wound care orders must have been changed and she didn't notice he was supposed to get collagen powder also. V8 stated wound care is expected to be completed as ordered.On 7/22/26 at 9:34 AM, V12 (Wound NP/nurse practitioner) stated she had recommended a culture of R6's wound back in March because she had concerns it was infected. V12 stated a culture is important to obtain to treat infection with the correct antibiotic. V12 stated the culture was not obtained until 3/25/26. V12 stated she does not know when R6 started antibiotics but on her 4/3/26 appointment he was on Bactrim. V12 stated she does not make orders for the facility, she only makes recommendations, and the PCP (primary care provider) has to put orders in place. V12 stated there was a delay in obtaining R6's culture which had the potential to let the infection worsen and spread to other tissue and bone. V12 stated R6's culture showed E.coli ESBL and that does not originate in the wound that she is aware of. V12 stated she never confirmed the x-ray results ordered to rule out osteomyelitis of R6's wound herself but confirmed with V8 (wound LPN) there was no osteomyelitis found. V12 stated if her recommendations are not being followed, she could take her concerns to the DON (Director of Nursing) but did not. V12 stated R6 was a tall guy, and she noticed his feet pressed up against the foot board of his bed she was concerned with and recommended cushion to be placed on it. V12 stated she would expect her recommendations to be completed within a week with concerns for his wounds.2. R11's Facesheet, with a print date of 7/22/26, documented she was admitted to the facility on [DATE] with diagnosis of, in part, unspecified convulsions, type two diabetes mellitus with other circulatory complications, and type two diabetes mellitus with diabetic neuropathy.R11's MDS, dated [DATE], documented she was cognitively intact.R11's Care Plan, initiated on 4/25/25, documented she had actual impairment to skin integrity with interventions of, in part, for staff to administer treatments as ordered and monitor for effectiveness dated 5/1/25. R11's Care Plan, initiated on 7/13/26, documented she had an infection of (staph) to wound of right heel with interventions added on 7/20/26 for doctor to follow wound care and give antibiotics as ordered by doctor.R11's Orders, dated 7/20/26, documented to apply antifungal powder under bilateral breasts until Verbal Miconazole powder comes from pharmacy every day and night shift for Wound.R11's Culture, dated 7/13/26, documented R11's right heel wound had proteus mirabilis and staphylococcus aureus.V17's Follow Up note, dated 6/18/26, documented she was seen after nursing alerted of concerns regarding findings of a new heel wound and increased pain to her right foot. Wound care nurse notified, and new orders were entered for right foot/heel x-rays and to start Doxycycline twice daily for 7 days due to history of diabetes, foot wounds, and amputation. The note continued to document new orders were entered for right foot/heel imaging to rule out possible osteomyelitis and wound care nurse was also made aware.V17's Follow Up note, dated 7/13/26, documented R11 reports concerns related to right heel wound and it possibly worsening. The note continued to document R11 reports that the dressing is not being changed daily, especially over the weekend. Treatment/dressing orders are in place for daily and PRN (as needed). R11 also reports that on one occasion only the dressing was changed, and the wound was not cleansed as ordered. Spoke with nursing regarding dressing changes and wound appearance. It was reported that when she had last changed the dressing and observed the wound, she felt it was similar in appearance with less drainage and minimal odor. It was mentioned, however, that the wound was observed after R11 had received her shower. A wound culture was already obtained, resulted today showing growth of heavy proteus Mirabilis and scant staphylococcus aureus. New order entered for Rocephin 2gm (gram) IV (intravenous) every 24 hours for 7 days.R11's June 2026 Treatment Administration Record (TAR) documented wound care for her right heel was not signed off as completed on 6/27/26 and 6/29/26.R11's July TAR documented she did not get wound care to her right heel signed off as completed on 7/1/26, 7/4/26, 7/8/26, 7/9/26, the evening of 7/18/26, or the mornings of 7/21/26 and 7/22/26. It continued to document R11 had no active wound care orders in place on 7/7/26 and did not get care signed off on that day.On 7/20/26 at 11:34 AM, R11's wound care was completed by V8 (wound nurse). V8 stated R11 has staph in her heel and is on contact isolation for that. V8 stated she could not find R11's powder to put under her breasts, if she can't find it in the cart she will have to reorder it. V8 stated she will have to wait on doing wound care to R11's breast right now since she can't find the powder. V8 stated she keeps meaning to get her wound cart organized better but it's a mess. At 11:36 AM, V8 stated she could not find R11's powder, still looking. R11 stated the staff don't always wear their gowns and gloves when providing care and the staff sometimes forget to do her wound care.On 7/21/26 at 1:17 PM, R11 stated she never refuses care but there has been some days they have not done her wound care. R11 stated, Am I supposed to let them know and responsible for reminding them?On 7/22/26 at 11:35 AM, V8 stated the staff nurses are supposed to be providing wound care on residents she is not seeing or when she is not here. V8 stated she expects wound care not to be missed. V8 stated she expects wound care to be completed especially on an infected wound and to be completed as ordered. V8 stated if wound care is missed and not done as ordered, a wound has the potential to worsen.On 7/22/26 at 1:25 PM, V2, DON (Director of Nursing), stated if a medication or treatment was not signed off, that would mean it was not completed, or she would need to speak with the nurse to find out why. V2 stated she expects wound care to be completed as ordered. V2 stated she would expect recommendations to be followed up on timely.On 7/22/26 at 11:53 AM, V17 (NP) stated cultures are ordered on wounds when there are complaints of drainage and worsening appearance of the wound. V17 stated cultures are important to obtain for proper antibiotics because the wrong antibiotic likely won't help the infection. V17 stated she did not order a culture for R11 back on 6/18/26 because the appearance of the wound did not look concerning but preventative antibiotics ordered because of her medical history. V17 stated she did talk to the nurse assigned to R11 that day (7/13/26) and the wound nurse about the wound care concerns mentioned to her by R11. V17 stated on 7/13/26 R11's wound culture showed heavy amounts of staph/MRSA (methicillin resistant staphylococcus aureus). V17 stated she was not aware of how many wound treatments R11 missed. V17 stated R11's missed wound care could have worsened the condition of her wound. V17 stated it is expected that staff are completing the wound care as ordered.On 7/22/26 at 2:20 PM, V1, Administrator, stated she expects the nurses to be following wound care orders as written and medications to be administered as ordered. V1 stated she would expect the wound NP (Nurse Practitioner) recommendations to be followed timely. V1 stated she was unaware V12 was not making orders and expects her to be.The facility's Skin Identification, Evaluation, and Monitory Policy, dated 2/2026, documented treatment to be applied/initiated per health care provider order in the medical record. The policy continued to document a skin integrity treatment program for staff to eliminate or reduce other sources of injury by evaluating the cause and providing interventions and managing or reducing the risk of infections.The facility's Infection Control Policy documented surveillance with review of microbiology culture and sensitivity reports should be done on a regular basis to identify types of organisms causing infections and monitoring of antibiotic use to help determine if appropriate.

Based on interview and record review, the facility failed to administer intravenous antibiotics to treat osteomyelitis in 1 of 3 residents (R7) reviewed for Medication Errors in a sample of 17.Findings include:R7's Facesheet, with a print date of 7/22/26, documented she was admitted to the facility on [DATE] with diagnosis of, in part, type two diabetes mellitus with foot ulcer, complete traumatic amputation of one unspecified lesser toe, and osteomyelitis.R7's Minimum Data Set (MDS), dated [DATE], documented she was cognitively intact.R7's Care Plan, initiated on 7/20/26, documented R7 is on IV (intravenous) medications/antibiotics related to Osteomyelitis with interventions for staff to administer medications as ordered by doctor.R7's Orders started on 7/9/26 documented Cefepime HCl Intravenous Solution 2 GM (gram)/100ML (milliliters), Use 2 gram intravenously every 12 hours related to osteomyelitis until 7/29/26.R7's July Medication Administration Record (MAR) documented on 7/20/26 for her 9:00 PM dose of Cefepime HCL a number 6 indicating to see progress notes on administration for the medication.R7's Progress Noted, dated 7/20/26 at 9:13 PM, documented there was no RN (Registered Nurse) to administer R7's Cefepime HCl intravenously.On 7/22/26 at 8:55 AM, R7 stated they need more night shift RNs (Registered Nurses) the other night she missed her IV antibiotics because there was no RN working.On 7/22/26 at 12:06 PM, V17 (NP/Nurse Practitioner) stated IV antibiotics for osteomyelitis are important to get. V17 stated she was not made aware that R7 missed a dose of her IV antibiotic the other night because there was no RN on duty.On 7/22/26 at 2:20 PM, V1 (Administrator) stated she expects the nurses to be following wound care orders as written and medications to be administered as ordered. V1 stated R7 missed her IV antibiotic a couple nights ago because there was no RN working.The facility's Physician Orders policy, dated 7/2025, documented drugs will be administered upon a clean, complete and signed order of a person lawfully authorized to prescribe.

Based on interview, observation, and record review, the facility failed to perform hand hygiene and follow Enhanced Barrier Precautions (EBP) for 3 of 6 residents (R15, R16, R13); reviewed for Infection Control in a sample of 17.Findings include: 1.R15's Facesheet, with a print date of 7/22/26, documented she was admitted to the facility on [DATE]. On 7/22/26 at 8:50 AM, V15 (Licensed Practical Nurse/LPN) administered R15's Insulin injection to her right up extremity without gloves or gown in place. R15's door has EBP sign. 2. R16's Facesheet, with a print date of 6/22/26, documented she was admitted to the facility on [DATE]. On 7/22/26 at 9:00 AM, V16 (pulmonary LPN) was completing pulmonary care with R16 at her bedside. V16 did not complete hand hygiene after leaving R16's room. On 7/22/26 at 12:06 PM, V17 (NP/Nurse Pracitioner) stated she expects EBP to be followed to prevent the spread of infections. On 7/22/26 at 1:23 PM, V16 (pulmonary LPN) stated, If EBP is on the door you are supposed to follow precautions with gown and gloves when providing high contact care as listed. V16 stated she's not sure exactly who is on EBP, when referring to R14 or R15. On 7/22/26 at 11:32 AM, V18 (Infection Preventionist) stated EBP is put in place to prevent further infections for residents, and she expects the staff to be maintaining it. On 7/22/26 at 1:25 PM, V2, Director of Nursing, stated she is not sure who is on EBP, when referring to R14 and R15, after reviewing their charts. Minutes later V2 stated R15 should be on EBP due to her blood glucose monitoring device. On 7/22/26 at 2:20 PM, V1, Administrator stated she noticed they have in-servicing to do on infection control measures. 3 On 7/22/2026 at 9:16AM, R13 observed in bathroom in his room with gait belt around his waist and walker in front of him. R13 assisted to stand by V11, Physical Therapy Assistant (PTA). V11 did not have a gown on, but did have gloves on. V11 instructed R13 to finish pulling up his pants. V11 then assisted R13 with gait belt and walker to the hallway. V11 removed gloves but did not sanitize hands after removing gloves. There is a sign posted on the outside door of R13's room, Enhanced Barrier Precautions. R13's physician orders sheet (POS), dated 6/23/2026, documents Enhanced Barrier Precautions: ostomy every shift. R13's care plan, dated 6/12/202,6 documents R13 has an ostomy related to volvulus. On 7/22/2026 at 11:07AM, V11, PTA, stated a gown and gloves are to be worn when transferring a resident or assisting with toileting. V11 stated hands are to be washed prior to exiting room. The Center for Disease Control (CDC)Enhanced Barrier Precautions, undated documents Stop; enhanced Barrier Precautions Everyone Must: clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities; Transferring, changing briefs or assisting with toileting.

Based on interview and record review, the Facility failed to prevent physical abuse in 4 of 4 residents (R1, R4, R5, R7) reviewed for abuse in the sample of 7. This past non-compliance occurred from 1/24/26 to 2/27/26. Findings include: 1.R1's Face Sheet documents R1 was admitted to the facility on [DATE], with diagnoses including Klinefelter Syndrome and intellectual disabilities. R1's Minimum Data Set (MDS), dated [DATE], documented R1 was moderately cognitively impaired, had no behaviors, and ambulated via wheelchair. R1's Care Plan, initiated 12/1/25, documents R1 has a behavior problem related to depression. R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including bipolar disorder. R3's MDS, dated [DATE], documented R3 was cognitively intact and ambulated via wheelchair. R3's Care Plan, initiated 9/30/25, documents R3 exhibits aggression characterized by cursing, yelling, threatening, and use of inappropriate language when frustrated or triggered. R1's Progress Note, dated 2/15/26, documents R1 made an accusation that another resident hit him on the right cheek. R1's Undated Statement obtained by V2, Director of Nursing (DON), documents, I went to check on my friend and she hit me in the face and chest 3 times (pointing at center of chest). I took my tootsie rolls back from her. She go her way - I will go my way. On 3/11/26 at 9:50 AM, R1 pointed to his right cheek and chest and stated R3 hit him on the face and the chest in the dining room. He stated he did not know why she did it because he did not do anything wrong. He stated does not feel afraid of R3 but tries to stay away from her. R1's 2/15/26 Resident to Resident Physical Aggression Received documents R1 had a face injury with slight redness to right cheek. R1's 2/15/26 Skin Check documents a new issue on R1's cheek. R1's Progress Note, dated 2/15/26 at 2:40 PM, documents R1 complained of pain to right cheek, and Tylenol was provided. The Facility's Final Report sent to IDPH (Illinois Department of Public Health) on 2/17/26 documents R1 stated he was talking with R3 when she smacked him on the cheek and chest with the back of her hand. There were no witnesses. R1 stated they are friends, but he needs to stay away from her for a little while. Licensed staff assessed R1 and noted a red area on his cheek. R1 and R3 were encouraged to remain in different areas of the dining room. 2. R4's Face Sheet documents R4 was admitted to the facility on [DATE], with diagnoses including dementia and bipolar disorder. R4's Minimum Data Set (MDS), dated [DATE], documented R4 was moderately cognitively impaired and required partial assistance with bed mobility and transfer. R4's Care Plan, initiated 1/12/26, documents R4 has a behavior problem related to anxiety. R4's Progress Note, dated 2/16/26, documents R4 and another resident got into an altercation where both residents were yelling and slapping each other. R5's Face Sheet documents R5 was admitted to the facility on [DATE], with diagnoses including dementia with behavioral disturbance. R5's MDS, dated [DATE], documented R5 was severely cognitively impaired, had physical symptoms directed toward others routinely, and required supervision with mobility. R5's Care Plan, initiated 12/23/25, documents R5 has a behavior problem. R5's Progress Note, dated 2/16/26 at 5:51 PM, documents R5 was in an altercation with another resident. The Facility's Initial Report sent to IDPH on 2/16/26 documents there was a physical altercation between R4 and R5. R4's Undated Statement obtained by V1, Administrator, documents the question, Can you tell me what happened between you and (R5)? R4's response was, Yes, we were in the dining area and she began yelling and talking bad to me. She grabbed my arm and tried to choke me. The staff stepped in and separated us. On 3/11/26 at 3:12 PM, R4 was lying in bed in her room. She stated R5 previously grabbed her around the neck and arms and was always causing problems on the unit. V7's (Certified Nursing Assistant) Written Statement, dated 2/16/26, documents, I was cleaning up dining room counter when I heard both residents arguing then I heard hitting I ran to both of them they instantly broke it up. I am unsure of who hit first. I did see both hitting at same time hands making contact to one another. On 3/11/26 at 2:54 PM, V7, Certified Nursing Assistant (CNA), stated she heard yelling, then went around the corner and saw R5 hitting R4 with her fist and R4 slapping R5. R4's SBAR Communication Form and Progress Note, dated 2/16/26, documents R4 got into an altercation with another resident where both residents were yelling and slapping each other. The Facility's Final Report sent to IDPH on 2/16/26 documents there was a physical altercation between R4 and R5 in the dining room at approximately 5:45 PM on 2/16/26. Staff reported they heard arguing and before they could reach the residents they both hit each other's hands. 3. R6's Face Sheet documents R6 was admitted to the facility on [DATE], with diagnoses including vascular dementia. R6's MDS, dated [DATE], documented R6 was severely cognitively impaired and ambulated via wheelchair. R6's Care Plan, initiated 1/19/26, documents R6 has a behavioral problem. R6's Progress Note by V15, Registered Nurse (RN), dated 1/24/26 at 7:30 PM documents V8, CNA, notified V15 of a resident to resident altercation witnessed by V8. R6 was moving down the hall in his wheelchair when his wheel became stuck on another resident's chair. Per V8, R6 was verbally aggressive toward other resident, and when he could not move his chair, he struck resident on the left arm with the back of his closed fist. On 3/12/26 at 1:05 PM, V15 was unavailable for interview. V8's Written Statement regarding 1/24/26 incident documents V8 walked out of a different resident's room and saw R5 sleeping in her wheelchair. R6's wheel was on one of R5's wheels. V8 went down to fix it when R6's closed fist punched R5's arm. On 3/11/26 at 2:36 PM, V8 stated she went to help another resident to bed and when she came out R5 and R6's wheelchairs collided. Before she could get over to help them, R6 hit R5 on her right arm with the back of his hand. The Facility's Final Report sent to IDPH on 1/28/26 documents staff exited another resident's room and observed R5 and R6's wheelchairs caught together while propelling themselves in the hall. R6 was attempting to release self, became agitated, and swung his arm, hitting R5 in the face. 4.R7's Face Sheet documents R7 was admitted to the facility on [DATE] with diagnoses including vascular dementia. R7's MDS, dated [DATE], documented R7 was severely cognitively impaired, required supervision with rolling from side to side, and required partial assistance with transfer. R7's Care Plan, dated 7/30/25, documents R7 has the potential for aggression related to dementia diagnosis. R7's Progress Note, dated 1/25/26 at 11:24 AM, documents R7 was in the hallway when another resident came up and hit her. V10, CNA, provided a written statement, dated 1/25/26, which documents she was in a resident's room and heard yelling. V10 walked into the hall and saw R5 and R7 hitting each other on the arms and chest with open hands. On 3/12/26 at 9:00 AM, V10 stated she remembers R5 and R7 slapping each other on the hands and yelling. V9, Activity Concierge, provided a written statement, dated 1/25/26, documenting V9 was in a resident room when she heard R5 and R7 yelling. She went out to the hall and saw them hitting each other on the face and chest and calling each other names. On 3/12/25 at 9:08 AM, V9 stated she remembers R5 and R7 whacking each other and had to separate them. Staff always tried to keep R5 distanced from other residents. The Facility's Final Report sent to IDPH on 1/28/26 documents staff were assisting another resident when they saw R5 and R7 slapped each other. On 3/12/26 at 1:20 PM, V1, Administrator, stated she expects the Facility to follow its abuse policy. The Facility's Abuse, Prevention and Prohibition Policy, dated 11/2025, documents each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The deficient practice that began on 1/24/26 was corrected/removed on 2/27/26 after the facility took the following actions to correct the noncompliance prior to the start of the current survey: 1-Abuse education was completed, focusing on identifying behaviors and defusing altercations before they happen. Staff will not work until education is completed. 2-Ad Hoc meeting was held with IDT (Interdisciplinary Team). The Medical Director was notified of the past-noncompliance and the plan to address. 3-The initial reports were submitted to IDPH. 4-Investigations were initiated. 5-All parties were notified of the incidents. 6-Final reports were submitted to IDPH. 7-IDT reviewed and updated care plans. 8-All residents have the potential to be affected. 9-The DON and/or designee will monitor staff understanding of abuse and how to identify behaviors and defuse altercations before they happen three times a week for 30 days. 10-Behavior tracking will be monitored during the clinical QA (Quality Assurance) meeting and if any areas of concern are identified, they will be addressed immediately. Compliance date: 2/27/26

Based on observation, record review, and interview, facility failed to ensure sufficient nursing staff to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. This failure has the potential to affect all 85 residents residing in the facility.Findings include:The Resident Council Minutes, dated 11/05/25, documents the facility needs to hire more night staff.The facility's Daily Staffing Sheet dated December 27, 2025, documents V21, Registered Nurse, as the only nurse working facility on midnight shift.On 1/22/2026 at 11:03 AM, R3 stated the facility has problems with staffing and need to hire more staff. R3 stated it takes a long time to answer the call light.R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact.On 1/22/2026 at 11:08 AM, R5 stated, The facility does not have any staff and it's worse on nights. Takes forever to get light answered.R5's MDS, dated [DATE], documents R5 is cognitively intact.On 1/22/2026 at 11:06 AM, R6 stated they need more staff. R6 stated the staff will tell them they are short, and it takes a long time to get care.R6's MDS, dated [DATE], documents R6 is cognitively intact.On 1/28/2026 at 9:24 AM, V22, Staff Coordinator/Scheduler, stated V22 does the schedules for both the Certified Nurse Assistants (CNAs) and Nurses. V22 stated she schedules for the census. V22 stated 4 nurses on days, 3 to 4 on evenings, and 2 on midnights. V22 stated they have had some staffing issues and she and the Assistant Director of Nursing cover when there are call offs. V22 stated on 12/27/2025, she received a call from the evening nurse saying her relief was not at the building. V22 stated she informed the nurse she needed to stay. V22 stated she was informed no. V22 stated she tried offering bonuses and nothing. V22 stated she did not have a nurse to go in, and she is a CNA and cannot perform nurse duties. V22 stated for the census and level of care, there should have been 2 nurses on shift.On 1/28/2026 at 10:48 AM, V20, (CNA), stated V21 was the only nurse in the building for the entire night shift.On 1/28/2026 at 2:09 PM, V21 stated he was the only nurse for the entire building from around 11 PM. V21 stated the evening nurse said she was leaving. V21 stated at that time, he refused to over the hall because he was the only nurse. V21 stated he informed the nurse to call and find out where was the relief. V21 stated he was informed the facility staff was not responding, and the nurse left. V21 stated he made attempts to contact management, and no one answered. V21 stated he left messages and no response. V21 stated the night was challenging; he had residents with changes of conditions requiring hospitalization and no help. V21 stated he called to notify of resident being transferred out and no response. V21 stated no one came.On 1/28/2026 at 2:30 PM, R13 stated staffing is bad and slow. R13 stated the facility uses a lot of agency staff, and they may or may not show up, leaving the residents without care or poor care. R13 stated they need more of their own staff.R13's MDS, dated [DATE], documents R13 is cognitively intact.On 1/28/2025 at 2:39 PM, V2, Director of Nursing, stated the facility does not have a staffing policy.On 1/28/2026 at 2:40 PM, V1, Administrator, stated the facility follows the CMS regulations.On 1/21/2026, the facility provided a Midnight Census report documenting 80 residents residing in facility.

Based on observation, interview, and record review, the facility failed to properly store controlled medication and discard expired medication for 7 of 7 (R1, R2, R3, R4, R5, R6, R7) residents reviewed for medication storage in a sample of 13.Findings include:On 1/21/2026 at 9:28 AM, the facility Medication room was inspected. Upon entrance to the medication room, the refrigerator was unlocked. The unlocked refrigerator located in the medication contained:*R1's bottle of oral Lorazepam Concentrated solution.On 1/21/2025 at 9:34 AM, the 300 Hall medication cart was inspected. The medication cart contained the following:*R2's open and partially used Insulin Glargine Solution vial. 1/5 was handwritten on the vial. The expiration date November 2025.On 1/21/2025 at 9:44 AM, V4, Registered Nurse (RN), stated the handwritten date was the date it was opened, 1/5/26. V4 verified the vial was open, in use, and expired November 2025.On 1/21/2026 at 9:50 AM, the 200 Hall medication cart was inspected. The lock box was unlocked and able to be opened by lifting the lid with a finger. The open and unlocked lock box contained the following:*1 open and partially used bottle with 19.25 ml of R1's Morphine Sulfate Oral Solution and 1 unopen bottle with 30 mls of R1's Morphine Sulfate Oral Solution.*1 open and partially used bottle with 1.5 ml of R1's Lorazepam Concentrated solution.* 1 card with 14 of R3's Oxycodone 5mg/325 mg tablets.*1 card with 20 of R3's Hydrocodone/APAP 5mg/325mg tablets.* 1 card with 14 of R4's Alprazolam 0.25mg tablets.* 1 card with 25 of R5's Hydrocodone/APAP 7.5mg/325mg tablets.*1 card with 6 of R6's Tramadol 500mg HCL tablets.* 1 card with 30 of R6's Tramadol HCL 500 mg tablets.*1 card with 8 of R7's Lorazepam 0.5mg tablets.On 1/21/2026 at 9:51 AM, V5, Licensed Practical Nurse, LPN, stated at times, the lock gets stuck and doesn't latch. V5 performed a count of the narcotics and verified R1's medication was open and partially used; R3's, R4's, R5's, R6's, and R7's medication was in the unlocked lock box and in use.On 1/22/2026 at 9:35 AM, V9, LPN, stated all narcotics and controlled are under a double locked system. V9 stated the controlled medication in the refrigerator would be under a double locked system. The medication room is locked, and the refrigerator is locked as well. V9 stated the medication cart is the same. V9 stated the controlled medication is stored in a locked drawer, and when not in use, the cart is locked. This creates the double locked system. V9 stated insulins expiration dates are on the vial or pen. V9 stated this date is checked prior to opening. If the medication is expired, it would not be used and discarded. The facility's Storage and Return of Drugs policy, dated 4/21, documents A. Drug supplies for the facility shall be stored under proper conditions, sanitation, temperature, light, refrigeration, and moisture. B. Residents' medications shall be properly labeled and stored at or near the nurse's station in a locked cabinet, a locked medication room, or in one or more locked mobile medication carts of satisfactory design for such storage. All mobile medication carts shall be under the visual control of the responsible nurse at all times when not stored either in a locked room or otherwise made immobile. D. Biologicals or medications requiring refrigeration shall be kept in a separate securely fastened box within a refrigerator, locked refrigerator, or in a refrigerator within a locked room. Such refrigerator shall contain a thermometer to ensure proper temperature for medication storage. Refrigerators used for medication storage should not be used for personal storage of food/drinks. E. Multi-dose vials and pens shall be stored and dated per the manufacturers guidance.The facility's Schedule II Drugs policy, dated 4/21, documents D. Schedule II controlled substances shall be stored in such manner so that two (2) separate locks, using two (2) different keys, must be unlocked to obtain these substances. This may be accomplished by using a locked cabinet within a locked room.

Based on observation, interview, and record review, the facility failed to prevent abuse from occurring and failed to document progressive interventions for 3 of 3 residents (R3, R7, R9) reviewed for abuse in the sample of 10. These failures resulted in R3 having R4's hands around her neck aggressively, R7 being hit in head by R4 and also being pushed down in chest by R4 while in bed, and R9 being slapped by R4. Using a reasonable person concept, R3, R7, and R9 would experience discomfort/pain and feelings of being scared, unsafe, shame, and humiliation. Findings include: R4's face sheet documents an admission date of 1/6/2025. Diagnoses include Vascular Dementia, Peripheral Vascular Disease, Chronic Atrial Fibrillation, and Cerebral Infarction. R4's Minimum Data Set (MDS), dated [DATE], documents R4 is severely cognitively impaired. R4 is independent with walking. R4's care plan, updated 8/6/2025, documents R4 has the potential to be aggressive related to dementia diagnosis. Interventions include approach/speak in a calm manner, divert attention, remove from situation ant take to alternative location as needed. Intervene as necessary to protect the rights and safety of others. Medication review will be done when appropriate, by psych Nurse Practitioner, NP. Transfer to inpatient psychiatric facility. R4 lives on a closely supervised unit. R4 on 1:1 observation. R4 will be redirected by offering activities or snack when agitation is noted. R4's care plan does not document abuse. R4's care plan does not include documentation of progressive interventions for incidents that occurred on 10/7/2025, 10/18/2025, 10/21/2025. 1.R3's face sheet documents admission date of 7/16/2024. Diagnosis include Alzheimer's Disease, Cerebrovascular Disease, Cerebrovascular Infarction, Heart Failure, Aphasia. R3's MDS, dated [DATE], documents R3 is severely cognitively impaired. R3's MDS dated [DATE] documents R3 requires moderate assist with walking.R3's care plan, updated 10/23/2025, documents R3 has been identified as being a vulnerable person related to her diagnosis of dementia. Interventions include frequent rounding by staff is provided to maintain safety and ensure resident needs are met. R3 resides on a closely supervised unit.Facility initial report, dated 10/14/2025, documents on 10/7/2025, it was reported R4 put her hands on R3's neck. The residents were immediately separated by staff and were placed on 1:1 monitoring. All parties were notified. An investigation initiated. Head to toe assessment completed with no injury to either resident. Neither resident can make a statement as to what happened. Staff were interviewed. Following the investigation into the incident, the staff responded appropriately to the incident. Staff placed R4 on 1:1 observation and sent to local hospital.On 10/30/2025 at 10:00AM, V19, CNA/Certified Nursing Assistant, stated, I was working on 10/7/2025 when R4 had an altercation with R3. I was walking with R4 back to her room for bed. When R4 and I walked into the room R4 looked at her roommate (R3), who was lying in bed, and said, 'Is that my grandmother?' I said, 'No that is not your grandmother'. R4 suddenly walked over to R3's bed, put her hands around R3's neck and began choking her. I immediately leaned across R3's body while at the same time taking R4's hands off R3's neck. When I got R4's hands released I took R4 out to the nurse working the hall and R4 was sent out to the hospital. I know R4 was on 1:1 observation for a while. I don't know for how long. No one was injured.2.R7's face sheet documents an admission date of 7/21/2025. Diagnoses include Dementia, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Atrial Fibrillation. R7's MDS, dated [DATE], documents R7 is severely cognitively impaired. R7's care plan indicates R7 has been identified as a vulnerable person. Interventions include R7 lives on a closely supervised unit.Facility's initial report, dated 10/18/2025, documents on 10/18/2025 at 5:45PM, R4 smacked R7 on the top of the head. Residents immediately separated. R4 was placed on a 1:1 observation for monitoring until R4 was sent to local hospital. Licensed nursing staff conducted a head-to-toe assessment with no injury noted. Investigation initiated. Neither resident able to make a statement regarding incident. On 10/30/2025 at 11:00AM, V21, Licensed Practical Nurse/LPN, stated, The incident on 10/18/2025 was between (R4) and (R7). We were in the dining room and (R4) had gotten up to leave. As (R4) was exiting the dining room she looked at (R7), who was sitting in her wheelchair. (R4) walked over and tap, tap, tapped (R7) on the head. (R7) turned around and grabbed (R4's) hands. They had their hands locked. I ran over and unlocked their hands and separated them. I called (V1, Administrator) and had (R4) sent out to the hospital. She came back a couple hours later and was put on 1:1 observation. When I work back there, I try to keep the medication cart in the center of the hallway so I can keep an eye on both ends of the hallway.Facility's initial investigation, dated 10/21/2025, documents on 10/21/2025 at approximately 1:30AM, it was reported to the administrator that R4 acted in an inappropriate manner to R7. R4 and R7 were immediately separated. R4 placed on 1:1 for monitoring until R4 sent to local hospital. R4 returned to facility and continued 1:1 monitoring until R4 transferred to psychiatric facility. On 10/30/2025 at 10:00AM, V19, CNA, stated, I was working on 10/21/2025 when (R4) had an altercation with (R7). I heard screaming in one of the rooms and ran into the room. (R4) had her hands on (R7's) chest pressing down on her chest. I immediately ran over to (R7) and laid my body over (R7) while removing (R4's) hands from (R7). I led (R4) out of the room and told the nurse what happened. (R7) said, 'I'm scared, I 'm scared.' I told her she was safe, and I would stand outside her door. I think (R4) was sent out and then was put on 1:1 observation again.3.R9's face sheet documents an admission date of 6/27/2025. Diagnoses include Chronic Obstructive Pulmonary Disease, Dementia, Type 2 Diabetes, and Epilepsy. R9's MDS, dated [DATE], documents R9 is severely cognitively impaired. R9's Care plan, dated 8/5/2025, documents R9 has been identified as being a vulnerable person related to the dementia diagnosis. Interventions include frequent rounding by staff is provided to maintain safety and ensure resident needs are met. Report any changes in resident condition/behaviors to physician following incident. R9 resides on a closely supervised unit. Trauma assessment completed.Facility's initial investigation, dated 10/28/2025, documents on 10/28/2025 at approximately 4:30AM, it was reported to the administrator R4 acted in an inappropriate manner to R9. R4 and R9 were immediately separated. Head to toe assessments completed with no injury noted. Investigation initiated. Notifications being made. Final report to follow.On 10/30/2025 at 1:00PM, V23, CNA, stated, On 10/28/2028, it was toward the end of shift, and we were doing our last round. R4 had been asleep all night and I heard screaming. I ran down the hall and found R4 in R9's room. R9 said She slapped me. Her roommate said Yes she (R4) slapped her (R9). We kept the residents separated and (R4) was put on a 1:1 supervision.On 10/29/2025 at 3:30PM, R4 lying in bed with eyes closed and audibly snoring. V10, CNA, sitting in room with R4. V10 stated, I've been here since 6:00AM and (R4) has been asleep all day.On 10/30/2025 at 8:00AM, R4 lying in bed with eyes open. R4 stated, I have to get up and finish this. V16, CNA, stated, I am here until 6:00PM. (R4) has been awake and ate her breakfast. On 10/30/2025 at 1:45PM, V1, Administrator, stated, I don't know what to do with (R4). Until we get her Power of Attorney (POA) situation straightened out we are at a standstill. Her husband is her POA, and he is divorcing her. He even blocked our calls. We are trying to get (R4's) POA changed to her daughter. The only answer until we can find (R4) new placement is to be on continuous one on one observations. I would expect progressive interventions to be updated and in the care plan. I expect the interventions to keep (R4) and the other residents safe. On 10/31/2025 at 11:15AM, V17, Nurse Practitioner, NP, stated, When I see (R4), she is usually pleasant or sleeping. I think some of her behaviors happen at night. I know (R4) has had a couple of urinary tract infections she was treated for. I think one on one observations help but I am not sure what the facility's policy is on when those are implemented and how staffing would be managed. Facility's abuse policy, with a revision date of 3/2025, states, This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. Annually, the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement.

Based on observation, interview, and record review, the facility failed to transfer 1 (R5) of 3 residents properly and failed to update a resident's care plan (R10) with progressive interventions to prevent future falls for 2 residents reviewed for accidents and falls in the sample of 3. These failures resulted in R5 having swelling and bruising to left ankle/lower leg and being diagnosed with an acute on chronic distal tibial fracture. Findings include: 1. R5's Care Plan documents at risk for falls r/t (related to deconditioning. Goals: the resident will be free from falls and injury through the review date. Intervention included utilize 2 assist for transfers dated 9/28/2025. R5's Quarterly Minimum Data Set (MDS), dated [DATE], documents R5 is alert. R5's Physician's Order Sheet (POS), dated 10/1/2025, documents resident requires assist of 2 for all transfers due to knee giving out without notice. R5's Health Status Note, dated 10/21/2025 at 8:13 AM, documents, Sending patient out to local ER (Emergency Room) after staff attempted to get resident up this morning and her Lt (left) ankle became twisted and caught up during transfer. lateral Lt ankle has an area of localized bruising and swelling along with a noted discoloration going up her leg above the ankle. she has a history of multiple fractures and hardware to her Lt ankle. needing stat imaging and evaluation.R5's Health Status Note, dated 10/21/2025 at 10:50 AM, documents, PT (Physical Therapy) staff informed RN (Registered Nurse) that patients left anterior lower extremity was swollen and bruised. NP (Nurse Practitioner) was in house and was notified to take a look, patient had a silver dollar sized bruise on the anterior shin/ankle, with redness and edema spreading around the bruise. Patient stated that she has broken that same leg/foot 3x and there is some hardware in there from past surgeries. Patient said when they were transferring/pivoting her feet gave out. NP assessed patient quickly and RN was given the order to sent patient to the ER for imaging evaluation. Patient was sent to the ER at approx 8:45am via EMS (Emergency Medical Services).R5's Health Status Note, dated 10/21/2025 at 10:54 AM, documents, the resident is experiencing a change in condition. See SBAR assessment for further information and family/physician The change in condition the resident is currently experiencing is Bruise and edema on left anterior ankle. NP gave orders to send patient to the ER.R5's Health Status Note, dated 10/21/2025 at 11:39 AM, documents, This RN spoke with (RN) at the ED at (local) area hospital regarding patient. A 2 view Xray of tib/fib (tibia/fibula) came back with findings of Medial tibial plateau fracture is present. There is intramedullary rod in the distal fib and tib, and indeterminate obliquely oriented fracture involving the distal tibial shaft. Patient is coming back splinted and 4mg of morphine was given at 8:45am from EMS. Patient has an appointment with Dr. [NAME] 8:45am. Administrator, ADON, Transport all made aware.R5's SBAR Communication Form and Progress Note, dated 10/21/2025, documents, situation: bruise and edema on left anterior ankle which started on 10/21/2025, symptoms worse when moving it and nothing makes it better. Other relevant information: patient was transferring/pivoting and legs gave out. Functional Status Changes: weakness. Nursing Note: NP gave orders to send patient to the ER (Emergency room.)R5's Emergency Medical Services (EMS) Run Sheet, dated 10/21/2025, documents they were called to the facility due to R5 fell and had an injury to her ankle. Left leg pain, swelling and tenderness documented and EMS staff administered 4 milligrams (mg) Morphine intravenous for pain. R5's ED (Emergency Department) Paperwork, dated 10/21/2025, documents, chief complaint: fall. History of Present Illness Narrative: patient presents after sustaining an injury yesterday in which her leg became caught in a wheelchair, resulting in pain and a fall. She reports pain localized to the distal third of the right (should be left) leg with associated swelling and bruising. X Ray imaging reveals an indeterminate fracture involving distal tibial shaft, raising concern for an acute fracture following the recent trauma. ED course: this patient sustained a traumatic injury resulting in pain, swelling and bruising localized to the distal third of the right (should be left) leg. This injury requires evaluation by orthopedics and may involve multiple management options depending on the final diagnosis and recommendations. The presence of swelling and bruising, along with the need for a specialist consultation, increases the complexity of the problem addressed beyond a simple, uncomplicated injury.R5's Health Status Note, dated 10/22/2025 at 7:38 AM, documents, Resident was sent to hospital to be eval. Resident has an appointment with ortho (orthopedics). Resident is a (mechanical lift) for all transfers at this time.On 10/29/2025 at 10:45 AM, V7, CNA (Certified Nurse Aide), and V8, CNA, entered R5's room to transfer her from recliner to bed. V7 and V8 used a mechanical lift to transfer R5 at that time. On 10/29/2025 at 11:50 AM, R5 sat in her recliner in her room. R5 was alert and stated when she injured her left foot, it was a freak accident because 1 staff member, V11 who is a CNA, transferred her from bed to wheelchair and her left foot got stuck behind the wheelchair wheel and started hurting immediately. R5 stated she doesn't want to get anyone in trouble, but V11 told her (R5) she knows she's supposed to be a 2 person transfer, but they were short staffed that morning and she had to get her up. R5 recalled she fell in the middle of the transfer back onto her bed and that was when her left foot got stuck in the wheelchair wheel. R5 stated V11 then got her to her wheelchair and left her in her room. R5 stated it wasn't until therapy staff (name unknown) came to get her for therapy that staff assessed her left ankle and stated it was bruised and swollen and she was transferred to the hospital shortly after. R5 stated she had a few fractures in her left leg in the past, and she hoped she didn't fracture it again. R5 stated she has to wear a boot for a while to keep her left foot/ankle from moving. R5 stated she wished V11 would have tried to find additional staff to transfer her because she isn't stable enough to be transferred by 1 staff, and that's why she fell and hurt her ankle. R5 had a boot on her left foot from her toes to her knee. On 10/29/2025 at 11:20 AM, V7, CNA, stated she wasn't working 10/21/2025, but she is usually assigned to 200 hall on day shift and she knows the residents well. V7 stated R5 was a 2 person assist with transfers until she recently had an incident and now, she is now a mechanical lift. V7 stated she always transferred R5 with a 2 person assist with a gait belt because she has Parkinson's is unstable at times, that's why she is a 2 person assist with transfers. V7 stated staff including CNAs find how residents transfer by reading the resident's care plan which they have access to. V7 stated she never transferred V5 without 2 staff and a gait belt, and she wouldn't ever do that because R5 is too unstable to transfer and she definitely doesn't want any residents, including R5, to be injured. On 10/29/2025 at 1:28 PM, V18, RN, stated she worked day shift on 10/21/2025 and was assigned to R5. V18 stated she is an agency nurse and recalled a therapy staff (name unknown) reported to her sometime that morning that R5's left ankle/lower leg was swollen, red, and bruised and she wanted a nurse to assess the area prior to R5 receiving therapy. V18 stated she went to R5's room and observed V17, NP, was in the room and assessed R5's left ankle/lower leg was bruised, red, and swollen, and she heard R5 tell V17 that she was transferred with 1 staff and it was supposed to be 2 and her left foot got caught in her wheelchair wheel and she knew it was hurt. V18 stated R5 cried when V17 let her know she was transferring her to the emergency room for x rays because she was recently at the hospital for unrelated medical issue. On 10/29/2025 at 2:05 PM, V21, Licensed Practical Nurse/LPN stated she worked day shift on 10/21/2025 but wasn't assigned to R5. V21 stated no staff reported to her that any resident including R5 fell that morning or that staff couldn't find R5's nurse to report that R5 fell. V21 stated she didn't know where to locate how residents transfer other than the nurse report sheet. On 10/30/2025 at 11:05 AM, V21, LPN, stated she spoke to V1, Administrator, and she told her the resident's transfer status is documented on the resident's care plan and Kardex. V21 stated she started working at the facility in June 2025 and didn't know the transfer status was documented there until V1 told her that today. On 10/30/2025 at 9:51 AM, V11, CNA, stated she worked 10/21/2025 day shift and was assigned to R5. V11 stated she got to the facility at 6:00 AM that day. V11 stated around 6:30 AM, she answered R5's call light and she wanted to get up for breakfast. V11 stated she assisted R5 to sit up on the side of the bed and put her wheelchair in front of her, as that is how she always transfers from bed to recliner, and she assisted R5 to stand by herself. She instructed R5 to pivot towards her recliner but when R5 went to pivot, she got shaky and her left foot got stuck in the wheelchair wheel, and R5 fell forward onto her stomach onto the bed. V11 stated she panicked and immediately turned R5's call light on, but 5 minutes went by and no staff responded, so she called the facility and spoke to V6, Business Office Manager, and told her she needs assistance from staff in R5's room, and V6 told her she'd sent staff to the room. V11 stated V4, Wound Nurse, entered R5's room approximately 10 minutes later and she assisted her to get R5 up and transferred R5 to her recliner. V11 stated she asked R5 many times if she was OK, and R5 stated she was OK. V11 left R5's room at approximately 6:50 AM and she was up in her recliner and was OK. V11 stated she looked for R5's nurse to report the resident fell and she couldn't find her nurse anywhere at the facility, and so she started getting other residents up and started passing breakfast trays. It was around 8:00 AM when she noticed V18, RN, V17, NP, and an unknown therapy staff were in R5's room. After they left R5's room, she entered her room and asked what was going on, and R5 told her that they think her left ankle is broken and she has to go the emergency room. V11 stated V2, DON (Director of Nurses), and V3, ADON (Assistant Director of Nurses), spoke to her the same day at 11:00 AM. She was told she was suspended pending the investigation of R5's improper transfer and she was in-serviced at the facility on 10/29/2025 and she comes back to work 11/1/2025. V11's Employee Personnel File documents an employee corrective action form, dated 10/29/2025, documents date of offense 10/21/2025 employee failure to follow departmental policies and procedures. Proper transfer procedures were not followed according to resident Kardex and/or plan of care. On 10/30/2025 a 12:07 PM, V3, ADON, stated she was working when R5 had a change in condition and was transferred to the emergency room. V3 stated she recalled the incident and was alerted by V17, NP, to go assess R5's left ankle/lower leg, and when she did she noted R5's left lower leg was swollen and bruised and she asked R5 how this occurred. R5 told her foot got caught in her wheelchair wheel during a transfer and she fell back onto the bed. V3 stated when a resident falls, she expects the CNA to notify the resident's nurse immediately, and if they can't find the resident's nurse to notify any nurse of a fall, and a nurse should assess the resident immediately for injury and pain and then should document the assessment and notify the resident's provider about what occurred. V3 stated when a resident initially falls, she expects staff to document a change in condition form (SBAR) which should document an immediate intervention which can include resident transferred to emergency room. After the resident is readmitted to the facility, the interdisciplinary (IDT) team will put a permanent intervention in place to prevent future falls on the resident's care plan. V3 would expect the permanent intervention to be documented on the resident's care plan within 24 hours of being readmitted to the facility. R5's permanent intervention was to have her be a mechanical lift, and V3 stated R5's care plan has been updated. V3 stated staff were verbally in-serviced on 10/21/2025, she ran around and verbally educated all staff working that they were to ensure residents were transferred properly to prevent injuries because R5 was improperly transferred and she sustained a left ankle/left leg bruising and swelling. V3 stated she put the in-service paperwork at the employee clock in for staff to read and some staff signed they were in-serviced prior to working, but not all staff were in-serviced prior to working. R5's Care Plan as of 10/31/2025 documents at risk for falls and intervention: utilize 2 assist for transfers dated 9/28/2025. No update to R5's care plan to show she is now to be transferred by (mechanical lift) as of 10/21/2025.On 10/31/2025 at 2:47 PM, V28, Care Plan Nurse, and V5, Regional Nurse Consultant, stated R5's care plan documents R5 is a mechanical lift under the ADL (Activities of Daily Living) category and is a 2 person assist under the fall category, V5 stated R5's transfer status should be the same in both places so it doesn't confuse staff. V28 stated she wasn't aware R5's fall care plan documented 2 person assist and she will update it immediately to reflect that R5 is now a mechanical lift. On 10/29/2025 at 11:50 AM, V17, Nurse Practitioner, stated she was at the facility on the morning of 10/21/2025, and therapy staff (unknown name) reported to her R5 had new bruising, redness, and swelling to her left ankle/lower leg. V17 stated she went and assessed R5 immediately and R5 told her she was transferred with 1 staff and her foot got caught in the wheelchair wheel and she fell forward onto the bed. V17 stated no nursing staff reported this injury to her, therapy was the first to report this injury to her. V17 stated R5 was crying at that time and stated she didn't want to go back to the hospital because she was recently there for pneumonia and she didn't want to go back. V17 stated she spoke to R5 and let her know due to the extent of the injury she needed to be assessed at the local emergency room for imaging to see the extent of the injury to ensure she received proper care and treatment. V17 stated she's not sure if the fracture is new or not because R5 was assessed by a foot and ankle specialist, and he documented the fractures on the x rays were past chronic fractures, not acute, but V17 did confirm that R5's left foot/leg was bruised, red and swollen upon assessment after she was transferred by 1 staff on the morning of 10/21/2025. V17 expects staff to follow the resident's care plan because that recommendation is the safest mode of transfer for the resident per therapy. If staff questioned how a resident is transferred, they can check the resident's care plan, and she expected the care plan to be up to date at all times, so staff know what the therapy recommendation is and residents are transferred properly to ensure no injuries are sustained during transfers. 2. R10's Undated Face Sheet, documents initial admission date 12/9/2021, with diagnoses including history of falls, neurocognitive disorder with Lewy bodies, unsteady on feet and lack of coordination. R10's Quarterly MDS, dated [DATE], documents cognitively impaired and no falls since admission/entry or reentry. R10's Fall Risk Data Collection Form, dated 7/1/2025, documents he is a low risk for falls. R10's SBAR note, dated 9/26/2025 at 4:45 AM, documents, The resident is experiencing a change in condition.See SBAR (change in condition) assessment for further information and family/physician notification. The change in condition the resident is currently experiencing is unwitnessed fall. This nurse walked into resident's room & found resident lying on his back next to his bed. This nurse call for CNA assistance. Resident was safely transferred to his w/c. Resident noted to have a drop in BP (blood pressure) when changing positions from lying to sitting, all other VS (vital signs) WNL (within normal limits). Neuros WNL. Resident c/o (complains of) pain to his rt (right) big toe. Resident noted to have new generalized redness to back. Resident was frequently monitored. Resident noted to be attempting to self-transfer again after the fall. This nurse attempted to notify (name), resident's POA. voicemail left to call the facility back. DON & provider notified of the fall. VS/Neuros initiated & N.O. (new order) for orthostatic BP x 3 days.R10's SBAR progress note, dated 9/26/2025 at 11:20 PM, documents The resident is experiencing a change in condition. See SBAR assessment for further information and family/physician notification.The change in condition the resident is currently experiencing is Unwitnessed Fall CNA found resident next to his bed on the ground on his back. Resident was safely transferred to his bed with the assistance of 2 staff members. No injuries noted. Denies pain. VS/ROM/Neuros WNL. VS/Neuros initiated. Resident noted to continue attempt to self-transfer at times. Resident's bed move to station 2 & mattress was placed next to bed. ADON notified of fall & provider notified. Will attempt to call POA in AM.R10's Care Plan addressed his risk for falls, but no progressive interventions added to care plan after the two falls on 9/26/2025 to prevent future falls until 10/3/2025 staff documented two new interventions to prevent falls: scoop mattress and low bed. On 10/31/2025 at 11:50 AM, V28, Care Plan Nurse, stated she doesn't understand why R10's care plan when printed documents the scoop mattress and low bed fall interventions were initiated on 9/26/2025, but in R10's Electronic Medical Record (EMR) documents those same fall interventions were created on 10/3/2025. V28 stated she's never seen this issue with the dates not matching before and wasn't sure what the issue is. V28 stated she didn't know what date the fall interventions were implemented on, either 9/26/2025 or 10/3/2025. On 10/31/2025 at 12:00 PM, V1, Administrator, observed R10's care plan fall interventions dates didn't match and stated she will ask V5, Regional Nurse Consultant, why the fall intervention dates of created and initiated don't match. V1 stated she's never seen this documentation issue before. On 10/31/2025 at 12:11 PM, V5, Regional Nurse Consultant, stated she called the facility's corporate office and she stated no one including her understand or has ever observed this documentation issue in a resident's EMR care plan. V5 stated the created date and the initiated date always match, and she doesn't know what's going on with the computer system and didn't know when R10's fall interventions of the scoop mattress or the low bed was implemented. On 10/31/2025 8:55 AM, R10 was observed sitting up in wheelchair in hallway. V26, CNA, propelled R10 to his room. V27,CNA, applied a gait belt around R10's waist and V26 and V27 assisted R10 to stand and pivoted him to sit on the side of his bed. V26 held R10's top half and V27 picked up R10's feet and assisted him to lay in bed. R10 didn't respond to surveyor's questions regarding the fall. R10 had a scoop mattress and he had a low bed. On 10/31/2025 at 2:00 PM, V5, Regional Nurse Consultant, stated the facility's physician's order policy only covers staff needing to administer medications per physician's orders and doesn't include following physician's order for transfer status and V5 stated the facility doesn't have a proper transfer status policy.

Based on interview and record review, the facility failed to notify a resident's emergency contact after an injury was sustained for 1 (R5) of 3 residents reviewed for notification. Findings include: R5's Undated Face Sheet, documents V29 is her emergency contact. R5's Quarterly Minimum Data Set (MDS), dated [DATE], documents R5 is alert. R5's Health Status Note, dated 10/21/2025 at 10:50 AM, documents PT (Physical Therapy) staff informed RN (Registered Nurse) that patients left anterior lower extremity was swollen and bruised. NP was in house and was notified to take a look, patient had a silver dollar sized bruise on the anterior shin/ankle, with redness and edema spreading around the bruise. Patient stated that she has broken that same leg/foot 3x and there is some hardware in there from past surgeries. Patient said when they were transferring/pivoting her feet gave out. NP assessed patient quickly and RN was given the order to send patient to the ER (Emergency Room) for imaging evaluation. Patient was sent to the ER at approx (approximately) 8:45am via EMS (Emergency Medical Services).On 10/31/2025 at 1:25 PM, V29, R5's emergency contact, stated no facility staff notified her on the morning of 10/21/2025 when R5 sustained an injury and was transferred to the emergency room. V29 stated R5 called her and told her she got her left foot stuck in the wheelchair wheel and her left foot/lower leg was injured and she was sitting in the emergency room. V29 stated she was upset because no facility staff notified her R5 was injured or that she was transferred to the emergency room, and if she would have been notified of the severity of the injury she would have met R5 at the emergency room to be there for family support. The Facility's Significant Condition Change and Notification policy, dated 12/2024, documents purpose: to ensure that the resident's family and/or representative. A significant change in resident's physical status includes onset of swelling, skin discoloration and transfer of the resident from the facility. Procedure: when any of the above situations exists, the licensed nurse will contact the resident's representative. Calls will be made to the resident's representative until they are reached. A message may be left on an answering machine that does not give specifics but leaves a request for the facility to be called.

Based on interview and record review, the facility failed to implement end of life/hospice skin care plan interventions for 1 of 3 (R2) residents reviewed for pressure ulcers in the sample of 5. This failure resulted in R2 developing multiple in-house acquired pressure ulcers between the dates of [DATE] and [DATE] when R2 expired at the facility. Findings include:R2's admission Record, print date of [DATE], documented R2 had diagnoses including dementia, COPD (chronic obstructive pulmonary disease), severe protein calorie malnutrition, thrombocytopenia, pressure ulcer of left heel, anxiety disorder, chronic atrial fibrillation, congestive heart failure, type 2 diabetes mellitus, osteoarthritis, and chronic kidney disease. R2's MDS (Minimum Data Set), dated [DATE], documented R2 was severely cognitively impaired and was dependent on staff for all mobility including bed mobility. R2's Pressure Score Risk document, dated [DATE], documented R2 was assessed as very high risk for skin breakdown. R2's Nursing Admission/readmission Data Collection document, dated [DATE], documented R2 was re-admitted to the facility following a local hospital admission with a pressure ulcer to his sacrum. This form documented R2's pressure ulcer of his sacrum was 1.1 cm in length and 1.0 cm in width with no depth documented. This form also documented R2's right heel had an old, healed blister and R2 had abrasions to his right antecubital. No other skin impairments were documented. R2's progress noted, dated [DATE] at 5:00 PM, documented R2 was admitted to (regional) hospice services on the same day he was re-admitted to the facility from a local hospital. R2's Hospice Certification and Plan of Care, dated [DATE], documented wound care to buttock and left heel every 3-5 days and PRN (as needed) for drainage; clean with wound cleanser; pat dry; apply skin prep; cover and secure with Mepilex dressing. Wound care to be performed by facility nurse. It continues, DME (durable medical equipment) and Supplies: alternating pressure pad. R2's care plan report, undated, documented R2 has actual/potential impairment to skin integrity r/t impaired mobility, incontinence, diabetes mellitus, poor appetite, CHF (congestive heart failure), COPD, anemia, EOL (end of life) process and his disease process. admitted with stage 2's to sacrum/coccyx, scarring to left heel r/t old, blistered area. DTPI (deep tissue pressure injury) right heal, several DTPI to bilateral torso/sides and back and left shoulder and right lateral leg, skin tears to right side. Interventions include Monitor dressing when providing care to ensure it is intact and adhering, report loose dressing to nurse. Monitor pressure areas for changes in color, sensation, temperature and report any change to nurse. Pressure redistributing mattress on bed. R2's progress note, dated [DATE] at 7:00 PM, documented, hospice nurse here to see resident. During care she asked CNA (Certified Nurse Assistant) why low air loss mattress isn't on bed CNA hospice nurse asked writer why and stated the CNA said, because the DON (Director of Nursing) doesn't like them. The writer explained I didn't know about it but perhaps she could talk to the DON tomorrow I'm sure there is a misunderstanding. Resident noted per hospice nurse to have several new wounds back, bilat torso, left shoulder, right elbow, buttock, right knee, and left heel. Daughter informed family and new treatment orders given.On [DATE] at 9:40 AM, V6, CNA, stated the air mattress hospice brought in for R2 was never put on his bed and she doesn't know why. V6 stated hospice picked the mattress up last week after R2 passed away.On [DATE] at 10:20 AM, V2, DON, stated she is a traveling DON, started at this facility approximately 3 weeks ago. Hospice ordered an overlay for R2. V2 stated, We decided those aren't safe, so we ordered an air mattress from hospice, and it didn't come until (R2) had already expired. V2 stated R2 had multiple pressure ulcers. V2 stated on [DATE], R2 had tiny areas on his coccyx, on the 22nd it appeared as a Kennedy ulcer and the Nurse Practitioner came and looked at it, and then diagnosed it as a Kennedy ulcer.On [DATE] at 10:25 AM, V10, RN (Registered Nurse), stated R2's pressure ulcers gradually got worse after he was re-admitted on [DATE]. V10 stated when R2 was re-admitted to the facility on [DATE], she completed R2's admission assessment including his skin assessment. V10 stated she observed an approximate nickel sized open area to R2's sacrum on [DATE]. V10 stated towards the end of R2's stay at the facility, he started developing more wounds. V10 stated R2's hospice company delivered an overlay for his mattress, but it didn't follow protocol, so it was never placed on his bed. V10 stated she is not sure who made the decision not to use the overlay. On [DATE] at 10:43 AM, V2, DON, was asked if the facility assessed, measured, and monitored R2's pressure ulcer on his sacrum between [DATE] when it was noted on his re-admission assessment as 1.1 cm in length x 1 cm depth until [DATE] when the next measurement of 2.36 cm length x 3.57 cm width x .2 cm depth. V2 replied, I can't tell you anything, unfortunately. We did have a wound care nurse, but she quit. Surveyor asked if a low air loss mattress/air overlay was ever implemented for R2, and V2 replied, not that I know of our mattresses are pressure reducing. Surveyor asked V2 if she was the DON referenced to in R2's progress note, dated [DATE] at 7 PM, that documented hospice nurse here to see resident. During care she asked CNA why low air loss mattress isn't on bed and the CNA said, because the DON doesn't like them. V2 replied, They were referring to me; I don't like them. Surveyor asked if the facility has any documentation regarding their requests for a different type of low air loss mattress for R2 from hospice and V2 replied, I don't know, you will have to ask (V10) RN. Surveyor asked V2 if the facility measures wounds/pressure ulcers weekly and V2 replied, I would have to look that up in the policy.R2's Skin Check form, dated [DATE], documented resident refused skin check. This form was documented by V12, LPN (Licensed Practical Nurse). On [DATE] at 2:56 PM, V12, LPN, stated she attempted to assess R2's skin on [DATE] and R2 refused by being combative. V12 stated she passed it on in report so the nurse on the next shift should have attempted to check R2's skin.R2's EMR (electronic medical record) does not document another skin assessment until [DATE]. On [DATE], R2's wound evaluation form documented stage 2 pressure ulcer on sacrum with measurements of 12.24 cm area, 2.36 cm length, 3.57 cm width, and 0.2 cm depth. R2's wound evaluation forms, dated [DATE], also documented R2 had a pressure ulcer of his right heel that was acquired in house with measurements of 4.76 cm area, 2.98 cm in length, and 1.93 cm in width, a pressure wound to his front right lateral lower leg that was acquired in house, age unknown with measurements of 2.74 cm area, 1.6 cm in length, and 2.22 cm in width. R2's Wound Evaluation forms, dated [DATE], documented R2 developed a new stage 1 pressure ulcer on his left scapula measuring 407.21 cm in area, 28.68 cm in length, and 17.04 cm in width. R2 also developed a stage 1 pressure ulcer to his right lower back measuring 39.66 cm area, 13.12 cm in length, and 3.79 cm in width. A skin tear to his right lower back measuring 55.52 cm in area, 10.5 cm in length, by 10.22 cm in width. R2 developed a blister to his front right trochanter (hip) measuring 21.44 cm area, 3.9 cm in length, and 7.91 cm in width. R2's wound evaluation form, dated [DATE], also documented the pressure ulcer to his sacrum was unstageable (slough and/or eschar) with dimensions of area 130.23 cm, length 12.33 cm, and width of 14.86 cm with a progress note documenting area x 3 to sacrum evaluated this week. Wound bed is pink in color. Small amount of serosanguinous drainage noted with no odor present. R2's wound evaluation form, dated [DATE], documented R2's pressure injury to his front right lateral lower leg measured area at 35.62 cm, 15.62 cm in length, and 2.98 cm in width. The facility's wound line list, dated [DATE], documented 5 new pressure ulcers that were not present on R2's re-admission assessment dated [DATE]. On [DATE] at 8:49 AM, V15, R2's daughter and POA (Power of Attorney), stated she called the DON on [DATE] and informed her that her dad (R2) did not have a dressing on his sacral wound when she visited. V15 stated the DON (V2) replied it didn't need a dressing. V15 stated her dad's wound was a stage 2 at this time and it did need a dressing. Surveyor asked V15 if she has medical experience and V15 replied, Yes, I am an LPN with 25 years of experience in long term care. V15 stated hospice ordered an air mattress and facility staff threw it in the closet and never used it. V15 stated she was at the facility the weekend of [DATE] and her dad's sacral wound was bigger, open, and bleeding onto his sheets. V15 stated the mattress overlay was still in his closet and she spoke to R2's hospice nurse about her concerns with his skin breakdown and lack of interventions. V15 stated the hospice nurse stated she ordered a full bed, and the facility refused it. V15 stated she visited her dad on [DATE], and shortly after, she left her niece, who was still at the facility, called her along with the hospice nurse because the hospice nurse wanted to make sure she knew her dad had developed more pressure ulcers, and the mattress overlay was still in his closet. On [DATE] at 1:48 PM, V11, Nurse Practitioner, was asked if she would have expected the facility to implement an alternating pressure mattress for R2, and V11 stated, I believe they were getting one from hospice. Surveyor then asked if she would have expected the facility to implement an alternating pressure mattress/overlay as care planned by R2's hospice program on [DATE] when R2 was re-admitted to the facility after a local hospital admission and R2 was started on hospice upon readmission. V11 stated, I don't know what their criteria are for that. Surveyor asked how she determined R2's pressure ulcer was a Kennedy ulcer, and if she had seen R2's sacral pressure ulcer prior to the day she diagnosed it as a terminal ulcer on [DATE]. V11 replied, I had not seen it prior to that. I was told he had 2 small areas a few days prior to that, and they changed fast, so I based it on that.On [DATE] at 2:58 PM, V6, CNA, stated R2 did not have a dressing on his sacrum when she worked on the weekend before R2 expired on [DATE]. V6 stated she told R2's nurse, and she replied R2 is dying and did not apply a dressing during her shift. V6 stated the mattress overlay provided by hospice remained in R2's closet and was never put onto R2's bed.On [DATE] at 11:25 AM, V14, Regional Nurse, stated all the facility mattresses are pressure relieving mattresses. V14 stated she would agree R2 developed 5 to 6 pressure ulcers between the dates of [DATE] and [DATE] when he passed away. V14 stated V18, Regional Nurse, looked for an air mattress in the facility shed on [DATE] and the facility didn't have any.On [DATE] at 1:18 PM, V19, LPN, stated she was R2's nurse on Saturday, [DATE], and hospice delivered the mattress overlay. V19 stated R2's daughter was at the facility when hospice delivered it, and she requested it be under her father/put on his bed, but the cord wouldn't reach the outlet, so she and the CNAS left the overlay on the table next to his bed. V19 stated she knew they would have to get it approved from management for some type of extension cord, but she is not sure what happened with it after that weekend.On [DATE] at 1:42 PM, V20, Maintenance Assistant, stated he did receive a note about R2 needing a power strip, and he placed a power strip on R2's wall for the air mattress hospice delivered the following week of [DATE].On [DATE] at 2:28 PM, V21, Hospice RN, stated she admitted R2 to their hospice program on [DATE] and saw him that weekend. V21 stated upon admission to hospice, R2 had 2 small pressure ulcers. V21 stated hospice initially provided an air overlay for R2, then she ordered a waffle overlay for his mattress to prevent R2 from developing more pressure ulcers and to prevent his current pressure ulcers from getting worse. V21 stated as far as she knew, this facility did not have an issue with implementing waffle mattress overlays for residents. V21 stated she is not aware of the facility requesting any other type of mattress for R2, and the hospice does have multiple different kinds of pressure reducing mattresses available. V21 stated when she assessed R2 again shortly before he passed away, he was covered with multiple stage 1 and stage 3 pressure ulcers. Surveyor asked V21 if she feels in her professional experience R2 would have developed multiple pressure ulcers if the waffle mattress overlay would have been implemented, and V21 replied No, I don't think he would have developed multiple pressure ulcers. Surveyor asked V21 if she assessed R2's pressure ulcer of his sacrum as being a Kennedy ulcer and V21 replied, No, because all his wounds did not develop at the same time and although he was a dark skinned African American, the wound base looked like a stage 3 pressure ulcer to me not a Kennedy ulcer.On [DATE] at 2:55 PM, V1, Administrator, stated she would have expected someone to follow up on the air mattress.The facility's Skin Identification, Evaluation, and Monitoring Policy, dated 1/2025, documented, the purpose of this policy is to outline a method of identification, evaluation, and monitoring for alterations in skin integrity. Communities will implement preventative measures and an individualized care pan will be formulated upon completion of findings. Preparation: A. Review of resident medical record to identify risk factors that have the potential to cause alterations in skin integrity. It continues, Procedure: A licensed nurse will evaluate skin integrity through a physical skin evaluation upon admission, weekly, and when a significant change is identified. The nursing assistant will observe the resident's skin for breakdown using the risk assessment tool upon admission, weekly for 3 consecutive weeks (totaling 4), quarterly, and when a significant change is identified. It continues, A. Complete a weekly skin check to evaluate for changes in skin integrity. B. Document in medical record the finding of weekly skin assessment. A. If wounds are present and previously identified: i. Document integumentary findings in weekly skin assessment. ii. Appearance of the wound, including measurements if the wound is due for a treatment change. iii. Complete weekly re-evaluation of previously identified skin alterations/wounds. iv. Treatment applied/initiated per health care provider order in the medical record. b. If new wound is identified: i. initiate protective dressing. ii. Notify health care provider of finding and further treatment orders. iii. Notification/education of resident and resident representative of finding and physician orders. iv. Notification of community wound care nurse for evaluation and Director of Nursing. C. Document evaluation in the medical records. D. Update plan of care with each intervention. It continues, Interventions and Prevention: SKIN A. S.-Surface Selection a. Select surface based on resident assessment. b. Ensure all residents at risk of developing pressure injuries are placed on a pressure-reducing surface. c. Use pressure-reducing chair cushion for at risk resident. Skin Integrity Treatment Program: A. Eliminate or reduce a. the source of pressure using positioning techniques, enhancement of mobility and circulation, support of ancillary team members. b. other sources of skin injury by evaluating the cause and providing interventions. B. Pain control C. Preventative measures to reduce the risk of further tissue loss. D. Managing and reducing the risk of infections. E. Interventions that increase the potential for healing.The facility's Hospice Services policy, undated, documented, each resident will receive, and this facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. This facility provides continuity of care that recognizes the spiritual needs and to assist residents, family members ad friends to live as fully and completely as possible with meaning and dignity. It continues, Definitions: Hospice care means a comprehensive program of services provided to a terminally ill individual that emphasizes the management of pain and other physical symptoms, as well as management of the psychosocial needs of the dying individual and the family members. Hospice care plan means a written plan of care developed by the interdisciplinary team that describes the care to be provided, including a notice of those life sustaining procedures that are not to be used. It continues, Procedures: provide and periodically review resident plan of care, addressing services, and support that accommodate and honor the resident's choices and rights, manage pain and other physical, mental, and psychosocial symptoms, and strive to meet the resident's physical, mental, psychosocial, and spiritual needs. It continues, the facility will coordinate care planning with the hospice provider including all services and supplies provided by the hospice provider including durable medical equipment. The resident's quality of care and life will by enhanced by meeting the resident's emotional, spiritual and social needs including: hygiene/skin.

Based on interview and record review, the facility failed to ensure allegations of verbal abuse were reported immediately to the Administrator of the facility and in a timely manner to the State Agency for 1 of 3 residents (R2) reviewed for verbal abuse in a sample of 5. Findings Include: R2's Face Sheet, original admission date of 11/21/22, documented R2 has diagnoses of but not limited to cerebral infarction, type II diabetes mellitus, major depressive disorder, and hypertension (HTN). R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact, with a Brief Interview for Mental Status (BIMS) of 13 out of 15, and requires some assistance with her activities of daily living (ADLs). On 06/24/25 at 9:25 AM, R2 said V4, Social Service Director (SSD), yelled at her and she didn't want to talk about it. She said she didn't report it to anyone because what was the use in telling, it wouldn't have accomplished anything, no one would have done anything, they never do. On 06/24/25 at 9:10 AM, V6, Certified Nursing Assistant (CNA), said, On Wednesday (06/18/25) of last week, (R2) was asking (V4) about going to the assisted living facility, and (V4) started yelling at (R2) and was going through (R2's) drawers and slamming the drawers after going through them. V6 said when she was done talking with R2, V4 even slammed R2's door when she walked out of R2's room. V6 said she didn't report the incident to anyone because there is no one to report it to. On 06/24/25 at 9:15 AM, V7, CNA, said she has heard and seen V4 yelling at R2. She said she was standing out in the hallway, and she saw V4 going through R2's drawers, and when she was done going through them, she slammed the drawer shut. V7 said she was yelling at R2 something about she (V4) just couldn't make the assisted living take her. She said she didn't report it to anyone because nothing would happen if she did report it. On 06/24/25 at 9:45 AM, V8, CNA, said she was here at the facility last week when the incident with V4 and R2 happened. She said she was standing out in the hallway and V4 was in the room yelling at R2. She said she doesn't remember specifically what V4 was saying to R2, but she was yelling at R2. She said she also saw V4 slam shut the dresser drawer, she was tossing things around and slammed the door when she left the room. V8 said she didn't report it because it doesn't do any good, nothing matters to management, and there is no one higher to go to. On 06/25/25 at 1:40 PM, V1, Administrator, said he would expect to be notified immediately if there is an allegation of abuse made. He said they have had multiple in-services since he started here at this facility, and he has made it clear they are to notify him directly with any abuse allegation. He said he always uses this scenario if there are three staff members standing at the nurse's station and they have a resident say someone was mean to them, yelling at them, or rough with them, then he would expect three phone calls. He said he tells them not to have the mentality of 'well I reported it to the nurse, or the other nurse will report it', they should be reporting it. On 06/24/25 at 2:00 PM, R2's Electronic Medical Record (EMR) was reviewed and there was no documentation regarding the alleged verbal abuse that happened on 06/18/25. R2's Illinois Department of Public Health (IDPH) investigation was reviewed and documented the following: Initial Report- June 24th, 2025: On 6/24/25 at approximately 11am, it was reported by an IDPH Surveyor that an allegation of verbal abuse was made by resident R2 regarding V4 (SSD). The investigation has been initiated, and V4 (SSD) has been suspended pending the outcome of the investigation. MD (Medical Doctor) and the local Police Department (Reference #), Ombudsman, and Responsible party are being notified.The final report to follow once the investigation is complete. The facility's Abuse, Prevention, and Prohibition Policy, date approved: 03/2025 documented, Abuse Prohibition Program The facility's abuse prohibition program includes the following sever components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response: The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. It also documented Investigation: Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. It further documented Initiate investigation including initial reporting to all required agencies.

Based on interview and record review, the Facility failed to provide showers for 1 of 3 residents (R1) reviewed for showers, in the sample of 8. Findings include: 1. R1's Face Sheet, dated 4/29/2025, documents R1 has a need for assistance with personal care. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires substantial/maximal assistance with showers/bathing. R1's Care Plan, dated 3/17/2025, documents R1 has ADL self care performance deficit and requires one staff member for bathing. On 4/24/2025 at 12:27 PM, V13, R1's daughter, stated, (R1) has ESBL (Extended-Spectrum Beta-Lactamase) in her urine. I get why she was on isolation, but I'm upset because the CNAs are telling her they can't give her an actual shower because of it. She is in a room by herself, with a shower attached. They told her she can't use the shower chair in case she peed. The shower chairs can be cleaned. They gave her a bed bath, and not even a good one. I've had to tell them to rinse the soap off afterwards. (R1) is continent most of the time, but she wears a (adult brief) just in case she dribbles. On 4/24/2025 at 5:45 PM, R1 stated she had been in the hospital recently. R1 stated the staff at the hospital told her to poop and pee on herself instead of taking her to bathroom or giving her a bed pan. R1 stated the hospital only gave her bed baths there, so when she got back to the facility she wanted a real shower, but was told she couldn't use the shower chair. On 4/25/2025 at 9:50 AM, V5, Certified Nursing Assistant (CNA), stated she was not aware of R1 not getting her showers. V5 stated R1 had a shower in her private room when she was in isolation, and the staff could have used a shower chair and cleaned it afterwards. On 4/28/2025 at 2:15 PM, V1 stated, I expect staff to re-approach a resident if they refuse the first time or find out why they are refusing. We would switch shower days/times if they have a different preference than when they are scheduled. There is a procedure for cleaning shower chairs. They are made out of PVC (PVC stands for polyvinyl chloride, a versatile and widely used synthetic polymer. It's known for its durability, affordability, and resistance to chemicals, making it suitable for various applications, including construction, medical devices, and packaging) material so that they can be cleaned. On 4/28/2025 at 2:30 PM, V2, Director of Nursing (DON), stated R1 had ESBL in her urine, but had a room with a shower in it. V1 stated the shower chair could be cleaned, and should be cleaned in between every resident either way. The Facility's Grievance Form, dated 4/24/2025, documents the date of occurrence was 4/23/2025, and R1's shower was not given due to isolation, and R1 was given a bed bath instead. The Facility's provided shower sheets for R1 for the Month of April. There were only 4 shower sheets provided dated 3/31/2025, 4/7/2025, 4/23/2025 and 4/25/2025. R1's shower sheet, dated 4/23/2025, documents R1 was given a bed bath. The facility was unable to produce any shower refusal documentation for R1. The Facility's Shower Refusal Documentation Form was reviewed and documents a place for the resident's name, date of refusal, CNA name, times attempted, and reason for refusal. The Facility's Activity's of Daily Living Policy documents, This facility provides each resident with care, treatment and services according to the resident's individualized care plan. Based on individual resident's comprehensive assessment, facility staff will ensure that each resident's clinical condition demonstrates that the decline was unavoidable, including: Bathing.

Based on interview and record review, the facility failed to ensure sufficient nursing staff to provide nursing and related services to meet the residents' needs for 1 of 3 residents reviewed for staffing in a sample of 6. This has the potential to affect all residents living in the facility. Findings include: The facility's Resident Council Minutes, dated 3/5/205, documents, New Business/Department Discussions: Still short staffed, call lights aren't being answered There is not enough in house staff, too agency workers that aren't doing their jobs correctly. Administration: Too short staffed, today was shower day but (R2) had to have a bed bath because there wasn't enough staff to care for everyone and still get showers done. 1. R1's Care Plan, dated 5/14/2021, documents R1 has an ADL (activity of daily living) Self Care Performance Deficit. It also documents BATHING: R1 requires supervision with bathing. Staff provide supervision as needed. R1's Minimum Data Set, dated dated [DATE], documents R1 is cognitively intact. On 3/12/2025 at 1:20 PM, R1 stated he is the president of resident council. R1 stated lack of staff is an ongoing concern. R1 stated this concern is addressed in the resident council meeting. R1 stated they voice these concerns but feel they are not being heard. R1 stated at times there is 1 nurse for the entire building. R1 stated the CNAs (Certified Nurse's Assistant) are short as well. R1 stated, Showers are not being completed. It's not enough. You must have staff to do these things and we don't. R1 stated he gets his showers because he does them himself. R1 stated he tells the staff and goes in the shower alone. R1 stated he is not supervised by anyone but himself. R1 stated they tell him if he goes in on his own because they don't have enough staff to supervise him. R1 stated the staff will tell them that they can't do something because they don't have enough staff. 2. R2's Care Plan, dated 7/7/2021, documents Care/ADL Preferences Staff will honor my preferences while caring for me. I prefer a shower 3 x week in the mornings. It also documents 1/18/2024 R2 has an ADL Self Care Performance Deficit r/t (related to) obesity, respiratory failure, and heart failure. BATHING: the resident requires 1 staff participation with bathing. R2's MDS, dated [DATE], documents R2 is cognitively intact and requires substantial/maximal assistance with bathe/showers. On 3/12/2025 at 11:30 AM, R2 stated she is scheduled to get a shower 3 times a week. R2 stated she does not always get a shower. R2 stated because they have 1 staff on the hall they can't do the shower, and if she wants to be cleaned, she would have to get a bed bath. R2 stated she wants a shower. R2 stated she is a large woman and requires the mechanical lift to get up and get in the shower. R2 stated when there is only 1 staff, they can't use the mechanical lift. R2 stated if there is one person, she does not get cleaned well, and it's rushed. R2 stated it takes a long time to perform the task. When asked how she knows it's because of staffing? R2 stated the staff tells her this is the reason. 3. R3's Admission Record documents R3 was admitted [DATE] with diagnosis of Cerebral Infarction due to Embolism of Right Anterior Artery. R3's Care Plan, dated 2/3/2025, documents the resident has an ADL Self Care Performance Deficit Impaired balance. It continues BATHING: the resident requires X1 staff participation with bathing. RESTORATIVE PROGRAM - Bed Mobility: Staff will assist and encourage R3 to do as much as she can, requires 2 staff to reposition in bed. [RNA,CNA,ResN] (restorative nurse's aide, certified nurse's assistant, restorative nurse) ? Requires documentation. RESTORATIVE PROGRAM - Grooming: R3 requires verbal cueing, Staff will hand (R3) a washcloth to bring to face to wash face and will assist with brushing hair. R3's MDS, dated [DATE], documents R3 is cognitively impaired and requires substantial/maximal assist with ADLs. R3's Shower schedule was Monday and Thursday night shift. On 3/14/2025 R3's Electronic Health Record (EHR) documents Shower/Bath documents, No data found for 30 days back. R3's Electronic Record does not document restorative programs performed. On 3/14/2025 at 10:30 AM, the facility provided R3's Nurse Skin Inspection report, dated 2/27/2025. As of 3/15/2025 at 12:30 PM, the facility did not provide shower documentation for the following dates 2/3/2025, 2/6/2025, 2/10/2025, 2/13/2025, 2/17/2025, 2/20/2025, 2/24/2025, 3/3/2025, 3/6/2025, and 3/10/2025. R3's Physical Therapy (PT) Discharge (D/C) Summary, dated 1/28/2025, documents R3 was discharged from PT 2/18/2025. It also documents, Discharge instructions: The patient will remain in LTC (Long Term Care) setting on RNP (Restorative Nursing Program) for PROM (Passive Range of Motion) and transfers. Restorative program established/trained = Restorative Range of Motion program, Restorative transfer. R3's Occupational Therapy Discharge Summary, dated 2/27/2025, documents R3 was discharged from Occupational Therapy on 2/27/2025. It also documents discharge instructions: Patient d/c'd to this facility. Would benefit from continued therapy services when insurance allows. Restorative Program established/trained = Restorative program on Range of Motion. R3's Care Plan and tasks do not document this restorative program. On 3/12/2025 at 11:21 AM, when asked if she was receiving showers? R3 stated, No. When asked if she was getting a bath? R3 stated, No. 4. R5's Care Plan, dated 2/14/2024, documents the resident has an ADL Self Care Performance Deficit. It continues BATHING: the resident is totally dependent on staff to provide a bath Bi-weekly and as necessary. R5's MDS, dated [DATE], documents R5 is cognitively impaired and dependent on staff for bathing. On 3/14/2025 at 10:30 AM, the facility provided R5's Nurse Skin Inspection report, dated 3/1/2025, 3/4/2025, 3/8/2025, and 3/11/2025. The facility provided the facility's shower schedule. R3 was scheduled for showers on Tuesday and Saturday. As of 3/15/2025 at 12:30 PM, the facility did not provide shower documentation for the following dates 2/1/2025, 2/4/2025, 2/8/2025, 2/11/2025, 2/18/2025, 2/22/2025, and 2/25/2025. On 3/12/2025 at 10:00 AM, V2, Director of Nursing/DON, stated they have some staffing challenges and are using agency to help fill in. On 3/12/2025 at 1:40 PM, V8, CNA, stated showers are not a priority. V8 stated when they are staffed ,they can get them done. V8 stated because they are short on staff, everything can't get done. V8 stated they clean the private areas and clean the residents when they are incontinent or go to the toilet. V8 stated they prioritize, and when they are short, restorative and showers are not priority when you have the hall alone. V8 stated the showers are documented on the shower sheets, identified the Nurse Skin Inspection report as the shower sheet, and in the computer. On 3/12/2025 at 2:19 PM, V7, CNA, stated the facility does have a staffing problem. V7 stated when they are short, they have to prioritize. V7 stated showers and restorative are not priority. V7 stated sometimes they don't get done. On 3/12/2025 at 2:05 PM, V6, CNA, stated she works the unit. V6 stated, For the most part, we are staffed on the unit because we got a staffing tag. At times, there is 1 CNA. The residents are always moving, and require being always watched, and showers are not done. You can't leave the residents unattended for that long. On 3/13/2025 at 3:10 PM, V9, CNA, stated R3 is alert and understands what is being said. R3 has difficulty with words. V9 stated R3 can answer yes and no questions appropriately. The facility's Sufficient Nursing Staff policy, dated 12/2024, documents, Policy The facility's Sufficient Nursing Staff policy, dated 12/2024, documents There will be sufficient team members with appropriate competencies and skill set available in each unit to provide nursing and related services to the resident as planned by the interdisciplinary team based on resident's assessment(s) to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. Facility leadership will provide sufficient personnel on a 24 hour basis to provide nursing care to all residents in accordance with the residents' individual care plans.

Based on interview and record review, the facility failed to supervise and provide showers as scheduled for 4 of 4 (R1, R2, R3, R5) residents in a sample of 6. Findings include: The facility's Resident Council Minutes, dated 3/5/205, documents, New Business/Department Discussions: Still short staffed, call lights aren't being answered. There is not enough in house staff, too agency workers that aren't doing their jobs correctly. Administration: Too short staffed, today was shower day but (R2) had to have a bed bath because there wasn't enough staff to care for everyone and still get showers done. 1. R1's Care Plan, dated 5/14/2021, documents R1 has an ADL (activity of daily living) Self Care Performance Deficit. It also documents BATHING: R1 requires supervision with bathing. Staff provide supervision as needed. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. On 3/12/2025 at 1:20 PM, R1 stated he is the president of resident council. R1 stated lack of staff is an ongoing concern. R1 stated this concern is addressed in the resident council meeting. R1 stated they voice these concerns, but feel they are not being heard. R1 stated at times, there is 1 nurse for the entire building. R1 stated the CNAs (Certified Nurse's Assistants) are short as well. R1 stated, Showers are not being completed. It's not enough. You must have staff to do these things and we don't. R1 stated he gets his showers because he does them himself. R1 stated he tells the staff and goes in the shower alone. R1 stated he is not supervised by anyone but himself. R1 stated they tell him if he goes in on his own he can get a shower, because they don't have enough staff to supervise him. R1 stated the staff will tell them that they can't do something because they don't have enough staff. 2. R2's Care Plan, dated 7/7/2021, documents Care/ADL Preferences Staff will honor my preferences while caring for me. I prefer a shower 3 x week in the mornings. It also documents 1/18/2024 R2 has an ADL Self Care Performance Deficit r/t (related to) obesity, respiratory failure, and heart failure. BATHING: the resident requires 1 staff participation with bathing. R2's MDS, dated [DATE], documents R2 is cognitively intact and requires substantial/maximal assistance with bathe/showers. On 3/12/2025 at 11:30 AM, R2 stated she is scheduled to get a shower 3 times a week. R2 stated she does not always get a shower. R2 stated because they have 1 staff on the hall they can't do the shower, and if she wants to be cleaned, she would have to get a bed bath. R2 stated she wants a shower. R2 stated she is a large woman and requires the mechanical lift to get up and get in the shower. R2 stated when there is only 1 staff, they can't use the mechanical lift. R2 stated if there is one person she does not get cleaned well, and its rushed. R2 stated it takes a long time to perform the task. When asked how she knows it's because of staffing? R2 stated the staff tells her this is the reason. 3. R3's Admission Record documents R3 was admitted [DATE] with diagnosis of Cerebral Infarction due to Embolism of Right Anterior Artery. R3's Care Plan, dated 2/3/2025, documents the resident has an ADL Self Care Performance Deficit Impaired balance. It continues o BATHING: the resident requires X1 staff participation with bathing. Date Initiated: 01/28/2025 and Revision on: 02/03/2025. R3's MDS, dated [DATE], documents R3 is cognitively impaired and requires substantial/maximal assist with bathing. R3's Shower schedule was Monday and Thursday night shift. On 3/14/2025, R3's Electronic Health Record (EHR) documents Shower/Bath documents No data found for 30 days back. On 3/14/2025 at 10:30 AM, the facility provided R3's Nurse Skin Inspection report, dated 2/27/2025. As of 3/15/2025 at 12:30 PM, the facility did not provide shower documentation for the following dates 2/3/2025, 2/6/2025, 2/10/2025, 2/13/2025, 2/17/2025, 2/20/2025, 2/24/2025, 3/3/2025, 3/6/2025, and 3/10/2025. On 3/12/2025 at 11:21 AM, when asked if she was receiving showers? R3 stated, No. When asked if she was getting a bath? R3 stated, No. On 3/13/2025 at 3:10 PM, V9, CNA, stated R3 is alert and understands what is being said. R3 has difficulty with words. V9 stated R3 can answer yes and no questions appropriately. 4. R5's Care Plan, dated 2/14/2024, documents the resident has an ADL Self Care Performance Deficit. It continues BATHING: the resident is totally dependent on staff to provide a bath Bi-weekly and as necessary. R5's MDS, dated [DATE], documents R5 is cognitively impaired and dependent on staff for bathing. The facility provided the facility's shower schedule. R3 was scheduled for showers on Tuesday and Saturday. On 3/14/2025 at 10:30 AM, the facility provided R5's Nurse Skin Inspection report, dated 3/1/2025, 3/4/2025, 3/8/2025, and 3/11/2025. As of 3/15/2025 at 12:30 PM, the facility did not provide shower documentation for the following dates 2/1/2025, 2/4/2025, 2/8/2025, 2/11/2025, 2/18/2025, 2/22/2025, and 2/25/2025. On 3/12/2025 at 10:00 AM, V2, Director of Nursing/DON, stated they have some staffing challenges and are using agency to help fill in. On 3/12/2025 at 1:40 PM V8, CNA, stated showers are not a priority. V8 stated when they are staffed, they can get them done. V8 stated because they are short on staff, everything can't get done. V8 stated they clean the private areas and clean the residents when they are incontinent or go to the toilet. V8 stated they prioritize, and when they are short, restorative and showers are not priority when you have the hall alone. On 3/12/2025 at 2:19 PM, V7, CNA, stated the facility does have a staffing problem. V7 stated when they are short. they have to prioritize. V7 stated showers and restorative are not priority. V7 stated sometimes they don't get done. On 3/12/2025 at 2:05 PM, V6, CNA, stated she works the unit. V6 stated, For the most part, we are staffed on the unit because we got a staffing tag. At times, is 1 CNA. The residents are always moving and require being always watched, and showers are not done. You can't leave the residents unattended for that long. The showers are documented on the shower sheet, identified the nursing skin sheet, and in the computer. On 3/13/2025 at 3:30 PM, V2, Director of Nursing, stated they do not have a specific policy for showers. V2 stated she was aware of the challenges in the facility, and is working to correct them. The facility's Activities of Daily Living, not dated, documents this facility provides each resident with care, treatment, and services according to the resident's individualized care plan.

Based on interview and record review, the facility failed to to provide restorative services for 1 of 3 residents (R3) reviewed for nursing programs in a sample of 5. Findings include: R3's Admission Record documents R3 was admitted [DATE] with diagnosis of Cerebral Infarction due to Embolism of Right Anterior Artery. R3's Care Plan, dated 2/3/25, documents the resident has an ADL (activity of daily living) Self Care Performance Deficit Impaired balance. RESTORATIVE PROGRAM - Bed Mobility: Staff will assist and encourage R3 to do as much as she can, requires 2 staff to reposition in bed. [RNA,CNA,ResN] (restorative nurse's aide, certified nurse's assistant, restorative nurse) ? Requires documentation. RESTORATIVE PROGRAM - Grooming: R3 requires verbal cueing, Staff will hand R3 a washcloth to bring to face to wash face and will assist with brushing hair. R3's MDS, dated [DATE], documents R3 is cognitively impaired and requires substantial/maximal assist with adls. R3's Electronic Record does not document restorative programs performed. R3's Physical Therapy (PT) Discharge (D/C) Summary, dated 1/28/2025, documents R3 was discharged from PT 2/18/2025. It also documents Discharge instructions: The patient will remain in LTC (Long Term Care) setting on RNP (Restorative Nursing Program) for PROM (Passive Range of Motion) and transfers. Restorative program established/trained = Restorative Range of Motion program, Restorative transfer. R3's Occupational Therapy Discharge Summary, dated 2/27/2025, documents R3 was discharged from Occupational Therapy on 2/27/2025. It also documents discharge instructions: Patient d/c'd to this facility. Would benefit from continued therapy services when insurance allows. Restorative Program established/trained = Restorative program on Range of Motion. R3's Care Plan and tasks do not document these restorative programs. On 3/12/2025 at 1:40 PM, V8, CNA, stated showers are not a priority. V8 stated when they are staffed they can get them done. V8 stated because they are short on staff everything can't get done. V8 stated they clean the private areas and clean the residents when they are incontinent or go to the toilet. V8 stated they prioritize, and when they are short, restorative and showers are not priority when you have the hall alone. V8 stated R3 doesn't have any restorative programs. V8 stated R3 was getting therapy. On 3/12/2025 at 2:19 PM, V7, CNA, stated the facility does have a staffing problem. V7 stated when they are short, they have to prioritize. V7 stated showers and restorative are not priority. V7 stated sometimes they don't get done. On 3/12/2025 at 2:05 PM, V6, CNA, stated she works the unit. V6 stated, For the most part, we are staffed on the unit, because we got a staffing tag. At times, there is 1 CNA. The residents are always moving, and require being always watched, and showers are not done. You can't leave the residents unattended for that long. On 3/13/2025 at 1:00 PM, V3, Therapy Director, stated, (R3) came to the facility from hospital with a recent stroke. (R3) initially recieved all 3 disciplines. (R3) is currently reciving speech therapy. (R3) has been discharged from therapy. Upon discharge, a restorative program was put in place, and the nursing staff was trained. The restorative program is to be completed by the nursing department. On 3/13/2025 at 2:42 PM, V11, CNA, stated they don't have restorative aides. V11 stated the CNAs do the programs and document it in the computer when completed. On 3/13/2025 at 3:00 PM, V12, CNA, stated they do the restorative programs. V12 stated they document it in the computer. On 3/13/2025 at 3:10 PM, V10, CNA stated R3 is on therapy and does not get therapy. On 3/13/2025 at 3:30 PM, V2, Director of Nursing stated they currently do not have a Restorative Nurse or aides. V2 stated the duties are split up, and they are working at getting it taken care of. The facility's Restorative Nursing Policy and Procedure, not dated, documents it is the policy of this facility to provide restorative nursing which promotes the resident's ability to adapt and adjust to living as independently and safely as possible.

Based on Interview and Record Review the facility failed to ensure a resident was free from abuse, from a resident with a history of prior altercations, for 1 of 6 (R4) residents reviewed for abuse in the sample of 6. Findings include: 1. R4's Face sheet documents an admitted [DATE]. Diagnosis include Unspecified Dementia with Agitation, Congestive Heart Failure, Respiratory Failure, and Malignant Neoplasm of Colon. R4's Minimum Data Set, MDS, documents R4 is severely cognitively impaired. R4 requires partial/moderate assist with transfers and mobility. R4's Care Plan, dated 2/19/2025, documents R4 has been identified as a vulnerable person related to cognitive deficit. R4 has the potential for aggression related to her cognitive deficit. Interventions include R4 at times will believe she recognizes residents as people from her past and will seek them out to confront them. Staff will provide redirection to other area of facility and offer activities of her choice. R4 will have 1:1 supervision with each resident-to-resident incident and sent to hospital for evaluation with 1:1 supervision for 24 hours after return. Staff educated completed regarding abuse and neglect. Trauma assessment will be completed with each incident involving another resident. R3's Face sheet documents an admitted [DATE]. Diagnosis include Metabolic Encephalopathy, Dementia, Hypertension, and Altered Mental Status. R3's MDS, dated [DATE], documents R3 is moderately cognitively impaired. R3 is independent with mobility and transfers. R3's Care Plan, dated 2/19/2025, documents R3 has potential to become aggressive related to dementia diagnosis. R3 has been identified as a vulnerable person related to diagnosis of dementia. Interventions include 1:1 supervision will be completed until R3 is sent to hospital for evaluation, and for 24 hours upon returning from hospital. Nursing will work closely with long term care psychiatrist related to medication reviews to ensure her needs are met. PHQ 9 assessment will be completed with each incident involving another resident. Trauma assessment will be completed with each incident involving another resident. When R3 is noted to be agitated, pacing or attempting to argue with others; staff will provide redirecting by offering a snack, glass of iced tea, or encourage R3 to participate in an activity of her choice. Staff to continue to redirect until redirection is successful. Facility Reported Incident, FRI, dated 2/14/2025 documents R3 and R4 were involved in an altercation. R1 observed R3 and R4 arguing and saw R3 open handedly strike R4 on left cheek. Staff initiated 1:1 supervision for R3. Head to toe assessment completed on both residents. No injuries. Parties notified. Police notified. R3 sent to hospital and 1:1 supervision resumed when R3 returned. Investigation immediately began. No staff witnessed incident. R1 stated R4 was sitting in wheelchair in 200 hall. R3 walked over to R4 and began yelling at R4 and open handedly struck R4 on left cheek. R1 yelled for help and staff immediately separated them. No other residents witnessed altercation. R3 and R4 were interviewed and did not recall incident. Assessments completed and IDT reviewed altercation. On 2/28/2025 at 2:45PM, V3, Assistant Director of Nurses/ADON, stated, (R3) and (R4) had more than 1 altercation. Their rooms were on the same hall, and each time (R3) went past (R4's) room, (R3) said things to (R4). We moved (R3) to another hall and that helped. (R4) discharged yesterday and we moved (R3) back to the previous hall, and she is now right across from the nurse's station. We kept (R3) and (R4) on 1:1 supervision for 24 hours after the altercation on 2/14/25. On 2/28/2025 at 3:00PM, R1stated, (R3) and (R4) did not like each other. (R3) slapped (R4) in the face. On 3/4/2025 at 1:00PM, V4, CNA, stated, I don't know about the altercation between (R3) and (R4), but we keep an eye on (R3). If we see her going down another hall other than the one her room is on, we redirect her. She is easily redirectable. She likes coffee so I will get her some coffee and take it to her room. On 3/4/2025 at 1:45PM, V6, CNA, stated, I did not witness the altercation between (R3) and (R4), but I did hear about it. We would try to always keep them apart. For some reason, they hated each other. We moved (R3) to another hall and would redirect her away from the hall (R4) was on. Since (R4) discharged , we have not had any issues with (R3). (R3) likes to stay up at the nurse's station. Facility policy, with a revision date of 1/2024, states, This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The resident must not be subjected to abuse by anyone in the facility. Will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. Annually, the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement.

Based on interview and record review, the facility failed to prevent physical abuse from occurring for 2 of 2 residents (R2, R3) reviewed for abuse in the sample of 7. Findings include: 1.) R2's face sheet, print date of 2/19/25, documented R2 has diagnoses of Alzheimer's disease with early onset, dementia, major depressive disorder, encephalopathy, amnesia, restlessness and agitation, and personal history of traumatic brain injury. R2's MDS (Minimum Data Set), dated 12/16/24, documented R2 is severely cognitively impaired. R2's care plan, print date 2/19/25, documented R2 has the potential to become aggressive related to dementia diagnosis. R2's progress note, dated 2/8/25 at 6:21 PM, documented R2 is experiencing a change in condition. The change in condition the resident is currently experiencing is hit another resident in the common area. Writer called to the hall and informed writer that R2 had held another resident's right forearm down and hit her closed fist on the left cheek. The incident was witnessed by CNA (Certified Nurse Assistant). R3's face sheet, print date 2/19/25, documented R3 has diagnoses of intellectual disabilities, hypertension, chronic kidney disease, cataracts, and hyperlipidemia. R3's MDS, dated [DATE], documented R3 is severely cognitively impaired. R3's care plan, print date of 2/19/25, documented R3 has the potential to become aggressive related to intellectual disabilities and that R3 has been identified as a vulnerable person related to intellectual disabilities. R3's progress note, dated 2/8/25 at 6:20 PM, documented R3 is experiencing a change in condition. The change in condition the resident is currently experiencing is resident on resident, this resident was hit by another resident. Writer was called to 100 hall by CNA. CNA informed writer that resident was involved in resident on resident in the common area. Another resident held R3's right forearm down and with a closed fist, hit R3 on the left side of her face. Skin assessment done, no redness, no bruising noted. The facility's final investigation, dated 2/14/25, documented on 2/8/25 it was reported to the department that R2 and R3 were involved in an altercation. Staff observed R2 hold R3's right forearm and with a closed fist strike her left cheek. Staff immediately separated the residents. It continues, V9, CNA, reports that she was standing in 100 assisting a family member when another resident yelled (R2) just hit (R3) in the face. When I approached them to separate them, R2 was holding R3's right arm, R3 was holding the left side of her face and said, get him away from me. V9 stated, I notified the nurse to ask for assistance, redirected (R2) away from (R3), and my nurse instructed me to stay with R2 1:1 until R2 is transported to the hospital. 2.) R1's face sheet, print date of 2/19/25, documented R1 has diagnoses of chronic atrial fibrillation, congestive heart failure, diabetes, conduct disorder, dementia, brief psychotic disorder, chronic kidney disease, and hypertension. R1's MDS, dated [DATE], documented R1 is severely cognitively impaired. R1's care plan, print date of 2/19/25, documented R1 has the potential for aggression related to dementia diagnosis. R1's progress note, dated 2/11/25 at 11:46 AM, documented this resident is experiencing a change in condition. The change in condition the resident is currently experiencing is resident hit another resident on the hand and knocked him down. Resident hit another resident causing a skin tear to other resident's right hand. Resident placed on one on one immediately. R2's progress note, dated 2/11/25 at 11:32 AM, documented the resident is experiencing a change in condition. The change in condition the resident is currently experiencing is resident was hit on the hand by another resident. Nurse applied 2 steri-strips and a band-aid per NP (Nurse Practitioner) direction. The facility's initial report to IDPH (Illinois Department of Public Health), dated 2/11/25, documented R1 and R2 were involved in a resident-to-resident altercation. The residents were immediately separated and placed on increased supervision. Licensed Nurse performed a head-to-toe assessment noting a skin tear to the top of R2's hand. The MD (Medical Doctor), POA (Power of Attorney), Ombudsman, and the local police department have been notified. Witness statement, dated 2/11/25, by V5, CNA, documented at10 AM, I was assisting resident going to the bathroom. I heard a resident yell and a couple other residents yelling. I went to check, and I found (R1) on his knees leaning over (R2) saying I told you I was going to hit you, Resident told me He started stuff, so he hit him. (R1) got up and tried to pull (R2) up while dragging him. I asked the resident to let go and step away to distract him. Witness statement, dated 2/12/25, by V10, CNA, documented, around 9:50 stepped out to warm up coffee for (R1) when I came back another resident was on the floor and (R1) said 'I didn't want to have to hit him. I slapped him.' Resident had a wound to right hand when we looked over resident that he said he hit. On 2/19/25 at 12:10 PM, V5, CNA, stated she did not observe R1 hit R2 on 2/11/25, but she did observe R2 lying on the floor with R1 standing over R2. V5 stated she then observed a skin tear on R2's right hand. On 2/19/25 at 2:36 PM, V7, Regional Nurse, stated the altercations did occur between R1 and R2 and between R2 and R3. V7 stated the altercation between R1 and R2 was not witnessed, so the facility is unable to substantiate R2's skin tear was caused by R1. The facility's final investigation of the resident-to-resident abuse between R1 and R2, dated 2/20/25, documented following the investigation, based on interviews from staff, the facility is not able to determine a physical resident-to-resident altercation. Staff stated that (R2) was sitting on the floor, and it appeared that (R1) was attempting to pull him. Staff did report that (R1) was yelling I told you I was going to hit you, but this was not witnessed. (R2) did sustain a skin tear to his right hand, but based on the statements from staff the facility, cannot determine if the skin tear was a result of the fall, or an altercation between the two residents. The facility's Abuse, Prevention and Prohibition Policy, revision date of 1/24, documented, Statement of Intent: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Policy: This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. Annually, the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement. Abuse Prohibition Program: The facility's abuse prohibition program includes the following seven components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response. The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. It continues, Prevention: The resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse; corporal punishment and involuntary seclusion. The owner, licensee, Administrator, employee, or agent of the facility shall not abuse or neglect a resident and must prohibit the misappropriation of resident property. Resident behaviors will be monitored for changes, which trigger abuse behaviors. The facility will reassess care plan interventions on a regular basis. Intervention strategies based on resident screenings will be implemented to prevent occurrences of abuse. It continues, Resident-to-Resident Altercations: When another resident is the alleged perpetrator of the abuse, a licensed professional shall immediately evaluate the resident's physical and mental status, care plan, monitor behaviors and notify the physician for a determination regarding treatment and/or discharge options. Residents will be referred for behavior management when indicated. Changes in room assignments and seating arrangements will be recommended as needed. The safety of other resident and employees of the facility is of primary concerns. Not every resident-to-resident altercation result in abuse. For example, infrequent arguments or disagreements that occur during the normal social interactions would not constitute abuse. Resident to Resident abuse includes the term willful. The word willful means that the individual's action was deliberate (not inadvertent or accident), regardless of whether the individual intended to inflict injury or harm. An example of a deliberate ('willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. It continues, Definitions: Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking.

Based on interview and record review, the facility failed to notify law enforcement of an allegation of sexual assault for 1 of 1 resident (R2) reviewed for reporting abuse in a sample of 6. Findings include: Local law enforcement report, dated 1/5/2025, documented, On 01/05/2025 at approximately 0120 hours, I, (V12, officer at local police department), was on routine patrol when my dispatch advised me of a nurse from (Regional Hospital) was needing to speak with me in reference to a sexual assault report she had just recently taken. The nurse, (V13, Sexual Assault Nurse Examiner/SANE, Registered Nurse) RN, was transferred from dispatch to my cell phone. R2's Regional hospital record, dated 1/5/2025, V13, SANE RN, documented, Writer contacted (local police department) and spoke with officer (V12, officer at Local Police Department.) Writer reported what was happening to the officer and officer gave a phone number for writer or (regional law enforcement agency) to contact him. (Regional law enforcement agency) was contacted at 1:15 am. On 1/07/2025 at 10:20 AM, V5, Admissions Coordinator, stated she was the weekend manager on 1/4/2025, in the facility that day, and was talking with R2 to finish her re-admission paperwork. V5 stated R2 stated to her that she was sexually assaulted in a grocery store. V5 continued to state she made sure R2 was safe, she let R2's nurse know what she had said to her, and she immediately called the Director of Nurses, since the Administrator had just quit. The Director of Nurses did not pick up her phone, so she called V2, Assistant Director of Nurses. V2 told her to get the statements from the staff that were there. V5 continued to state R2 has been in and out of the hospital recently and she just got back from the hospital that week. On 1/07/2025 at 12:45 pm, V2, Assistant Director of Nurses, stated she did not call the police because she got busy with the investigation, and then she saw where the hospital notified them in the hospital paperwork, so she did not call the local police. The facility's policy, Abuse, Prevention and Prohibition Policy, dated 1/2024, documented, An employee and agent or any Covered Individual will make or cause a report to be made to law enforcement and the facility.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopements for 1 of 8 residents (R49) reviewed for supervision to prevent elopements in a sample of 57. This failure resulted in an Immediate Jeopardy when on 8/17/24 at an unknown time, R49, who has a known history of elopement attempts and dementia, eloped from the facility without staff knowledge and was located 60 miles away from the facility. The Immediate Jeopardy began on 08/17/24 when R49 eloped from the facility without staff knowledge. R49 was last seen in the facility on 8/17/24 at 11:30 , and was found 60 miles away at his past home residence. Due to R49's physical and cognitive vulnerabilities, R49 had the likelihood of serious harm and injury when R49 eloped. V1, Administrator, and V33, Regional Director, were notified of the Immediate Jeopardy on 09/19/24 at 2:00 PM. Surveyors confirmed by observation, record review, and interview, the Immediate Jeopardy was removed 9/23/24 but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of staff's in-service training, and implementation of interventions for those at risk for elopement. Findings include: R49's Admission Record, with an original admitted [DATE], documented R49 has diagnoses of, but not limited to: diastolic congestive heart failure (CHF), Type II diabetes mellites with chronic kidney disease, repeated falls, end stage renal disease, dependence on renal dialysis, and dementia. R49's Minimum Data Set (MDS), dated [DATE], documented R49 is severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 07 out of 15, and he requires setup/clean up assistance with his activities of daily living (ADL) and is independent with bed mobility and transfers. R49's Elopement Assessment, dated 03/11/24, documented R49 was cognitively impaired, and was not at risk for elopement. R49's Progress Note, dated 04/06/24 at 16:23 (4:23 PM), documented Front door alarm was sounding. Writer was on the hall and went to the front door to check on alarm. Nobody was standing at the front door. Writer went outside to investigate who set the alarm off. Resident was walking back toward front door with walker with CNA (Certified Nursing Assistant) assisting him. CNA was outside returning from break when she noted this resident walking outside in front of the building to the facility van by himself. CNA was assisting resident back inside. Writer stayed with resident and CNA. Resident noted to have confusion and said he needed to meet at the van because the girl that gives rides was going to bring him home. Resident assisted back into facility without incident. Resident's nurse was updated. Resident went to his room to rest for a little while. R49's Elopement Assessment, dated 05/01/24, documented R49 is cognitively impaired, has history of elopement, desire to leave the facility, and anger issues relate to placement in the facility. It also documented, What interventions were put in place to prevent resident from eloping? Picture in elopement book, frequent visual monitoring, and provided with distracting activity. R49's Care Plan, print date of 09/19/24, documented Date Initiated: 05/01/2024, Focus: (R49) is an elopement risk/wanderer as evidence by (AEB) history of attempts to leave facility unattended. He believes someone is coming to take him home. Goal: The resident will not leave facility unattended, and the resident's safety will be maintained through the review date. Interventions include but are not limited to Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate and resident not allowed outside of community independently, initiated on 04/06/24. R49's Progress Notes, dated 05/09/2024 at 03:33 PM, documented Dialysis called and informed staff that patient (R49) was restless and attempting to leave. Did complete his treatment. Dialysis staff is requesting a possible sitter to be with patient during treatments. R49's Progress Notes, dated 05/10/2024 at 09:34 AM, documented the Social Worker from dialysis called the facility to make them aware R49 is exit seeking at their facility and he attempted to get in someone's vehicle, and she wanted to discuss the situation over with V14, Social Services, and see what they can come up with for a solution. R49's Progress Notes, dated 05/17/2024 at 01: 06 PM, documented dialysis called V14, Social Services, to express a concern with the elopements and agitation they are experiencing with R49 when he goes to dialysis. Dialysis informed V14 there is a policy in place that states in a circumstance such as this, the facility is to supply a sitter for R49 as he takes dialysis. V1, Administrator, states the facility will have a sitter for tomorrow's services as it is one of his scheduled days. R49's Progress Notes, dated 08/16/2024 at 02:04 PM, documented R49 was going outside facility in courtyard. Writer reminded R49 he was not supposed to be going outside without supervision, he became upset, was yelling at staff to leave him alone, and refused to come back inside the facility. On 09/18/24 at 09:25 AM, V24, Licensed Practical Nurse (LPN), stated before the incident on 8/17/24, she had seen R49 go out the back door where the smokers sit, and she explained to him that he needed supervision while he was outside. She said if they have someone who tries to get out the doors have alarms on them and will sound. R49's Progress Notes, dated 08/17/24 at 01:30 PM, documented elopement reported to writer and elopement policy followed. R49's Police Report, dated 08/17/24 at 2:01 PM, was reviewed and documented, (V53, Local Police Officer), was dispatched to the report of a missing person at a local nursing facility. At approximately 2:09 PM, (V53) arrived at the facility where numerous staff were searching nearby areas for (R49), and two county officers (V54 and V55) were already on scene. (V54) had already spoke with (V1, Administrator) and got all (R49's) personal information and what he was last seen wearing. Dispatch had advised (V53) there was a possibility (R49) was with his wife (V30). (V1) was asked if (R49) had left on foot and (V1) advised (V53) that no one had seen (V30, R49's wife), but they have had numerous issues with her wanting to take (R49) in the past. (R49) has limited mobility, and his wheelchair was still in his room, so more than likely (R49) was with (V30). (V1) had informed the officers (R49) had a legal court appointed guardian (V31), and he wasn't supposed to leave the facility. (V1) also stated (V30) was allowed to visit (R49), but she was aware she was not allowed to take him. (V54) had the local county telecommunicators obtain (V30's) vehicles registration information. Once (V54) had the car information he checked them with the License Plate Readers (LPR) located in the county and had two responses, one at 10:07 AM in another town, and one locally at 10:21 AM. (V54) had the local sheriff's office reach out to the county sheriff's office where (V30) resides to see if (R49) and (V30) were there. (V54) and (V55) cleared the scene and (V1) wished to enter (R49) as a missing person. At approximately 2:45 PM the next county sheriff's office made contact with the local sheriff's office and stated that a deputy had made contact with (V30) at her home where she told the deputy that (R49) is here he needs to be and slammed the door in the deputy's face. At approximately 5:41 PM (V56, [NAME] for the other sheriff's office) contacted (V53) and informed him they had (R49) in their custody now after locating him at (V30's) residence. (V1, Administrator) then asked the police and sheriff's office to take (R49) to the local hospital to be evaluated prior to coming back to the facility. At approximately 6:24 PM, (V1) was updated on (R49) and told he was being taken to a local hospital and that the facility would have to transport (R49) back to the facility themselves. R49's Illinois Department of Public Health (IDPH) Elopement Investigation, dated 08/17/24, documents, at approximately 1:30 PM, documented this letter is to notify the department of a final report regarding a resident that was possibly missing from the facility. On 08/17/24 at approximately 1:30 PM a licensed staff reported to the administrator that staff were not able to locate (R49), the Elopement policy was implemented immediately, and an investigation was initiated. (R49's) physician and guardian along with the ombudsman and police department were notified. (R49) is alert with confusion and has a BIMS (Brief Interview for Mental Status) of 7 and he needs assistance with his ADLs. (R49) has diagnose of dementia, anemia, diabetic, depression, HTN (hypertension), and receives dialysis treatment The staff immediately started searching the facility and the facility grounds and then extended the search per policy. A 100% head count was completed validating all residents were accounted for. A staff member was designated to imitate a timeline of events. The police were provided with a description of the resident and the clothing he was wearing. Attempts were made to contact the resident's spouse, and a message was left to call the facility back. The police contacted the administrator and reported they were able to ping the resident's spouse car indicating she was in a town not far from the facility. Staff were interviewed, they stated they did not witness resident's spouse in the facility, residents were interviewed, and they had no knowledge of residents leaving the facility. At 3:25 PM the police department notified V1, administrator that (R49) was with his spouse at their residence in another town. The police reported they knocked on the door, (V30) answered the door, and then closed the door on the police. The police notified the facility at approximately 5:50 PM they were able to talk with (V30) and (R49) left the residence with the police officers without incident. The police department stated they wouldn't be transporting (R49) back to the facility. (V1) requested (R49) be taken to the hospital for an assessment and the facility would provide transportation back to the facility. R49's Elopement Assessment, dated 08/18/24, documented R49 is cognitively impaired, has history of elopement, desire to leave the facility, and anger issues relate to placement in the facility. It also documented What interventions were put in place to prevent resident from eloping? Picture in elopement book, frequent visual monitoring, provided with distracting activity, and moved resident to a secured unit. R49's Care Plan was updated to include the following information after his elopement on 08/17/24. R49 has been moved to the memory care unit, 1:1 supervision times 24 hours, if no issues, R49 will change to visual checks every 15 minutes times 24 hours, if no issues, they will chant to visual checks every 30 minutes times 24 hours, and if not issues R49 will be re-evaluated at that time. Resident is not allowed outside of community independently, and R49 has a past history of plotting a plan to leave the facility with V30. Staff should observe for this behavior and prevent it from happening. 09/17/24 02:14 PM, V31, State Appointed Guardian, stated she is a lawyer in a surrounding county and was appointed by the court to be R49's legal guardian due to there not being anyone else to do it. She said on the day of the incident, she received 2 missed calls that she believes was from the facility, but there were no messages left. She said she doesn't answer numbers she doesn't recognize on the weekends, but if they would have left a message, she would have called them back. V31 said when she returned to work on Monday after the incident, she had 2 or 3 emails from the facility regarding R49 leaving the facility. She said from what she knows, the wife came into the facility after parking in the hospital parking lot. She (wife) got R49 up and walked him back to her car. Wife confirmed it with her too. She said the facility called law enforcement and they were dispatched to the county where his wife had taken him back home. She said his wife had a standoff with the police and slammed the door in the police officers face. V31 said his wife (V30) eventually opened the door and let law enforcement in, and they were able to get R49 out of the house. The facility requested R49 be taken to the emergency room (ER) to be cleared before he was taken back to the facility. V31 said she became involved when there was a founded case of neglect made by adult protective services, they filed a petition for public guardian because there wasn't anyone to care for him. After the incident with his wife taking him home, an order of protection/restraining order was put into place. On 09/17/24 at 3:25 PM, this surveyor knocked on R49's door, introduced self, and asked if I could ask him a few questions. R49 said to come on in and have a seat. R49 was asked if he remembered the incident in August when he went home with his wife. He said he thinks he remembers it. This surveyor asked if R49 could tell me about it. R49 stated his wife parked over at the hospital parking lot, he walked up the hill, met her in the car, and they went home. He was asked if his wife came over to the facility and got him and he said no, they had made plans a while ago to do this. He said but the straw that broke the camel's back was he went into Social Services (V14) and asked when they were going to release him, and she told him he wasn't going to be released until the end of January. He said he can't leave his wife for that long; she depends on him. When questioned how he knew when to go over to meet his wife and how she knew what time to be there to get him R49 stated he had to call her to let her know. He said they went home, then the police came to get him, and so there wouldn't be any ramifications for his wife, he returned to the facility. R49 said after this, the District Attorney forbid him to talk to his wife, and if he did there would be consequences. On 09/18/24 at 10:21 AM, V14, Social Services, was interviewed at this time about the conversation she had with R49 the day before he eloped. V14 stated she came in and made rounds like she does every day. She said R49 was lying in bed, and she asked him how he was doing. V14 said he was going on about what is going on with him and court, and how he hates it. She said she tried to get him to go out to activities and he just acted like he didn't hear her, and he just laid back down in his bed. V14 stated she never had a conversation with R49 that day about discharging him. She said when it comes to talking with him about discharges, she watches what she says because she doesn't want to get his hopes up just to let him down. V14 said she was working on the day of the incident and that she had just come in to help by taking residents to their appointments (dialysis). V14 said she was between transports when they notified her they couldn't find R49. V14 said the CNAs were prepping for lunch when they noticed they couldn't find R49. She said they made the call over the intercom and began searching for R49 and she immediately started the elopement process, called V1, Administrator and V2, Director of Nursing. V14 stated if someone is an elopement risk, they would be in the elopement book. She said R49 use to sit up by the front door area and just hover around, and he would think every vehicle that he saw was here to pick him up. She said as far as she knows, R49 had never tried to elope before this incident. V14 said she has talked with Adult Protective Services (APS), and she was informed by them that there were issues with R49's previous living conditions. She said they told her there was a substantiated neglect case involving V30, R49's wife. V14 said there were issues when APS went to talk with V30, and she wouldn't let them in the house. V14 said when APS was finally able to enter the house, they found the house was in deplorable conditions. She said they told her there was feces lying around the house, lack of food, some safety issues regarding R49 using the stove by himself and leaving it on for multiple hours, and R49 not making it to his dialysis appointments. They said the wife was showing signs of confusion; that is how APS got involved in the situation. Their son/daughter notified APS and telling them their mom was very confused, agitated, and all over the place. On 09/18/24 at 10:45 AM, V1, Administrator, was interviewed at this time regarding the elopement of R49. She said she wasn't in the facility at the time of R49's elopement. She said when staff discovered R49 was not able to be located they notified her, and she immediately came in. She said they called 911, and the staff then searched the outside of the facility. She said the police and the local county sheriff's department even came out and helped with the search. V1 said V30 was known to come to the facility on the weekend or in the late evening to see R49. V1 said the police were able to look at cameras and they got a ping for V30, and she was headed toward the facility, so they then notified other police departments about the situation. She said they sent police to V30's house and when they got there V30 wouldn't let them in, and she slammed the door in their face. V1 said the police were finally able to get R49 out of the house, and she wanted R49 checked out at the hospital before coming back to the facility. V1 stated she doesn't recall R49 having eloped from the facility any time prior to this incident. V1 said she doesn't know much about R49 and the APS situation. She said all she really knows is R49 was deemed not safe at home with V30. V1 said prior to this incident, V30 was able to talk with and come and visit R49, but now there is an order of protection, and they are not supposed to have any contact with each other. V1 stated since the order of protection (OOP), V30 tried to come and visit one time, but the police were called immediately, and she was removed. On 09/18/24 at 11:07 AM, V1, Administrator, stated the facility doesn't use electronic monitoring devices. 09/19/24 10:35 AM, V65, CNA, stated the other CNA (V66) that was working on 08/17/24 with her, was the one who noticed R49 was not able to be found. V65 stated V66 noticed around lunch time, and came and told her she thinks R49 is gone. V65 said she knew he wasn't gone to dialysis, so they looked at the sign out book, didn't see where anyone had signed R49 out, so they checked with R49's friend to see if he had seen him, but he hadn't, so they immediately started working together checking the hallways, they did a head count, and then they did a sweep outside of the building, but were still unable to locate R49. V65 stated they don't know what door R49 went out and no identified alarms went off that she knows of. On 09/25/24 at 2:27 PM, V2, Director of Nursing (DON), and V33, Regional Director, stated they would expect staff to supervise the individuals who were an elopement risk. Monitor with supervision and make sure their care plans are up to date. On 09/18/24 at 02:02 PM, V32, V29's Nurse/ Licensed Practical Nurse (LPN), called this surveyor back and stated she had spoken with V29, R49's primary care physician (PCP), at the time of the incident, and asked him if he thought R49 would be safe outside of the facility by himself, and remember to take his medications and to go to his dialysis appointments? V32 said V29 stated, no he does not think R49 would be safe outside of the facility by himself and doesn't think he would remember to take his medication or go to his dialysis appointments. The facility's Elopement policy, with a reviewed date of 05/2023, documents, Policy It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans. Responsibility All staff is responsible. Definitions For the purpose of this policy, missing resident shall be defined to mean a resident who has left the facility grounds without signing him/herself out of the facility. It also documents Environmental Considerations for the Prevention of Missing Residents and Elopements. 1. Residents who are at risk for elopement shall be provided at least one of the following safety precautions by the facility: Door alarms on facility exits; and /or a personal safety device that will alert facility staff when the resident has left the building without supervision (i.e.: Code Alert or Wander guard bracelet/anklet system); and/or staff supervision. It further documents Routine procedures for prevention of missing residents and elopements or attempted elopements. 1. Using the MDS resident assessment schedule, all residents shall be reviewed for safety concerns and precautions. Residents at risk for elopement shall be identified and documented in the individual plan of care. 2. Unless otherwise identified in a plan of care, residents who are a risk for possible elopement shall be accompanied when leaving the facility grounds. The resident representative shall sign the resident out of the facility on the resident sign-out sheet. The facility presented an abatement plan to remove the immediacy on 9/19/24. During the validation of the abatement by the survey team on 9/23/24, multiple observations from 8AM-11AM, residents were observed inputting the door alarm to the smoking patio. V1 stated the facility attempted to change the door alarm code, but the system was reverting to the original code. V1 stated the door alarm company would be out later today to fix the alarm code issue and the facility will have a staff member sitting outside the smoker's patio door to ensure residents are not using the old code. At 3:07PM, the facility provided an updated abatement plan to reflect the door alarm was changed and working as of 9/23/24. The Immediate Jeopardy that began on 08/17/24 was removed on 09/23/24, when the facility took the following actions to remove the immediacy. The facility provided an abatement plan that included the following: -On 8.17.24, at approximately 11:30 AM, staff observed the resident (R49) ambulating alone and assisted him to his w/c (wheelchair). At 1:30 PM staff were unable to locate the resident (R49) for lunch meal. The facility staff notified the Administrator (V1) and the Director of Nursing (V2) at 1:50 PM. V14, SSD, was designated person to record the sequence of events. At 1:55PM the regional nurse was notified by the Administrator (V1). The Regional Nurse notified the Director of clinical Operations at 1:57 PM. A 100% validation of residents being accounted for by completed head count was done at 1:58 PM per the facility policy. The interior building was searched and completed at approximately 2:00 PM. The Administrator (V1) notified the Police Department at 2:00 PM and a description was provided to the police. The police were notified of the R49's clothing as he was wearing a yellow polo shirt and PJ pants with slippers. The weather for the day was sunny with a temperature of approximately 83 degrees. Attempts were made to contact R49's spouse at 2:06 PM with no answer. A message was left to return the call. At 2:06 PM the County Sheriff was notified. R49's guardian was notified by phone and email at 2:15 PM. R49's physician was notified by phone at 2:15 PM. At 2:30 PM, V1 went to the area hospital to check to see if R49 was located there and later a call was made to follow-up. At 3:25 PM, the Administrator (V1) notified the State Survey Agency by email. At 551 PM V1 was notified by the County Sheriff Dispatch that the police have R49. R49 was transported to the hospital for evaluation per Administrator's (V1's) request. At 6:00 PM, R49's guardian was made aware R49 was with the police and was being transported to the ER for evaluation. At 6:15 PM, R49's was notified the resident (R49) was with the police and was being taken to the hospital for evaluation before returning to the facility. R49 returned to the facility with no injuries. The Elopement assessment was updated. The resident's (R49's) care plan was reviewed and updated. The resident (R49) was assisted to the memory care unit. The resident's (R49's) guardian is aware. On 8.17.24 The facility completed the following corrective actions: -The DON (V2) and the Administrator (V1) initiated staff re-education on the elopement policy and procedure. All staff was educated within 24 hrs., no staff worked without being educated. -The door alarm policy including door alarms should never be shut off or disengaged for any reason. -Emergency Ad Hoc QAPI meeting was held on 8.17.24 to discuss plan. -Medical Director notified at 2:15 PM on 8.17.24. -On 8.17.24 100 % of staff were educated within the first 12 hours. -8.17.24 Care plan for the resident (R49) involved has been revised to include resident specific interventions related to the resident's (R49's) risk for elopement. -8.17.24 100% Audit of the elopement risk assessment for all facility residents has been completed. -8.17.24 The facility residents that trigger at a risk for elopement have had their care plans reviewed and revised to include resident specific interventions. The Facility has a book in place with pictures and pertinent information of residents that trigger at risk for elopement. Staff can identify where the book is located. Door codes to be changed and staff educated that at no time are residents to be given the door alarm code. Staff are to input the code for anyone needing to exit the community. Ongoing The facility will provide ongoing education to all new employees and agency at the time of hire on the facility elopement policy and procedure and the door alarm policy. Education will be provided prior to a new employee being allowed to work in the facility as well as agency staff members. Concerns will be addressed immediately and discussed during the monthly QAPI (Quality Assurance Performance Improvement) Committee for resolution. On 9/19/24, at 2:00 PM, it was determined by the Illinois Department of Public Health that the facility was not in compliance. During the annual survey, a request was made to review the file of the Elopement that occurred as stated above. At 2:00 PM, a surveyor and her supervisor discussed an IJ violation with V1, Administrator and the V33, Regional Nurse, regarding the elopement. A template was emailed to the Administrator. The Administrator immediately initiated an abatement. The facility has individualized care plans for all residents with their specific interventions. Staff have been educated on the location on the elopement books and how to look at PCC (Point Click Care) and POC (Plan of Care) to ensure they know which residents are high risk and the interventions are in place. Staff members are and will continue to be in-serviced on new interventions put into place. All staff members were in serviced on 9/19 on how to locate interventions on Kardex and Care plans. R49 was placed on 1:1 in memory unit for the first 24 hours, then for 15-minute checks for 24 hours, 30-minute observations for 24 hours and no issues were identified upon return to facility. Staff continue to provide 1:1 supervision to resident while at Dialysis. He remains a resident on the Memory unit. What interventions implemented for R49 on the unit to ensure he doesn't attempt to elope from the unit? The resident remains on the secured courtyard unit where the door alarms sound if a resident attempts to leave without entering a security code. Doors are managed by an egress exiting. The exterior courtyard is secured by a gate that is alarmed. Following the initial incident, the immediate action included the above-mentioned 1:1 care and 24-hour checks. With the increased monitoring it was identified the resident was not exit seeking and the increased monitoring was removed, and is now managed in accordance with facility policy and procedure. -The Elopement Policy and Procedure was reviewed by V1, Administrator, V67, Regional Director of Operations, and V33, RN Regional Nurse, on 9/19/24 at 4:00 PM. -V33, Regional Nurse, V2, DON (Director of Nursing), and the V1, Administrator, immediately initiated education on the Elopement Policy and Procedure on 9/19/24 at 2:45 PM to all staff. All staff educated on location of Elopement books and identifiers of POC and PCC. No staff are to work without receiving education. -V33, Regional Nurse, V2, DON, and the Administrator, V1, immediately initiated education on the Door alarm policy including door alarms should never be shut off or disengaged for any reason on 9/19/24 at 2:45 PM to all staff. -An Ad Hoc QAPI was completed including V40, Medical Director, to discuss the plan on 9/19/24 at 4:50 PM by V1, Administrator, and V33, RN Regional Nurse. -V40, Medical Director, was notified on 9/19/24 at 4:50 PM. -All residents have been reviewed and completed for risk of elopement on 9/19/24 by 4 PM. The assessments were completed by V14, Social Service Director (SSD), V24, MDS, and V68, Admission Coordinator (AMC). -All residents identified at high risk for elopement have current care plans that have been reviewed for appropriate interventions on 9/19/24 by 5 PM. The high risk for elopement care plans were reviewed and updated by V24, MDS. Ongoing: -All staff will be educated at the time of hire on the Elopement Policy as part of the orientation process by the V1, Administrator or designee. -All staff will be educated at the time of hire on the door alarm policy as part of the orientation process by the V1, Administrator or designee. -Elopement drill will be completed Quarterly. -V14, SSD, will randomly question 5 staff per week on what to do in the event there is an elopement. Date of Compliance: 9/23/24

Based on interview and record review, the facility failed to prevent the verbal and physical resident to resident abuse for 4 of 4 residents (R17, R31, R32, R49) reviewed for abuse in the sample of 57. This failure resulted in R49 grabbing a large fist of R32's hair and pulling it out of her scalp. Findings include: 1. R32's Admission Record, with an original admitted [DATE], documents R32 has diagnoses of, but not limited to: Alzheimer's Disease, Type II Diabetes Mellitus, and Hypertension (HTN). R32's Minimum Data Set (MDS), dated [DATE], documented R32 is severely cognitively impaired and requires partial/moderate assistance with oral hygiene, upper and lower body dressing, substantial/maximal assistance with toileting hygiene, putting on/take off footwear, personal hygiene, dependent on staff with shower/bathe, and she is always incontinent of bowel and bladder. R32's Care Plan, dated 09/26/24, was reviewed, and no documentation was noted regarding R32 being at risk for abuse. R49's Admission Record, with an original admitted [DATE], documented R49 has diagnoses of but not limited to diastolic congestive heart failure (CHF), Type II diabetes mellites with chronic kidney disease, end stage renal disease, dependence on renal dialysis, and dementia. R49's MDS, dated [DATE], documented R49 is severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 07 out of 15, and he requires setup/clean up assistance with his activities of daily living (ADL) and is independent with bed mobility and transfers. The facility's Illinois Department of Public Health (IDPH) initial investigation, dated 09/21/24 at 4:32 PM, documented, the administrator was notified at 3:55 PM of an incident that had just occurred between resident (R32) and (R49). (R49) allegedly pulled (R32's) hair, the two residents were immediately separated, Power of Attorney (POA), Primary Care Physician (PCP), Ombudsman, and local police department were notified of incident. Licensed nurse performed head to toe assessment. Investigation started and final report to follow. R32's Progress Notes, dated 09/21/24 at 4:01 PM, was reviewed and documented, Situation, Background, Assessment, and Recommendation (SBAR) (R32) was harmed by another resident (R49) at the facility. (R32) noted to wander into (R49's) room. Writer was at the nurse's station when they heard yelling coming from (R49's) room. The writer entered (R49's) room (R49) was noted to have pulled out a fist full of (R32's) hair. Both residents were immediately separated with the help from the other nurses on duty. Vital signs (VS) taken/range of motion (ROM)/Neuros within normal limits (WNL). (V1, Administrator) was called and notified. (R32's) husband and physician were notified. R49's Progress Notes, dated 09/21/24 at 4:34 PM, documented SBAR assessment for further information and family/physician notification. The change in condition the resident is currently experiencing is Resident to Resident event. (R49) noted to harm another resident. Writer was at the nurse's station when he heard yelling coming from (R49's) room. Writer and CNA went into (R49's) room and found (R49) ripped out a chunk of another resident's hair. Residents were immediately separated with help from other nurses on duty. (V1, Administrator) and (V77, Nurse Practitioner), was called and notified with new order (N.O.) to monitor patient 1:1. Attempted to call (R49's) guardian unable to reach, voicemail (vm) left. V69, Licensed Practical Nurse (LPN), statement, undated, documented on Saturday 09/21/24 a CNA stepped off of the 100-hallway to request additional assistance from of the other nurses in the facility. When V69, Licensed Practical Nurse (LPN) arrived at the unit she noted a large mass of hair lying on the floor outside of R49's room. V72, LPN was in the room with R32. R49 was walking down the hallway with a CNA and his face was red with an angry expression. V69 said she went into R49's room, and R32 was observed sitting on the floor between bed one and two with her back up against bed two, and some of R32's hair was noted to be at the foot of bed two. V69 said she checked the back of R32's head, there was no bleeding noted, but there was a large bald patch in the back of her scalp. Vital signs (VS) obtained, range of motion (ROM) within normal limits (WNL). V69 and the CNA assisted R32 up the CNA and another nurse assisted R32 to the toilet. On 09/25/24 at 2:37 PM, R32 was sitting outside in the courtyard with other residents. R32's hair/head was observed, and there was an approximate softball size area on the back of R32's head where she had hair missing. On 09/25/24 at 2:40 PM, V9, Certified Nursing Assistant (CNA), and V25, CNA, stated R32 usually has thick hair. V25 said when she came into work yesterday, she asked other staff what had happened to R32, and they told her staff heard a scream and went down the hall and they found R32 on the floor, and they had to pull R49 off R32, and he had her hair in his hands. She said R49 has threatened other resident's before, but he has never actually done anything to anyone. V25 stated R32 does wander on the unit. V25 said she is glad R49 is in the hospital at this time, because she is scared something else would happen. On 09/25/24 at 2:27 PM, V2, Director of Nursing (DON) and V33, Regional Director, stated they would expect staff to provide activities, attempt to keep them separated, if possible, redirect frequently, and to use the intervention they put into place. The facility Abuse, Prevention and Prohibition Policy, revision date of 1/24, documented Statement of Intent: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It continues, Resident to Resident Altercations: Resident to Resident abuse includes the term willful. The word willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. 49494 2. R31's Face Sheet, dated 9/24/24, documented R31 has diagnoses of COPD (Chronic Obstructive Pulmonary Disease), benign prostatic hyperplasia, muscle weakness, hyperlipidemia, PTSD (post-traumatic stress disorder), depression, hypertension, obstructive and reflux uropathy, chronic migraine, and low back pain. R31's MDS, dated [DATE], documents R31 is cognitively intact. R31's Care Plan, print date 9/17/24, documents R31 has a behavior problem related to cursing about his loss of independence and showing signs of frustration. The Care Plan documents R31 suffers from PTSD related to his military background. R31's care plan documented R31 will show signs of PTSD and staff interventions could include: 1. Ensuring resident's and other residents' safety while PTSD is displayed. R17's Face Sheet, dated 9/24/24, documented resident has diagnoses of end stage renal disease, type 2 diabetes mellitus, psychotic disorder with delusions, pseudobulbar affect, muscle weakness, anxiety disorder, major depressive disorder, auditory hallucinations, cerebral infarction, schizophrenia, cognitive communication deficit, legal blindness, cardiomyopathy, heart failure, and hypertension. R17's MDS, dated [DATE], documented resident is moderately cognitively impaired. R17's care plan, print date 9/24/24, documented R17 has a mood problem related to depression and anxiety. R31's Progress Note, dated 8/30/24 at 5:16 PM, documented Patient made threatening comments about the neighbor patient yelling. Stating 'if she keeps doing it, I am going to shove a sock down her throat.' Education provided about behaviors and how legal action would be taken if such an event happened. Patient stated, 'I don't give a s***.' R31's Progress Note, dated 9/2/24 at 5:58 PM, documented, (R31) was in the hallway at this nurse's med cart to get medications when another resident, that was sitting in her room, started hollering. (R31) hollered loudly, Shut the f*** up. The other resident stated, you shut up you mother *****. This resident states, shut the f *** up or I will come in there and rip your f****** throat out. This nurse tried to calm resident and explain to him that he cannot talk to other residents that way. Resident wheeled down the hall to go outside. (V1, Administrator) and Doctor (V20) notified. Will continue to monitor. The Facility's Investigation, undated, documented the Administrator was notified of an incident involving R31 and R17. Staff members reported that R31 yelled at R17 to shut the f*** up and R17 yelled back calling him a mother f*****. R31 then yelled at R17 that he would cut her throat out. On 9/19/24 at 7:55 AM, V38, Certified Nurse's Aide/CNA, stated she was working the night R31 and R17 verbally abused one another, but she did not witness it. V38 stated another coworker told her about the occurrence, and she does not know what intervention was put into place to keep it from happening again. On 9/19/24 at 9:02 AM, V19, CNA, stated she witnessed the abuse incident between R31 and R17 on 9/2/24. V19 stated she heard R31 yell at R17 that he was going to slit her throat. V19 stated she does not know what intervention was put into place to prevent this from happening again.

Based on interview, observation, and record review, the facility failed to maintain a resident's dignity in 1 of 4 residents (R2) reviewed for resident rights in the sample of 4. This failure resulted in R2 having a negative impact on her self-esteem and self-worth. Findings include: R2's Face Sheet, Undated, documents R2 has a diagnosis of Unspecified Depressive Episodes, Osteoarthritis, Abnormalities of Gait and Mobility, Type 2 DM and Muscle Weakness R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of a 13, has depression, and requires assistance with ADLs (Activities of Daily Living). R2's Care Plan, dated 5/4/21, documents R2 has depression and has an ADL self-care performance deficit. On 8/29/23 at 7:40 AM, R2 was observed in her room. R2's hair appeared dry, was cut short about 1 inch in length, and was a dark brown/black color. R2 stated she had bought some hair dye a while back, but didn't use it because her hair was too long, and she wanted it cut before she applied the hair dye. R2 stated she (R2) cut her hair and a nurse, (unsure of name, later identified as V5, Agency Licensed Practical Nurse/LPN) didn't like it and was going to fix it and put dye on her hair. R2 stated this nurse put the dye on her hair and left it on for 2 hours; she (R2) had to get into the shower to rinse it out. R2 stated the dye was only supposed to be left on for 20 minutes. R2 stated, It is a terrible thing, my hair looks terrible. I was just going to do it myself, leave it on for 20 minutes and then rinse it out. They thought they could do it better. I don't know why they did it that way. It was horrible. I don't like it. I had cut my hair myself, but then that girl, a Certified Nurses Assistant (CNA), (unsure of name, later identified as V6, Agency CNA), thought she could do better, so she kept cutting and clipping my hair, there was a bunch of my hair all over the floor and all over me. It was one of the worst things I've ever had to do. I had to get into the shower, it took so long my legs were hurting and they never did get all the dye out. Then she used a hair thing that burnt my neck. I kept telling her my legs hurt, but she didn't listen. It happened about a week ago during the afternoon/evening time. It feels terrible. I don't feel right. I feel like a man. I feel bad, alone, and I don't like it. It ruined my hair and I don't feel like a woman. On 8/29/23 at 7:35 AM, V1, Administrator, stated R2 was trying to cut and dye her own hair, and an agency nurse (V5) helped her. V1 stated V6, Agency CNA, has caused problems in the facility, and she has canceled all of V6's upcoming shifts with her agency. On 8/29/23 at 8:05 AM, V4, CNA, stated she was here for part of what had occurred with R2. V4 stated R2 wanted to cut and dye her own hair, there was an agency nurse, unsure of name, that put hair dye all over R2's hair and someone had cut it. V4 stated she is not sure what happened after that as her shift ended and she left the facility. V4 stated when R2 cut her hair it looked cute and when she (V4) came in the next day, you could tell it had been cut after R2 had cut it. V4 stated R2 was upset about it. On 8/29/23 at 8:15 AM, V6, Agency CNA, stated on 8/26/23, she was working the 6 AM - 6 PM shift and there was an agency nurse, unknown name (later identified as V5), that was working 2 PM-6 PM that cut R2's hair and put hair dye in it. V6 stated R2 had chemical burns to her ears, head/scalp and chin. V6 stated the dye burned R2's hair and there was hair dye everywhere. V6 stated she took R2 into the shower and had to shampoo R2's hair 4 times to get the dye out. V6 stated she was asked by V1, Administrator, to provide a statement, which she did, but hasn't been allowed to come back to the facility. V6 stated V1 canceled all of her future shifts and she is unable to sign up for more. On 8/30/23 at 8:50 AM, V3, Assistant Director of Nurses (DON), stated she was informed by V12, Licensed Practical Nurse/LPN, that R2 applied hair dye on her own hair, the nurse tried to help her and wash it out. V3 stated it had been on her hair a long time, she was told an hour, and then someone else said 2 hours. V3 stated she has not talked to R2 about the incident. On 8/29/23 at 9:30 AM, V5, Agency Nurse, stated she was working on the 200 hall on 8/26/23. V5 stated there were 2 extra nurses working that day, and the Wound Nurse, unsure of name or if she was agency or facility staff, dyed R2's hair and that is all she knows about it. V5 denies cutting or dying R2's hair. On 8/30/23 at 10:55 AM V12, LPN, stated she was at the facility when the incident with R2 occurred. V12 stated a staff member, unsure of name, came off of the 300 hall where R2 resides and told her (V12) that she was leaving, her shift had ended, and R2 had hair dye in her hair that needed rinsed out. V6, Agency CNA, stated to her (V12) that she would give R2 a shower to wash the hair dye out. V12 stated she reported it to R2's nurse and she doesn't know of anything that happened after that. On 8/30/23 at 2:00 PM, V1, Administrator, stated she talked to R2 on 8/28/23, and R2 told her that she was cutting her own hair and was going to put hair dye on it; they (V5, Agency LPN and V6, Agency CNA) told her they would assist her because R2 was going to do it and wanted it done. V1 stated R2 told her R2 couldn't tell who it was or what they looked like, that put the hair dye in her hair. V1 stated R2 told her it was the blonde aid (V6) that cut her hair because she was already cutting it and they were trying to help her. V1 stated she asked R2 if she needed help and R2 told her she was trying to get it off of her shoulders, so yes. V1 stated R2 told her she felt her hair was too short, but didn't say it made her feel bad. On 9/1/23 at 10:45 AM, V14, LPN, stated on 8/26/23, she was working on the 400 hall and overheard in report, not sure who the staff member was, asking who dyed R2's hair. V14 stated V6, Agency CNA, stated an agency nurse was dying R2's hair. V14 stated V6 told her (V14) she had given R2 a shower, and had to cut her hair to fix what they had messed up. V14 stated she told V6 to lay R2 down because R2 doesn't like being up for very long because it causes her pain in her legs. V14 stated about 15 minutes later, she went and looked at R2's hair and did not see any redness or anything that resembled chemical burns. V14 stated R2's hair was dyed and cut short. V14 stated R2 told her she hurt a lot and she didn't like her hair. The Facility Investigation, dated 8/26/23, documents the following: (V6, Agency CNA), called and stated a nurse had colored (R2's) hair and left it on for too long, and she felt she (R2) had burns from it. Spoke to (V12, LPN), regarding hair dye incident. She stated an agency nurse found (R2) in her room cutting her own hair and trying to dye it. Nurse tried to help with incident. Black hair dye was left on for about an hour, which was within limits. Hair dye was scrubbed off. Spoke to (V14, LPN), regarding concerns with (V6, Agency CNA), and (V6) working out of her scope. She (V14) stated she and (V19, LPN) went down to talk to (R2) about her hair, and (R2) stated (V6) was very rude to her and talked down to her. 8/27/23 - CNA (V6) placed on do not return list from facility due to multiple concerns including the way she talked to resident. Called agency supervisor and reported incident. The facility Initial Report to the Illinois Department of Public Health (IDPH), dated 8/30/23, documents an alleged abuse involving R2. Incident summary: On 8/30/23, Administrator and Social Services followed up with R2 on an incident that occurred on 8/26/23. R2 stated today that she felt she was treated poorly by on 8/26/23 by an agency aide (V6) who cut her hair after it had been colored by someone else. R2 stated she did tell agency aide not to cut her hair while in the shower room, but she (V6) did it anyway. Due to the concerns voiced today, a full investigation was started and report to follow. On 9/1/23 at 9:35 AM, V2, Director of Nurses (DON), stated she would expect the residents to be treated with dignity and respect. The Resident Rights policy, dated 2018, documents employees shall treat all residents with kindness, respect, and dignity.

Based on observation, interview, and record review, the facility failed to provide timely incontinent care in order to maintain the resident's dignity, as well as prevent a resident from experiencing embarrassment due to incontinence, for 3 of 16 residents (R6, R23, and R25) reviewed for respect/dignity and personal worth in the sample of 34. This failure resulted in R6 feeling angry, R23 feeling lousy, and R25 being embarrassed. Findings include: 1. R23's Minimum Data Set, (MDS), dated [DATE], documents R23 is totally dependent on staff for toileting needs. On 8/15/2023 at 9:20 AM, R23's wife, V9, stated, We had some issues Friday night. (R23) hit the call light 4 times during the night, (to be cleaned up from incontinence), he was so soaked. The whole bed, even the mattress, had pee standing on it. His diaper was so heavy it was making his hip hurt; he is already gaulded. Talk to (V10 and V11, Certified Nursing Assistants, CNAs). They (V10 and V11) worked Saturday and said every bed on this hall had to be changed completely. At this time, R23 stated, It made me feel lousy, how would it make you feel? They don't even offer me to use the urinal. V9 continued, to state she filed a grievance with the facility. On 8/16/2023 at 8:30 AM, V9 stated, she just put R23's call light on and told the CNA he needed to be changed. V9 stated she had been in R23's room since 6:30 AM, and no one had been in to check on R23. On 8/16/2023 at 8:43 AM, R23's call light had been turned off. V9 was in R23's room and said the CNA turned the call light off and said she had to find help. On 8/16/2023 at 8:48 AM, R23 had still not been assisted with incontinent care. On 8/16/2023 at 8:50 AM, R23 activated his call light again. On 8/16/2023 at 8:55 AM, V7, CNA, responded to R23's call light and turned it off. R23 stated he needed to be changed. V7 stated, Give me just a moment and left the room. At this time, R23 stated, That's what the last gal said. On 8/16/2023 at 8:58 AM, V8, CNA, entered R23's room and told R23 she was going to get linens. On 8/16/2023 at 9:07 AM, a staff member, (who was not a CNA or Nurse), entered R23's room and turned off light, and offered R23 water or apple juice. R23 declined and the staff member then left the room. At this time, R23 stated, There goes a third one, and re-activated his call light. On 8/16/2023 at 9:10 AM, V7 and V15, CNAs, entered the room and checked R23 for incontinence. R23's adult brief had blue lines to indicate R23 was wet with urine. R23's scrotum was red and gaulded. V7 stated she was taking R23 to the shower because it was his shower day. At this time, V7 asked R23 when the last time he was previous checked for incontinence and R23 stated it was around 5:30 AM. On 8/16/2023 at 2:45 PM, V16, Social Service Director, stated, We did receive one grievance in August. It was (R23's) wife. It went straight to administration for investigation. The Facility's Grievance Form, dated 8/12/2023, documents, Resident: (R23). Description: On August 11th I didn't get my shower. Also had my call light on four times the evening of August 11th the CNAs came in shut it off and walked away, never changed me once. My hip got to hurting so bad I had to loosen my diaper, because I was soaked. On 8/21/2023 at 11:17 AM, V2, Director of Nursing, (DON), stated from 8:30 AM until 9:10 AM is too long to wait to be changed after requesting it to be done. 2. R6's MDS, dated [DATE], documents, R6 is cognitively intact, has an indwelling catheter, and is totally dependent on 2 staff for toileting needs. The Facility's Grievance Report Form, dated 5/17/2023, documents, Name of Resident: (R6) Describe the nature of the grievance/complaint: Resident asked staff to perform peri-care and the staff left without assisting the resident. On 8/16/2023 at 2:50 PM, R23 stated, The 'ones' here the other night, Friday night, wouldn't take me to the bathroom. I had to have a BM, (Bowel Movement). They kept giving me excuses starting at 6:30 (PM). Then they came in and said they had to clean me up, because a new group of people were coming in at 6 AM. I guess they thought I would mess the bed. I didn't think I could hold it all night, but I managed to keep it in. I told someone, and two ladies came in to talk to me, because come to find out, the whole floor, (hall), was complaining. It made me mad. That shouldn't happen to anyone! R23 added he uses a machine, (mechanical lift), and he uses the toilet normally, because the bed pan hurts. 3. R25's MDS, dated [DATE], documents R25 is cognitively intact and is totally dependent on staff for toileting needs. R25's Care Plan, dated 5/4/2023, documents, R25 is incontinent of bowel and bladder. It further documents, R25 is on Diuretic Therapy. On 8/16/2023 at 10:15 AM, R25 stated the regular employees of the facility treat her with dignity and respect, but agency not so much. R25 continued, The latest embarrassing thing that happened was because I have no control of my bowels or bladder. The whole time she (an unknown CNA) was changing me, she was giving me a lecture telling me that I should find out what is causing it, and that I was using too many linens. She also told me I should let them know right away when I go, but when they put me from my chair to bed, they won't get me back up because it takes too long, so I've been ignoring it until I have to have a bowel movement. I told everyone who came in that next morning. The Resident Rights Handbook documents, Your Rights and Protections as a Nursing Home Resident. It continues to document it is a resident right to be treated with respect. It further documents, You have the right to be treated with dignity and respect.

Based on observation, interview, and record review, the facility failed to implement the Registered Dietician's recommendations and care plan interventions, resulting in a severe weight loss of 16.47% in a period of six months for 1 of 3 residents (R40) reviewed for weight loss in a sample of 34. Finding include: R40's Face Sheet, print date of 08/21/23, documents she has a diagnosis of Alzheimer's disease, unspecified. R40's Minimum Data Set, (MDS), dated [DATE], documents R40 is severely cognitively impaired and requires limited assistance, one-person physical assist with bed mobility, dressing, personal hygiene, extensive assistance, one-person physical assist with transfer, toilet use, supervision, setup help only with eating. R40's Care Plan, print date of 08/21/23, documents R40 has unplanned/unexpected weight loss, poor food intake. --The resident will consume _x_50% two of three meals/day through the review date. --Alert Dietician if consumption is poor for more than 48 hours. --Give May supplements as ordered. Alert nurse/dietitian if not consuming on a routine basis. --Offer substitutes as requested or indicated. (Finger foods) --The resident will eat at least one bite of each food offered daily --The resident will not have weight loss or complications, related to refusing food by review date. --The resident needs encouragement/support to be independent with eating. Allow the resident to feed self if desired, regardless of skill. --The resident's food preferences are: Hot tea with creamer, fish sandwiches, french fries with ketchup, chips. R40's Physician's Orders, dated 01/26/23, documents, Regular diet, Regular texture, Regular Liquid consistency. R40's weights for the past six months are as follows: 3/1/2023 12:23 137.2 lbs. (pounds) 4/4/2023 09:16 132.2 lbs. 4/8/2023 15:45 132.2 lbs. 5/1/2023 15:36 129.8 lbs. 6/1/2023 13:12 125.6 lbs. 7/4/2023 12:45 113.4 lbs. 7/12/2023 13:59 113.4 lbs. 7/22/2023 13:59 113.5 lbs. 8/1/2023 11:08 112.0 lbs. 8/5/2023 13:59 112.0 lbs. 8/8/2023 11:45 111.2 lbs. 8/15/2023 14:04 114.6 lbs. R40 has had a -16.47% weight loss in the past six months. R40's Meal consumption for the past month (07/23/23-08/20/23) was reviewed. R40 only has 51 meals documents, out of the 90 meals for the past 30 days. 0-25%- 16 meals documented. 26-50%- 13 meals documented. 51-75%- 5 meals documented. 76-100%- 15 meals documented. R40's Progress Notes, dated 5/11/2023 at 10:34 AM, documents: Dietary Note weight status Weight (5/1)-129.8 lbs., BMI (Body Mass Index)-23. significant weight loss triggering -15.2 lbs. x 12/4(10.5%). Regular diet order with intakes typically 50-100%, varied at times. Able to feed self with setup help. No issues noted on current diet order. Eats in restorative dining room. At increased nutritional risk related to Alzheimer's dementia dx, (diagnosis). No recent acute changes reported. Continue to encourage intakes and provide alternatives at meals as indicated. Recommend: Provide super cereal at breakfast and ice cream at lunch to halt further weight loss. RD, (Registered Dietician), to f/u, (follow up), PRN, (as needed) Review of R40's Electronic Medical Record, (EMR), was done and there was no order noted for R40 to receive Super cereal for breakfast. R40's Progress Notes, dated 6/19/2023 at 1:22 PM, documents, Dietary Note weight status Weight (6/1)-125.6 lbs., BMI-22.2. Significant weight loss triggering -11.6 lbs. x 3 months (8.5%), -19.4 lbs. x 6 months (8.5%). Regular diet order with intakes 0-100%. Able to feed self with setup help. No issues noted on current diet order. Eats in restorative dining room. At increased nutritional risk related to Alzheimer's dementia dx. No recent acute changes reported. Continue to encourage intakes and provide alternatives at meals as indicated. Recommend: 1. Provide super cereal at breakfast 2. Provide house supplement 90 ml BID, (twice a day), to halt further weight loss RD to f/u PRN Review of R40's Electronic Medical Record, (EMR), was done and there was no order noted for House supplement 90ml BID and super cereal. R40's Progress Notes, dated 7/17/2023 at 12:48 PM, documents, Dietary Note weight status Weight (7/12)-113.4 lbs., BMI-20.1. Significant weight loss triggering -16.4 lbs. x 5/1(12.6%), -25.4 lbs. x 2/1(18.3%). Noted varied intakes at meals. Receiving regular diet order. Set up help at meals. At increased nutritional risk related to Alzheimer's disease progression. Recommend: 1. Add house supplement 120 ml TID (three times a day) for nutrition support 2. super cereal at breakfast for nutrition support 3. weekly weights to monitor nutritional status Monitor. RD to follow R40's Physician' Orders, dated 07/25/23 at 6:00 PM, documents, House Supplement after meals for nutrition support 120 milliliters (ml). R40's Physician's Orders, dated 07/26/2023 at 8:00 AM, documents, Super cereal one time a day for nutrition support at breakfast. On 08/15/23 at 9:30 AM, R40 was dressed in clothes that were big and baggy, and they hung on her. R40's skin on her cheeks and neck area was loose and hanging. On 08/15.23 at 12:10 PM, R40 was observed being given her noon meal tray, which included Salisbury steak, broccoli, steamed rice, a dessert, and bread. On 08/15/23 at 12:20 PM, R40 was observed picking up her Salisbury steak with her fingers and took one bite, and put it back down on her plate. On 08/15/23 at 12:25 PM, R40 was observed pushing her tray away. On 08/21/23 at 11:52 AM, V25, Registered Dietician stated when she gives a recommendation, she sends an email to the Director of Nursing, (DON), Administrator, and the Dietary Manager. She said, The DON is to send the recommendation to the Physician for him to sign off on if he agrees with the recommendations. She said she would expect that once she makes a recommendation, they would get it to the Physician in a timely manner for him to sign off on it. On 08/21/23 at 1:19 PM, V2, Director of Nursing, (DON), stated she would probably consider a 16% weight loss, a severe weight loss. When asked what she expected of the nurses when it comes to implementing the Dietician's recommendations, she stated she really couldn't answer that, because she just started in July. The facility's Policy Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol, revised date of September 2012, documents, Assessment and Recognition 3. The threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss = [usual weight- actual weight]/ [usual weight] x 100): a. 1 month- 5% weight loss is significant; greater than 5% is severe. b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months- 10% weight loss is significant; greater than 10% is severe. It further documents Treatment/Management b. Nutritional needs: The Dietitian and Physician consult to determine the appropriate diet for the resident based on the resident's degree of nutritional impairment, expressed wishes, and underlying causes and conditions. Order for appropriate will be obtained from the Physician. c. Supplementation: Strategies to increase a resident's intake of nutrients and calories may include fortification of foods, increasing portion sizes at mealtimes, and providing between-meal snacks and/or nutritional supplementation.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring to prevent falls for 1 of 3 residents (R5) reviewed for falls in the sample of 9. This failure resulted in R5 having 3 falls during first week of her stay in the facility and sustaining a non-operable re-fracture of her left hip. Findings include: R5's Face Sheet documents she was initially admitted to the facility on [DATE], with diagnoses of Unspecified Dementia, Other Specified Disorders of Bone Density and Structure, Hypothyroidism, Depression, Vertigo, Atherosclerotic Heart Disease, Diverticulitis, Chronic Kidney Disease, Stage 3, and Personal History of Cardiac Arrest. R5's Physician Order Summary Report lists her diagnosis as Fracture of Unspecified Part of Neck of Left Femur, Initial Encounter for Closed Fracture. R5's Referral Information to facility, dated 7/13/23, includes hospital reports document R5 was admitted to the hospital on 7/3/23 after a fall in her memory care facility that resulted in a closed hip fracture. The referral information included documentation R5 sustained a subdural hematoma on 7/8/23 while in the hospital when she fell after she attempted to stand but was off balance and fell to the ground and was found on the floor. The referral information included the hospital's Assessment/Plan that listed her diagnoses to include: Acute Subdural Hematoma: Patient had a fall on 7/8/23, CT (Computed Tomography) head shows subdural hematoma, neurosurgery consulted, repeat CT head stable, appreciate neurosurgery recommendations, fall precautions, monitor neurochecks. R5's Minimum Data Set (MDS), dated [DATE], documents she is severely cognitively impaired, has behaviors including inattention and disorganized thinking, and requires assist with Activities of Daily Living (ADLs) including bed mobility, transfers, walking in room, dressing, eating and toileting. According to this MDS, R5 is not steady when moving from a seated to a standing position, when moving on and off toilet, and with surface-to-surface transfers (transfer between bed and chair or wheelchair) and is only able to stabilize with staff assist. R5's Care Plan, dated 7/14/23, documents, The resident is at risk for falls. The interventions for this care plan include: Be sure (R5's) call light is within reach and encourage the resident to use it for assistance as needed; Ensure floor mat is place beside bed when resident is in bed; Ensure floor mat is picked up when resident is not in bed; Ensure personal items are within reach; Ensure that (R5) is wearing appropriate footwear when ambulating or mobilizing in wheelchair (w/c); Gripper socks; Keep bed in lowest position when in bed; Physical Therapy/Occupational Therapy (PT/OT) evaluate and treat as ordered or as needed (prn); Resident moved to memory care unit for centralized care (closer supervision)-initiated 7/28/23; Staff to assist resident to toilet after meals and more frequently related to (r/t) urgency; Staff to encourage participation in activities of her choice when restless in bed. R5's Fall Risk Data Collection, dated 7/14/23, documents the score of 28 indicating she is at high risk of falls. Fall Risk Data Collection documents, dated 7/15/23 and 7/20/23, document R5 continued to be at high risk of falls. The facility's document Occurrence Type: Falls, dated 2/1/23 through 8/1/23, documents R5 had two falls on 7/15/23 and a third fall on 7/20/23. R5's Fall Report dated 7/15/23 at 1:15 PM, documents, At 1:15 PM writer was alerted by CNA that resident was on the floor. Writer entered resident's room and found resident sitting on her buttocks with left leg extended forward and right leg bent. Resident was found at the foot of her bed, gripper socks were on both feet, area was well lit, and no obstacles were in the pathway. Writer assessed the resident; vs (vital signs) 118/60, 68, 97.8, 97%, A&O x1 (alert and oriented to person) baseline. Resident voiced complaint of (c/o) pain and discomfort. Writer instructed CNA to stay with resident and instructed both CNA and resident to avoid moving. Writer left room to notify appropriate personnel. Writer notified resident's daughter and called 911 for transport to hospital for eval at 1:31 PM. Resident left the facility with 2 ambulance attendants, POLST, Notice of Transfer, and bed hold policy. Writer gave report to (local hospital.) This fall report documents a recommendation to be implemented after the fall: Staff to encourage participation in activities of her choice when restless in bed. R5's Progress Note, dated 7/15/23 at 4:53 PM, documents, Resident report received via ER (emergency room ) nurse. Resident had ct (Computed Tomography) head, neck bilat hips, all resulted negative. Nurse reports (indwelling urinary catheter) inserted, and urine specimen obtained and sent to lab resulted in dx (diagnosis) of UTI (urinary tract infection). Positive blood, nitrates ketones and WBCs (white blood cells). Resident to be sent back via ambulance stretcher and with prescription for Macrobid. 1st dose to be given prior to return to facility. (Indwelling Urinary Catheter) will be dc'd (discontinued) prior to transport. Report given to resident's nurse. All questions answered. R5's Hospital Discharge Instructions, dated 7/15/23 at 4:22 PM, documents, Tylenol, Ibuprophen as needed; Assistance with any movement and close observation. R5's second Fall report, dated 7/15/23 at 6:55 PM, documents, Writer called to resident's room by CNA. Upon entering resident's room, resident noted to be lying on the floor in front of resident's bathroom. Resident lying on her right side with her head lying toward the door and feet towards the wall. Resident c/o right shoulder pain and is lying on her right arm. Resident c/o left hip pain and low back pain. Resident is not moved from position, CNA stayed with resident while nurse called 911. Resident had non-skid socks on. Floor clean, room quiet. 911 called at 7:01 PM. (R5's daughter/responsible party) called, HIPPA compliant voicemail left to return call to facility. Report called to (local ER) and (ER staff) informed the writer would need to speak with the MD (Medical Doctor). MD, unable to understand name due to accent, spoke with writer and informed writer that resident had already been sent to the ER prior and he gave orders for resident to be 1:1 and he did not understand how she fell again. Writer explained to MD that resident is confused and gets up without assistance. MD asked why she was being sent back to ER. Writer informed MD that due to resident c/o pain to right shoulder, left hip and back pain writer cannot move resident from the position to risk further injury if anything fractured. MD advised writer to call the Administrator and let her know that resident needs to be 1:1 to prevent resident from falling and being sent back and forth to the ER. Writer informed MD that Administrator would be informed of his concerns. (Local ambulance) called to inform they were on another call dropping them off at the hospital and would be to facility after completing that call. 7:17 PM Administrator informed of incident and conversation with MD. Writer informed to call family to see if family could sit with resident. No return call from responsible party, (emergency contact #2) called and explained concern and need for family to sit with resident due to falls. (Emergency contact #2) informed writer that if family was able to sit with her 24/7, they would not have placed in facility, but she understands and will speak to (Healthcare Power of Attorney/HCPOA). 7:36 PM (local ambulance) arrived, resident transferred to (local hospital ER) via stretcher. Bed hold policy sent with paperwork. (HCPOA) returned call to facility and spoke with writer stating she believes if the pain medication and /or Ativan was more frequent that every 8 hours she believes resident would not be attempting to get up and having falls. Writer informed (HCPOA) that on call MD would be called to see if he can increase the frequency and writer would call her back. On call MD paged and returned call at 7:47 PM. New order Norco 5/325 milligrams (mg) every 4 hours for pain but Ativan order would remain the same. Writer called HCPOA and informed of new orders. On-call nurse notified. The fall report documents the recommendation after the fall: 1:1 provided for safety of resident. Staff to assist resident to toilet after meals and more frequently related to urgency. R5's fall investigation of her second fall on 7:15 PM included documentation that 1:1 monitoring was initiated at 1:00 AM on 7/16/23 with every 1-hour monitoring done by staff until 7/17/23 at 5:00 AM. R5's Hospital Discharge Orders, dated 7/15/23 at 11:58 PM, documents, Continue home medicine; Close observation; and Contact her orthopedic for follow-up. R5's third fall report, dated 7/20/23 at 10:48 PM, documents, Writer in hallway at med cart on 200-hall. A loud noise was heard and a voice from 200 hall. Writer went to investigate and noted resident laying on the floor in her room with commode tipped over near her feet. Resident's head was pointing south with head up against dresser. Room was quiet and floor dry except some urine that had spilled from commode. Room was dim lit. Resident was wearing no skid socks. Call light was on bed rail in reach from where resident had been sleeping in bed. Call light was not on. Resident unable to give a statement of what happened due to cognition with dementia. Personal belongings were in reach of where resident had been laying in bed. Resident c/o pain to left temple and hematoma noted. Resident c/o left hip pain. Resident has known healing left hip fracture (fx). Decision made to not move resident and contact MD. R5's Hospital Records, dated 7/23/23 at 6:05 AM, documents, under Impression/Plan: New left peri-implant proximal femoral fracture, history of falls, history of dementia, Alzheimer's type. Plan: Orthopedics consulted-no operative plans at this time. On 8/2/23 at 8:43 AM, V11, Certified Nursing Assistant (CNA), and V25, CNA, provided incontinent care to R5 in her bed. R5 had a scar on her left hip that had a few superficial scabs on the healed incision line. R5 complained of pain and discomfort when her pants were taken off and when she was rolled side to side for care. R5 stated she did not know why her hip was hurting like that. R5's room was at the very end of her hall, farthest away from the nurse's station. On 8/3/23 at 3:45 PM V1, Administrator, stated she was not given all the information about R5's previous falls when the referral was sent to the facility before she was admitted . V1 stated V30, Business Office Manager, and V31, Admissions Coordinator, reviewed the information for her admission. V1 stated she heard about the additional fall R5 had while in the hospital after the fact, but when she was admitted , R5 was placed in the room that was closest to the nurse's station. V1 stated there were no female beds available in the dementia unit. V1 stated if she had been aware of R5's fall in the hospital, she would have looked at putting her on one of the halls that had more staffing available for closer monitoring. V1 stated the facility cannot typically do 1:1 monitoring with a resident, so they called her family when the doctor said he wanted 1:1, but the family refused to come in and sit with her. V1 stated staff had just been in R5's room on 7/15/23 15 minutes before she fell . On 8/4/23 at 12:01 PM, V1 stated staff did not call and inform her R5 had fallen on 7/15/23 until she had her second fall on that same day and the emergency room doctor did not want her sent back to the emergency room . V1 stated she came to the facility, but by then, the ER doctor was agreeable for R5 to be transported to the ER for evaluation. V1 stated it was after R5's second fall on 7/15/23 that she found out the ER doctor had ordered her to be monitored 1:1 after she returned from ER after her first fall. V1 stated she directed the staff to call her family to see if they would come in and sit 1:1 with R5, but they refused stating it was facility's job to do 1:1 and that was why she was here. V1 stated R5's 1:1 was only done for a couple of days because after that she was doing better, and she was kept at the nurse's station for closer observation. V1 stated to her recollection, the order for 1:1s was not an on-going order. V1 stated after they stopped the 1:1's, R5 was kept in public places, there was a mattress in place on the floor when she was in bed, and they were doing frequent checks on R5. V1 stated she would expect frequent checks to mean the staff checked on R5 at least every 1 to 2 hours and whenever they walked by her room. V1 stated they also had R5 going to activities. V1 stated since her last fall on 7/20/23, R5 does not try to get up and walk any more. On 8/4/23 at 1:38 PM, V32, CNA, during phone interview, stated she has worked with R5 a few times. She stated she worked with her on 7/20/23 when R5 fell . V32 stated she was in another resident's room down the hall helping her with the bed pan when R5 fell . V32 stated R5 had been sleeping most of the night before she fell . V32 stated she had been trying to check on R5 about every 15 minutes because she still tried to get up by herself, but R5 was not trying to get up as much because she was in pain. V32 stated she did not see R5 fall but from the way R5 was laying close to the commode, and the commode was tipped over, she assumed R5 was going to the bathroom when she fell . V32 stated the nurse was also checking on R5 frequently when she (V32) was in other residents' rooms. V32 stated it was impossible to 1:1s with R5 because there is not enough staff; if you are 1:1 with R5, no one else would get their care. V32 stated she did the best she could. V32 stated she has worked with R5 since she has been moved to the dementia unit and stated R5 continues to try to get up on her own sometimes. She stated just this past Saturday she caught R5 standing up trying to get to the bathroom on her own. On 8/4/23 at 1:55 PM, V33, Registered Nurse (RN) ,stated she is an agency nurse who worked at the facility on 7/15/23 and 7/16/23. She stated she received the call from the ER nurse after R5's first fall when she was returning to the facility. V33 stated she is an ER nurse herself and remembers she asked the questions regarding labs and x-rays, but does not remember the nurse telling her R5 should be on 1:1s when she returned. V33 stated she was working with V14, Licensed Practical Nurse/LPN, who would have received R5's discharge paperwork from the hospital. V33 stated R5 would have come back just when the nurse was finishing her medication pass and getting ready to change shifts, so something may have been missed. V33 stated she worked again the next day (Sunday) 7/16/23, and she went out to the shed herself to find R5 a (reclining wheelchair). V33 stated she kept R5 up at the nurse's station with her, and R5 was frequently trying to stand up and walk. She stated R5 was very feisty and was not easily redirected by staff. V33 stated there was not enough staff to do 1:1's. She stated now she understands about 1:1's because she compared trying to monitor R5 to trying to monitor a six-month-old and stated, You would have to be right by her all the time. On 8/4/23 at 2:50 PM, V1 stated, If I had known the emergency room doctor had ordered for R5 to be monitored on 1:1s I would have gotten someone to come in and do 1:1s or I would have done them myself. On 8/8/23 at 11:24 AM, V1 provided a copy of the facility's Fall Policy, which was revised 9/17/19. The fall policy referred to the Fall Program. V1 stated she has no idea what the fall program was before she got here, and stated the Fall Program now is outlined in the untitled document, dated 8/4/23, which she presented along with the Fall Policy which outlined a review of recent falls and a plan to educate staff on the Fall Prevention System. Per this document, V24, Regional Nurse, reviewed falls for the past 3 months and determined the Fall Prevention System was not fully in place. V1 stated she knows they went around and put leaves on residents' doors who were determined to be at risk for falls. The facility's policy, Fall Policy, revised 9/17/19 documents, The purpose of the Fall Management Program is to develop, implement, monitor and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that foster resident independence and quality of life. The Fall Management Program promotes safety, prevention and education of both staff and residents. Policy: The facility shall ensure that a Fall Management Program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety. Per the policy, residents found to be at high risk for falls are place on the Fall Program, and interventions are implemented to meet individual needs.

Based on interview and record review, the facility failed to ensure medications were given as ordered for 1 of 7 residents (R2) reviewed for significant medication errors in the sample of 18. This failure resulted in R2 having a seizure and being sent to the hospital for evaluation. Findings include: R2's Face Sheet, print date of 05/15/23, documents R2 has a diagnosis of Conversion disorder with seizures or convulsions. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is severely cognitively impaired and has a seizure disorder. R2's Care Plan, print date of 05/15/23, documents the resident has Seizure Disorder and interventions include but are not limited to Give medications as ordered. R2's Physician's orders, dated 01/26/18, documents R2 is to receive Zonisamide Capsule 100 MG (milligrams), Give 1 capsule by mouth two times a day for seizures. R2's Medication Administration Record (MAR), dated 05/03/23 at 8:00 AM, documents #5 (Hold- see progress notes). R2's Health Status Note, dated 05/03/23 at 9:43 AM, documents, Writer contacted Critical Care pharmacy to check status on Zonisamide refill. Per pharmacy #60 was shipped to facility and signed for on 4/20/23. R2's Administration Note, dated 5/3/2023 9:52 AM, documents, (R2's) Zonisamide was unable to be located- not available in stat safe. R2's MAR, dated 05/04/23 at 8:00 PM, documents R2 was given his Zonisamide 100 mg. R2's Health Status Note, dated 05/04/23 at 8:18 PM, documents, Pharmacy and DON (Director of Nursing) aware Zonisamide 100 mg capsule not available on 05/04/2023 at 8:18pm. Incorrect documentation. R2's MAR, dated 05/05/23 at 8:00 AM, documents Zonisamide #6 (other- see progress notes). R2's Administration Note, dated 05/05/23 at 8:43 AM, the facility is still waiting on the medication from the pharmacy. R2's MAR, dated 05/06/23 at 8:00 AM, documents Zonisamide #6 (other- see progress notes). R2's Administration Note, dated 05/06/23 at 1:01 PM, documents Zonisamide capsule medication not available, awaiting pharmacy. R2's MAR, dated 05/06/23 at 8:00 PM, has no documentation noted for R2's Zonisamide medication. R2's MAR, for the dates of Sunday 05/07, Wednesday 05/10, and Friday 05/12/23 at 8:00 AM, documents Zonisamide #6 (other- see progress notes). R2's Administration Note, dated 05/07/23 at 10:26 AM, and 05/10/23 at 10:36 AM, documents medication not available waiting on the pharmacy. R2's Administration Note, dated 05/12/23 at 8:57 AM, documents, Facility still out of medication - not available in stat safe - writer called critical care to request a fax to be sent so facility can approve payment for this medication d/t (due to) card of medication that facility reports facility rcvd (received) has not been located. R2's Health Status Note, dated 5/12/2023 at 12:27 PM, documents Note Text: writer paged to 300 hall and notified that resident was currently having a seizure. Resident noted to be staring off and having difficulty speaking. Resident's wife by his side and had noted upon entering his room and notified staff. Resident having some shaking throughout body. Resident's wife noted hx (history) of improvement with supplemental oxygen. Supplemental oxygen initiated via nc (nasal canula). Resident primarily mouth breathing at this time and oxygen mask applied. Resident's vs (vital signs) stable. Resident has a hx (history) of seizures. Three nurses at bedside monitoring. Decision was made to send to ER (emergency room ) d/t resident not coming out of seizure as quick as previous seizures. On 05/17/23 at 9:37 AM, V4, Licensed Practical Nurse (LPN), stated she wasn't sure what day it was that she was unable to locate R2's Zonisamide. She said she searched the medication cart and could not find it anywhere, she looked for it in the stat safe and could not find it, so she called the pharmacy about it, and they told her the medication was sent and signed off on 04/20/23. V4 said she left a note for the Assistant Director of Nursing (ADON) to get permission for the facility to pay for it. She said she thought the ADON was going to come in on that day, but ended up not coming in. She said she then didn't work on that hallway again for a while, but when she did, she was still unable to locate the medication. V4 said she then called the pharmacy and requested a fax so the facility could cover the cost. She said she then had the Administrator sign off on it so the pharmacy could deliver the medication. She said after everything was requested and before the medication was delivered, R2 had a seizure and was sent out to the ER. R2's Health Status Note, dated 5/12/2023 at 1:44 PM, documents, per local hospital ER, they cannot allow resident to return to facility until we have Zonisamide available. R2's ER Record, dated 05/12/23, documents chief complaint seizure like, and discharge diagnosis of Status post seizure due to subtherapeutic medication level. R2's ER Lab Report, date collected 05/12/23 at 1409 (2:09 PM), documents Zonisamide level < (less than) 2 low, Range 10.00-40.00. R2's Medication Error Details Report, report date of 05/15/23 at 9:00 AM, documents medication was not administered on 5/3 at 8 AM, 5/5 at 8 AM, 5/6 at 8 AM, 5/7 at 8 AM, 5/10 at 8 AM, and 5/12 at 8 AM Resident was sent to ER for eval (evaluation) and treat (treatment) on 5/12/23. Error Type missed dose; error detected at 05/03/23 8:00 AM. Physician notified none called (nurse did not notify physician until 05/12/23). On 05/16/23 at 8:25 AM, V3, R2's wife stated the only time R2 has seizures is when he misses his seizure medication. She said this happened last year when he missed doses of his Depakote. On 05/16/23 at 9:10 AM, V8, LPN, stated she worked a day or 2 when R2 was out of his Zonisamide, and she made a note it was not available, but that it had been ordered. She said if R2 had the medication available it should have been on the cart. On 05/17/23 at 12:55 PM, V2, Regional Nurse, stated she would expect the nurse to look for the medication on the cart, if they were unable to find it on the cart, the nurse should call the pharmacy and check to see if they delivered it, if not call and order it, call the DON, ADON, Administrator, then call and notify the doctor, ask them if they want to hold the medication or see if they want to substitute with another medication, assess the patient, and notify the Power of Attorney (POA) or responsible party. On 05/16/23 at 12:52 PM, V10, Nurse Practitioner, stated, Yes it could be the reason, but it's hard to say if (R2) going without his Zonisamide would have caused him to have a seizure. (R2) has been on other seizure medication and had seizures. V10 stated even if she were to have the lab results back from the hospital, it could be possible there was something else wrong with R2. V10 stated she would expect the nurse, with any medication that was ordered, if it wasn't given, to document it and give a reason it wasn't given. If the medication wasn't available, there needs to be certain steps taken to see what the problem is. If the medications are not given, it should be documented at the time it wasn't given and not later, and I would expect the provider to be notified. V10 stated she wasn't informed of R2 not receiving his Zonisamide until (05/15/23) when she walked into the facility. On 05/16/23 at 2:10 PM, V12, Pharmacist, stated any missed doses of a seizure medication will increase the risk for a breakthrough seizure. He said, You would not want to miss any scheduled doses of any medication especially a seizure medication. The facility Policy and Procedure for Administration of Medication, revise date of 04/21, documents B. The nurse's station shall have necessary items and equipment available for proper administration of medications, and current standards of practice should be followed. C. Immediately after a drug is ingested, it should be recorded on the MAR: 1. If for any reason a physician's order cannot be followed, the physician shall be notified as soon as is reasonable. A notation shall be made on the nurse's progress notes in the patient's clinical record. 2. Nursing staff will report immediately to the attending physician any medication errors, or adverse drug reactions. It further documents E. The facility shall check the Physician's Order Sheet and MAR against the current Physician's Orders, to assure proper administration of medication to each resident.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity, had needs met timely, and provide privacy for 4 of 18 (R44, R46, R53, R175) residents reviewed for resident rights in the sample of 51. These failures resulted in R46 having feelings of embarrassment and she doesn't matter, R175 having feelings of embarrassment and crying when talking about her experience of being exposed and with not receiving timely care, and R53 being upset and feeling dirty. Findings include: 1. On 6/22/2022 at 3:00 PM, R46 was sitting in main lobby with abdomen exposed. R46's shirt was above her abdomen beneath her breast. Staff were observed walking past R46, and no attempts were made to pull clothing down or change clothing. On 7/5/2022 at 8:30 AM, R46 was sitting in her wheelchair in the main lobby, with large stomach and abdominal dressing exposed and uncovered. Staff were observed walking past R46, and no attempts were made to assist with adjusting clothing. On 7/5/2022 at 11:05 AM, R46 stated she gets embarrassed when people look at her stomach. R46 stated no one helps her pull her shirt down, or cover her large stomach. R46 stated once her clothes are on, they are on. R46 stated when she notices someone looking at her uncovered stomach, she goes to her room and stays in there so no one can see her. R46 stated, I don't matter. When talking about this, R46 dropped her head, and looked down and away. On 7/5/2022 at 12:20 PM, V21, Licensed Practical Nurse (LPN), stated she has worked with R46. V21 stated she has had conversations with R46. V21 stated sometimes R46 doesn't respond to her, but sometimes she does. V21 stated, It's a 50/50. V21 stated when R46 does respond, she responds appropriately. V21 stated she is aware of R46 clothing revealing her abdomen, and would expect the staff to change her or assist with pulling R46's shirt over her abdomen. V21 stated she understands how this would make R46 feel embarrassed. On 7/5/2022 at 3:32 PM, V63, R46's mother, stated R46 is able to talk when she wants. V63 stated R46 would not like for her stomach to show. V63 stated if R46 said she was embarrassed, then she was embarrassed. 2. R175's Care Plan, dated 6/9/2022, documents YOUNITE Story - Care/ADL (activities of daily living) Preferences. It continues (R175) prefers to wear her clothes from home. She prefers when she is up in her chair throughout the day to always have on pants and shirt from home. On 6/21/22 from 9:30 AM to 11:00 AM, based on 15 minute observation intervals, R175 remained sitting in recliner, with her incontinent brief visible to staff and residents passing by her room. R175 resides in area with busy foot traffic. On 6/27/22 at 11:15 AM, R175 stated her incontinent brief is her underwear. R175 stated she does not like sitting with her underwear showing as people walk past her room. R175 stated sitting in her room with her underwear showing is indecent. R175 stated it is embarrassing, and she does not want anyone looking at her in her underwear. R175's face was red, andnd eyes were [NAME] up with tears when discussing the subject. The Residents' Rights for People in Long-term Care Facilities, dated 5/18, documents that You have the right to privacy. 3. R53's Care Plan,dated 1/10/22, documents (R53) Care/ADL Preferences: prefers to have a shower two times a week. It continues (R53) has an ADL Self Care Performance Deficit. Interventions: requires one staff participation with bathing, requires one staff participation to dress, requires one staff participation with personal hygiene and oral care, requires two staff participation to reposition and turn in bed. R53's Minimum Data Set (MDS), dated [DATE], documents R53 is cognitively intact and requires extensive assistance from two staff members for transfers and toilet use. R53 is totally dependent on one staff member for bathing. R53 requires extensive assistance from one staff member for dressing and personal hygiene. R53 is always incontinent of both bowel and bladder. On 6/22/22 at 11:35 AM, V9, Corporate Nurse, and V22, Certified Nursing Assistant (CNA), were perrforming perineal care on R53, with the window blinds left open, with a view of a parking lot out the window. On 6/27/22 at 8:45 AM, V8, CNA, and V29, CNA, were performing perineal care for R53, with the window blinds left open, and with a view of a parking lot out the window. On 6/28/22 at 12:05 PM, R53 stated, It makes me feel dirty and really upsets me when I don't get my showers like I'm supposed to and when they leave me sitting in urine or stool. They definitely need some more help here. On 7/05/22 at 1:20 PM, R53 stated, I would prefer for them to close the blinds when they are taking care of me. I don't like it when someone can see in here, especially when it's dark out and the lights are on in here. On 6/30/22 at 10:52 AM, V8 stated, If I am doing resident care, I will close the window blinds, pull the curtain around the bed and shut the door to maintain their privacy. On 6/30/22 at 11:05 AM, V23, CNA, stated, For resident privacy, I make sure the door is closed, the curtain is pulled, the blinds are shut and the bathroom door is closed. On 6/28/22 at 11:15 AM, V6, Corporate Nurse, stated, We don't have a specific policy for incontinent care. We have a check list that every employee does to get checked off for that procedure. The Facility's Skills Checklist, undated, documents Identify Patient, Wash Hands, and Ensure Privacy. 4. R44's Care Plan, with revision date of 6/8/22, documented R44 is dependent on two nursing staff for assistance with her care needs. R44's Minimum Data Set (MDS), dated [DATE], documented R44 has a mild cognitive impairment, and is not stable with her upper and lower body extremities, which requires two staff for assistance. On 6/7/22 at 10:50 AM, R44 activated her call light, and at 11:07AM, a staff member walked by R44's activated light without answering. At 11:25AM, the call light was de-activated by V5, Certified Nurse Assistant, (CNA). On 6/7/22 at 11:28 AM, when asked which resident activated their call light, V5 stated, The resident in the first bed stated she did not need anything. When questioned if she asked (R44) in the second bed, V5 stated, No. On 6/7/22 at 11:30 AM, R44 stated she activated her call light to have her incontinent briefs changed. V5 and another nursing assitant in training then assisted R44 with her care. The facility's Grievance Log, dated 6/1/22, documents, Call lights are not answered timely. And residents can tell that staff are working short. The Grievance Log, dated 5/4/22, documented, Call lights not answered in a timely manner, turning off lights and not coming back. The Grievance Log, dated 4/6/22, documents In the evenings it takes a little longer for call lights to be answered. The Grievance Log, dated 3/8/22, documented, Call lights are not answered in a timely manner. On 6/9/22 at 9:00AM, V1, Administrator, stated the facility does not have a policy or procedure for answering of call lights to address residents care needs.

Based on interview, observation, and record review, the facility failed to notify the Physician of a change of condition in a timely manner for 2 of 18 residents (R20, R40) reviewed for Physician notification in the sample of 51. These failures resulted in R40 having an infected surgical site that led to the incision site opening up, R40's having swelling causing pain, and R40 needing antibiotics; and R20 having a significant weight loss. Findings Include: 1. R40's Health Status Note, dated 6/23/22 at 1:30 PM, documents, Resident returned to facility after surgery via transportation driver. VS (Vital Signs) stable and no c/o (complaint of) voiced, denies any pain at this time. New orders for follow up appointment with (V50) at (local hospital) on July 12th at 4:00 PM. New order to leave dressing on left hand for 24 hours then remove it. Will continue to monitor. R40's Health Status Note, dated 6/23/22 at 7:57 PM, documents, Drsg (dressing) intact to left hand, fingers edematous, slightly reddish purple, moving fingers freely. Up adlib (at liberty) ambulating independently. No acute distress, no s/s (sign and symptoms) pain/discomfort. R40's Discharge Instructions from the local hospital for Excisions, dated 6/23/22, documents, Incisional Care: Look at the appearance of incisions each day and watch for signs of infection, including: redness, swelling, heat, green/yellow or foul-smelling drainage, fever 101 or higher, or severe pain not controlled by prescribed medication. If you suspect an infection, call your doctor. It also documents, You can reach your doctor at one of the follow numbers. For urgent problems, go to the nearest emergency room . V50's name and number was checked. R40's Health Status Note, dated 6/24/22 at 6:23 AM, documents, Resident c/o pain to left hand PRN (as needed) Tylenol given per MD (Medical Doctor) orders, stitches intact with noted [CONDITION(S)] to top of left hand and fingers on left hand, no redness noted. Will continue to monitor. R40's Health Status Note, dated 6/24/22 at 3:53 PM, documents, Sutures intact to left hand, picks at area at times. No s/s infection noted. R40's Health Status Note, dated 6/25/22 at 9:04 AM, documents, Resident recently had procedure to hand and has stitches in place. Hand is swollen and warm to touch. Resident unable to keep hand elevated to help with swelling. Resident complaining about tape to hand - resident does not have tape to hand. R40's Health Status Note, dated 6/25/22 at 12:47 PM, documents, Resident complaining about hand hurting, writer attempted to administer Tylenol prn as ordered and resident spit medication out and threw it on the floor. Resident complaining that she is cold. Writer took resident to room and put on sweater, sat in recliner with two blankets. R40's Health Status Note, dated 6/25/22 at 4:45 PM, documents, Picking at left hand sutures causing bleeding to area, dry protective drsg applied for protection, continues to pick and tries to remove drsg. Fingers remain edematous, warm to touch. Afebrile. R40's Health Status Note, dated 6/26/22 at 5:10 PM, documents, Writer has re applied 2 dressings to L (left) anterior hand sutures. Resident has picked at sutures until they are bleeding. L hand is red/swollen and irritated. Resident continues to pick at sutures and hand. Will apply another dressing and wrap in kerlix to see if this helps from resident picking at surgical incision. Will continue to monitor. R40's Health Status Note, dated 6/27/22 at 5:00 AM, documents, Resident noted to have [CONDITION(S)] and redness to L (left) dorsal hand. Sutures are CDI (clean, dry, and intact). MD notified. Awaiting response. On 6/27/22 at 6:43 AM, R40 exited her room. R40's left hand gauze dressing was pulling up leaving the top of her hand exposed. The top of R40's left hand had sutures, the area was swollen and red. R40's fingers were swollen. At that time, R40 stated, My tummy hurts. My hand hurts. I need help. On 6/27/22 at 8:08 AM, R40 was sitting at the dining room table. R40 was unwrapping the gauze bandage on her left hand. R40 was picking at the sutures. R40 stated, My hand hurts. This tape hurts. At that same time, V5, Certified Nurse Assistant (CNA), V37, CNA, and V38, Activity Director, were in the dining room passing out breakfast trays. No one acknowledged R40 or tried to redirect her from picking at her bandage. On 6/27/22 at 8:18 AM, V20, Licensed Practical Nurse (LPN), stopped her medication pass to redress R40's hand. R40 stated, My hand hurts. Don't touch my hand. My hand hurts. On 6/27/22 at 8:55 AM, R40 was walking in hallway stating that her hand hurts. On 6/27/22 at 10:28 AM, V20 stated, (R40) had like a horn growing out of the top of her hand. It is a large incision and has sutures. At this time, R40 came walking down the hall with the left hand gauze pulled up and the top of her hand bleeding. R40 stated, My hand hurts. On 6/27/22 at 10:30 AM, V20 stated, The night shift nurse faxed the surgeon to let him know and we are waiting to hear back from him. V20 told R40 she will get her some Tylenol to help. V20 took R40 to her room to cleanse and redress R40's left hand. R40 continued to say her hand hurt. V20 cut the remaining bandage off with scissors. R40's hand and fingers were very swollen. The top of her hand had an incision approximately 2 inches long, starting at the top of the hand, going past the knuckle to her inner finger. V20 cleansed the wound with normal saline, applied a gauze pad and wrapped the hand in gauze. R40's Health Status Note, dated 6/27/22 at 3:39 PM, documents, Sutures intact to left hand, hand/fingers remain edematous and red, will not leave protective drsg on. Call out to (V50, Surgeon) regarding suture removal and the [CONDITION(S)]/redness of hand, awaiting return call. R40's Health Status Note, dated 6/28/22 at 4:13 AM, documents, L hand remains edematous and reddened. Sutures appear removed at this time. Resident will not allow dressing to cover incisional wound. Area cleansed. Scant amount of sanguineous drainage noted. On 6/28/22 at 8:45 AM, R40 was walking in the dining room. R40's left hand had no bandage on it. R40's top of her hand had a small amount of drainage coming form the wound. The incision was scabbed over. R40's hand and fingers were more swollen than on 6/27/22. R40's hand remains red. R40 was telling V16, CNA, not to bump her hand and that her hand hurts. R40's Health Status Note, dated 6/28/22 at 9:53 AM, documents, Resident continues to pick top of left hand at surgical site, area red, and edematous. Writer wrapped left hand with dressing and cling, resident said get that off, then removed dressing and began picking left hand again. (V40, Doctor) notified and awaiting response from MD. R40's Health Status Note, dated 6/28/22 at 10:26 AM, documents, New order received from (V40, MD) to cover top of left hand with gauze, then cover with Geri sleeve or glove. R40's Health Status Note, dated 6/28/22 at 10:48 AM, documents, (V40) MD updated on resident's surgical site to top of left hand, red, edematous, with serosanguineous drainage noted. Resident's temp 98.7 at this time. Awaiting on MD response. On 6/28/22 at 10:49 AM, V39, Registered Nurse (RN), stated, (R40) is a picker, she won't leave anything on her hand which isn't surprising because it is swollen. I spoke with the doctor and he said to wrap it and to cover the dressing with a brace or 'arm sleeve' to keep her from picking at it. I just dressed the wound. V39 stated, The wound has some drainage on it so I am going to reach out to the doctor to see if I can get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V39 stated she was notifying (V40, Medical Director). R40's Health Status Note, dated 6/28/22 at 2:19 PM, documents, Left hand remains red and edematous, continues to pick at surgical site, removes protective drsg once on. R40's Health Status Note, dated 6/29/22 at 3:41 AM, documents, Resident's L hand remains edematous and reddened. Scant amount of drainage noted. Resident has not c/o pain or discomfort thus far this shift. Continue to monitor for worsening of condition. R40's Health Status Note, dated 6/29/22 at 8:30 AM, documents, Resident is out in the dining room at this time, resident has picked off current bandage on left hand. Hand evaled (evaluated) at this time. Residents hand is red and swollen 3 plus pitting. Resident states that it hurts when touched. Residents hand cleaned and new dressing applied per MD order. Resident does have limited range of motion in her left hand related to swelling. Residents hand is not hot to touch. Will address with MD (V40) per fax to see if we can get a culture and a different dressing because resident picks this one off. Resident is unable to remember to leave dressing alone related to disease process. On 6/29/22 at 8:50 AM, R40 had removed the dressing from her left hand. R40's left hand and fingers were very swollen. The top of the hand was red. The redness from the hand was migrating down the fingers. The bottom of the incision that did run down the inner 4th finger has now pulled up to the knuckle and has opened up with drainage noted. The incision on the top of the hand has the the sutures intact and they were scabbed over. R40 was asked to move her fingers, R40 could not move the 4th finger and could only move the other 4 fingers slightly due to [CONDITION(S)] and pain. On 6/29/22 at 8:50 AM, V4, RN, stated, We have gotten a culture of her hand and are waiting on results. I have given her Tylenol. The bottom of the incision has opened up, there is a little drainage, the other sutures are scabbed over. Her hand and fingers are swollen. R40's Health Status Note, dated 6/29/22 at 9:05 AM, documents, Note faxed to MD (V40) office reguarding hand dressing and culture needed. Awaiting fax back. R40's Health Status Note, dated 6/29/22 at 9:05 AM, documents, Called MD (V40) office at this time, at 0937, asked to speak with a nurse reguarding hand and vaginal bleeding. 0938-- (V71, V40's office staff), on the phone. Writer explained situation reguarding residents hand and vaginal bleeding. (V71) states that (V72, Nurse Practitioner) will be in today to eval (evaluate) resident. Writer asked what time (V72) will be here because I feel like it is very important with residents hand and bleeding. (V71) states she will be in this afternoon. Writer asked if we could go ahead and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (V71) states (V72) wants to see it before anything else is done. On 6/29/22 at 9:30 AM, V4, stated, I told you wrong. The culture request was made but not gotten and the doctor faxed back orders that the Nurse Practitioner will see this week. I have faxed over a request for steri-strips and a better dressing and a culture. On 6/29/22 at 9:35 AM, V4 was questioned why a phone call has not been made to the doctor instead of faxing, V4 stated, The office will just tell us that we need to fax and wait for a response. On 6/29/22 at 10:30 AM, V4 stated she had called the doctor's office and they said the Nurse Practitioner will come and see her today. V4 stated she asked if she could get a culture and the office said no the nurse practitioner wants to evaluate it first. On 6/29/22 at 10:41, V49 (V50's Medical Assistant) stated, We have not been made aware of any issues (R40) has been having with her incision. (V50) is in surgery until 1:30 PM, I will have him call you when he gets out. R40's Health Status Note, dated 6/29/22 at 12:37 pm, documents, Residents hand has some purple discoloration noted to the left-hand top side. middle of the hand. (if you would look between the 2nd and 3rd finger and go up about 3cm (centimeters) and towards the ring finger, this is where the discoloration is noted). Residents radial pulse is still present. Resident continues to have 3 plus pitting [CONDITION(S)] in it and has limited range of motion. Area is red and appears shinny (sp) and taught. On 6/29/22 at 12:48 PM, V4 stated, (R40's) hand is starting to bruise up by the incision now. She has a radial pulse. Her fingers are stiff but she can move them. On 6/29/22 at 12:50 PM, V18, CNA, stated, Her (R40) hand looks more red today. I know that it is swollen and the nurse is taking care of it. On 6/29/22 at 12:53 PM, V20, LPN, stated, The night shift nurse faxed I think the her doctor here about the swelling and redness. I told the evening nurse to keep an eye out for the response. She was picking at it. I was monitoring her swelling. No, I did not reach out to the doctor because the night nurse had faxed the doctor. We can reach out by fax or phone if it is urgent. On 6/29/22 at 1:00 PM, V41, LPN, stated, If there is a change of condition, I will complete a SBAR (Situational Background Assessment Recommendation) and fax it to the doctor. Some doctors prefer the fax and if you call their office their nurses won't even let you talk to them. V40 likes faxes so you fax and wait for a response. On 6/29/22 at 1:35 PM, V50, R40's Surgeon, stated, I was not made aware of (R40's) change of condition. I expect the nurses to call me if there is a problem not (V40, R40's Primary Doctor/Medical Director). She is my patient this is my problem. I have been going there for [AGE] years and they have never had problems calling me before. If I would have known, I would have seen her in the clinic or seen her there. This will heal it is just going to take more time. The [CONDITION(S)] has caused the wound to dehiscence (open up). She is going to need antibiotics for the infection and probably wound clinic to heal the wound now. On 6/29/22 at 2:13 PM, V39, RN, stated, I did not reach out to the surgeon the other nurse did and we were waiting on a response. I faxed (V40) to update him but did not get a response. On 7/6/22 at 10:00 AM, V6, Regional Nurse, stated the nurses should have called the doctor and not faxed him when problems with her pain and incision started. On 7/6/22 at 2:16 PM, V40, Medical Director, stated he expects the nursing staff to notify someone at the first sign of infection. The Facility's Significant Condition Change & Notification Policy, undated, documents Purpose: To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: An accident or incident, with or without injury, that has the potential for needed medical practitioner intervention. A significant change in the resident's physical, mental or psychosocial status: New wounds, bruises or skin tears, Abrupt onset of [CONDITION(S)], Onset of swelling, Symptoms of an infectious process, Ten percent weight loss or gain in six months, Abnormal, Unusual or new complaints of pain, Allegation of abuse of neglect, and Resident to resident altercations require notification for both resident residents. A need to significantly alter treatment. It continues When any of the above situations exist, the licensed nurse will contact the resident's representative and their medical practitioner. Prior to calling the medical practitioner the nurse will complete the SBAR assessment. The medical practitioner will be contacted immediately for any emergencies regardless of the time of day. Non-emergency notifications may be made the next morning if the situation occurs on the late evening or night shift. This applies to any day of the week including holidays. If the medical practitioner cannot immediately be reached in any emergency, the medical director will be called. If that medical practitioner cannot be reached, the Director of Nursing or the charge nurse can make arrangements for transportation to the emergency department. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the medical practitioner. In a non-emergency situation, the primary medical practitioner will be called unless he/she has left an alternate name to call. If after two attempts, there is no response to the calls, the medical director will be contacted. 2. R20's weight log documents R20's weights as follows: 12/1/2021 130.0 Lbs (pounds); 1/2/2022 123.0 Lbs; 2/9/2022 121.8 Lbs; 2/13/2022 121.8 Lbs; 3/9/2022 117.0 Lbs; 4/1/2022 117.0 lbs; 5/1/22 125.6 lbs; and 6/15/2022 114.8 lbs. R20's Dietary Note, dated 1/13/2022 at 11:06 AM, documents, Note Text: RD (Registered Dietician) NOTE: Resident with Regular diet, adequate for nutrition needs, weight at 123#, < (less than) IBW (ideal body weight) Range, this is usual weight for resident when reviewing weight hx (history). decrease noted 5.4% x 30 days, Ice Cream is given 1xday- 101 yo (year old) advanced age r/t (related to) weight changes as well. Resident is Covid+ and weight changes expected to continue r/t illness. Rec (recommend) MPS for nutrition/weight support. Refer PRN ( as needed). R20's Dietary Note, dated 4/8/2022 at 9:56 AM, documents, Note Text: RD NOTE: Resident with weight changes past 6 months, 117#, <IBW Range. Regular diet is adequate for 101 yo, on IceCream also. intake is good at meals per records. Dementia dx (diagnosis) noted. D/T (due to) Weight decline, REC House Supplement 60cc (cubic centimeters) 2x day. Refer PRN. R20's Dietary Note, dated 6/21/2022 at 12:28PM documents, Note Text: RD NOTE: Resident 101 yo with 8% decrease this month, current weight at 115#, <IBW Range, stable with April weight, diet is adequate for nutrition needs, also on Ice-cream for addtl (additional) nutrition/caloric support. intake is ~50% at meals. REC house supplement for nutrition, Refer PRN On 6/29/22 at 12:33 PM, V51, Registered Dietician, stated, Per guidelines, 8% weight loss in one month is considered significant. I can't say whether (R20) would have lost weight if she had received the Med Pass. I would expect staff to encourage a resident to eat who has had significant weight loss. After I visit the facility, I send a full report to the DON (Director of Nursing), Administrator, and Dietary Manager. It may also go to someone in corporate, but I'm not sure about that. I review weights twice per month, but I'm physically in the facility once per month. On 6/29/22 at 12:50 PM, V34, Dietary Manager, stated, I get a report from the Dietitian once a month. It goes to me and the ADON (Assistant Director Of Nursing). Usually the ADON notifies the doctor, but last month, we didn't have the ADON, so I sent the report to all the nurses so they could contact the doctor. If there is a new doctor order, the nurses will let me know. Sometimes, nurses will refer to the Dietitian, and I will let the Dietitian know to see them. If a resident needs encouragement, extra fluids, etc. I write it on the 'notes' section of their meal ticket. The CNAs (Certified Nursing Assistants) or nursing are responsible for carrying that out. I order the Med Pass, Magic Cups and ice cream. I am not sure if nursing is still ordering Boost or Ensure, but they used to. I only pass the Magic Cups and ice cream. The nurses take care of Med Pass. On 6/29/2022 at 1:00 PM, V52, RN at V64's office, stated the facility did not notify them of R20's weight loss, or recommendations from the Dietician. V52 stated it is the expectation the facility notify V64, R20's Primary Physician, and/or the office, of R20's weight loss and recommendations. V52 stated when notified of a significant weight loss, the doctor reviews the previous weights, condition, age, consults the family, and reviews any recommendations. V52 stated at that time, interventions would be put in place, and in this case it would have been the supplements. V52 stated they did not get that opportunity because they were not notified of any weight loss until June 28th. V52 stated the interventions are put in place to stabilize and help prevent further weight loss. V52 stated, She should have been on the supplements. On 7/5/2022 at 1:20 PM, V3, LPN (Licensed Practical Nurse), stated R20 has had significant weight loss. V3 stated if there was a recommendation from the Dietician, then the recommendation should have been followed. V3 stated interventions are put in place to prevent future weight loss and stabilize the resident. V3 stated not putting interventions in place contributed to R20's weight loss. On 7/5/2022 at 1:43 PM, V56, R20's Guardian, stated she was not aware of R20's weight loss and supplement until yesterday (7/4/2022). V56 stated she brings in snacks, and the problem is they are not in her reach. V56 stated her mom has a short term memory problem, and would not remember to ask for them. V56 stated her mom would allow staff to provide encouragement and assistance for her during the meal. V56 stated her mom can do some things for herself, but requires help at times. V56 stated she would expect to receive calls. On 7/6/2022 at 2:17 PM, V40, Medical Director, stated with a resident who is having a weight loss and with multiple comorbidities, he would expect the physician to be notified of the weight loss and the Dietician recommendations. V40 stated he would expect that interventions would have been put in place. V40 stated interventions are put in place to stabilize and prevent more weight loss. V40 stated the resident should have been placed on the supplements. V40 stated not having the intervention in place contributed to R20's weight loss. The facility's Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol. Assessment and Recognition 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time. 2. As part of the initial assessment, the staff and physician will review the individual's current nutritional status and identify individuals with recent weight loss and significant risk for impaired nutrition 3. The threshold for significant unplanned and undesired weight loss will be based on the following criteria a. 1 month-5% weight loss is significant; greater than 5% is severe. c. 6 months-10% weight loss is significant; greater than 10% is severe.

Based on interview, observation, and record review, the facility neglected to provide timely treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R4's wound swelling, causing increasing pain, and the wound becoming infected and opening up. Findings Include: R40's Health Status Note, dated 6/23/22 at 1:30 PM, documents, Resident returned to facility after surgery via transportation driver. VS (Vital Signs) stable and no c/o (complaint of) voiced, denies any pain at this time. New orders for follow up appointment with (V50) at (local hospital) on July 12th at 4:00 PM. New order to leave dressing on left hand for 24 hours then remove it. Will continue to monitor. R40's Discharge Instructions from the local hospital for Excisions, dated 6/23/22, documents, Incisional Care: Look at the appearance of incisions each day and watch for signs of infection, including: redness, swelling, heat, green/yellow or foul-smelling drainage, fever 101 or higher, or severe pain not controlled by prescribed medication. If you suspect an infection, call your doctor. It also documents, You can reach your doctor at one of the follow numbers. For urgent problems, go to the nearest emergency room . V50's name and number was checked. R40's Health Status Note, dated 6/23/22 at 7:57 PM, documents, Drsg (dressing) intact to left hand, fingers edematous, slightly reddish purple, moving fingers freely. Up adlib (at liberty) ambulating independently. No acute distress, no s/s (sign and symptoms) pain/discomfort. R40's Health Status Note, dated 6/24/22 at 6:23 AM, documents, Resident c/o pain to left hand PRN (as needed) Tylenol given per MD (Medical Doctor) orders, stitches intact with noted [CONDITION(S)] to top of left hand and fingers on left hand, no redness noted. Will continue to monitor. R40's Health Status Note, dated 6/24/22 at 3:53 PM, documents, Sutures intact to left hand, picks at area at times. No s/s infection noted. R40's Health Status Note, dated 6/25/22 at 9:04 AM, documents, Resident recently had procedure to hand and has stitches in place. Hand is swollen and warm to touch. Resident unable to keep hand elevated to help with swelling. Resident complaining about tape to hand - resident does not have tape to hand. R40's Health Status Note, dated 6/25/22 at 12:47 PM, documents, Resident complaining about hand hurting, writer attempted to administer Tylenol prn as ordered and resident spit medication out and threw it on the floor. Resident complaining that she is cold. Writer took resident to room and put on sweater, sat in recliner with two blankets. R40's Health Status Note, dated 6/25/22 at 4:45 PM, documents, Picking at left hand sutures causing bleeding to area, dry protective drsg applied for protection, continues to pick and tries to remove drsg. Fingers remain edematous, warm to touch. Afebrile. R40's Health Status Note, dated 6/26/22 at 5:10 PM, documents, Writer has re-applied 2 dressings to L (left) anterior hand sutures. Resident has picked at sutures until they are bleeding. L hand is red/swollen and irritated. Resident continues to pick at sutures and hand. Will apply another dressing and wrap in kerlix to see if this helps from resident picking at surgical incision. Will continue to monitor. R40's Health Status Note, dated 6/27/22 at 5:00 AM, documents, Resident noted to have [CONDITION(S)] and redness to L dorsal hand. Sutures are CDI (clean, dry, and intact). MD notified. Awaiting response. On 6/27/22 at 6:43 AM, R40 exited her room. R40's left hand gauze dressing was pulling up leaving the top of her hand exposed. The top of R40's left hand had sutures, the area was swollen and red. R40's fingers were swollen. At that time, R40 stated, My tummy hurts. My hand hurts. I need help. On 6/27/22 at 8:08 AM, R40 was sitting at the dining room table. R40 was unwrapping the gauze bandage on her left hand. R40 was picking at the sutures. R40 stated, My hand hurts. This tape hurts. At that same time, V5, Certified Nurse Assistant (CNA), V37, CNA, and V38, Activity Director, were in the dining room passing out breakfast trays. No one acknowledged R40, or tried to redirect her from picking at her bandage. On 6/27/22 at 8:18 AM, V20, Licensed Practical Nurse (LPN), stopped her medication pass to redress R40's hand. R40 stated, My hand hurts. Don't touch my hand. My hand hurts. On 6/27/22 at 8:55 AM, R40 was walking in hallway stating that her hand hurts. On 6/27/22 at 10:28 AM, V20 stated, (R40) had like a horn growing out of the top of her hand. It is a large incision and has sutures. At this time, R40 came walking down the hall with the left hand gauze pulled up and the top of her hand bleeding. R40 stated, My hand hurts. On 6/27/22 at 10:30 AM, V20 stated, The night shift nurse faxed the surgeon to let him know and we are waiting to hear back from him. V20 told R40 she will get her some Tylenol to help. V20 took R40 to her room to cleanse and redress R40's left hand. R40 continued to say her hand hurt. V20 cut the remaining bandage off with scissors. R40's hand and fingers were very swollen. The top of her hand had an incision approximately 2 inches long, starting at the top of the hand, going past the knuckle to her inner finger. V20 cleansed the wound with normal saline, applied a gauze pad and wrapped the hand in gauze. R40's Health Status Note, dated 6/27/22 at 3:39 PM, documents, Sutures intact to left hand, hand/fingers remain edematous and red, will not leave protective drsg on. Call out to (V50, Surgeon) regarding suture removal and the [CONDITION(S)]/redness of hand, awaiting return call. R40's Health Status Note, dated 6/28/22 at 4:13 AM, documents, L hand remains edematous and reddened. Sutures appear removed at this time. Resident will not allow dressing to cover incisional wound. Area cleansed. Scant amount of sanguineous drainage noted. On 6/28/22 at 8:45 AM, R40 was walking in the dining room. R40's left hand had no bandage on it. R40's top of her hand had a small amount of drainage coming form the wound. The incision was scabbed over. R40's hand and fingers were more swollen than on 6/27/22. R40's hand remains red. R40 was telling V16, CNA, not to bump her hand and that her hand hurts. R40's Health Status Note, dated 6/28/22 at 9:53 AM, documents, Resident continues to pick top of left hand at surgical site, area red, and edematous. Writer wrapped left hand with dressing and cling, resident said get that off, then removed dressing and began picking left hand again. (V40, Doctor) notified and awaiting response from MD. R40's Health Status Note, dated 6/28/22 at 10:26 AM, documents, New order received from (V40, MD) to cover top of left hand with gauze, then cover with Geri sleeve or glove. R40's Health Status Note, dated 6/28/22 at 10:48 AM, documents, (V40) MD updated on resident's surgical site to top of left hand, red, edematous, with serosanguineous drainage noted. Resident's temp 98.7 at this time. Awaiting on MD response. On 6/28/22 at 10:49 AM, V39, Registered Nurse (RN), stated, (R40) is a picker, she won't leave anything on her hand which isn't surprising because it is swollen. I spoke with the doctor and he said to wrap it and to cover the dressing with a brace or 'arm sleeve' to keep her from picking at it. I just dressed the wound. V39 stated, The wound has some drainage on it so I am going to reach out to the doctor to see if I can get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V39 stated that she was notifying (V40, Medical Director). R40's Health Status Note, dated 6/28/22 at 2:19 PM, documents, Left hand remains red and edematous, continues to pick at surgical site, removes protective drsg once on. R40's Health Status Note, dated 6/29/22 at 3:41 AM, documents, Resident's L hand remains edematous and reddened. Scant amount of drainage noted. Resident has not c/o pain or discomfort thus far this shift. Continue to monitor for worsening of condition. R40's health status note, dated 6/29/22 at 8:30 AM, documents, Resident is out in the dining room at this time. Resident has picked off current bandage on left hand. Hand evaled (evaluated) at this time. Residents hand is red and swollen, 3 plus pitting. Resident states that it hurts when touched. Residents hand cleaned and new dressing applied per MD order. Resident does have limited range of motion in her left hand related to swelling. Residents hand is not hot to touch. Will address with MD (V40) per fax to see if we can get a culture and a different dressing because resident picks this one off. Resident is unable to remember to leave dressing alone related to disease process. On 6/29/22 at 8:50 AM, R40 had removed the dressing from her left hand. R40's left hand and fingers were very swollen. The top of the hand was red. The redness from the hand was migrating down the fingers. The bottom of the incision that did run down the inner 4th finger has now pulled up to the knuckle and has opened up with drainage noted. The incision on the top of the hand has the the sutures intact and they were scabbed over. R40 was asked to move her fingers, R40 could not move the 4th finger and could only move the other 4 fingers slightly due to [CONDITION(S)] and pain. On 6/29/22 at 8:50 AM, V4, RN, stated, We have gotten a culture of her hand and are waiting on results. I have given her Tylenol. The bottom of the incision has opened up, there is a little drainage, the other sutures are scabbed over. Her hand and fingers are swollen. R40's Health Status nNote, dated 6/29/22 at 9:05 AM, documents, Note faxed to MD (V40) office regarding hand dressing and culture needed. Awaiting fax back. R40's Health Status Note, dated 6/29/22 at 9:05 AM, documents, Called MD (V40) office at this time, at 0937, asked to speak with a nurse regarding hand and vaginal bleeding. 0938-- (V71, V40's office staff), on the phone. Writer explained situation regarding residents hand and vaginal bleeding. (V71) states that (V72, Nurse Practitioner) will be in today to eval (evaluate) resident. Writer asked what time (V72) will be here because I feel like it is very important with residents hand and bleeding. (V71) states she will be in this afternoon. Writer asked if we could go ahead and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (V71) states (V72) wants to see it before anything else is done. On 6/29/22 at 9:30 AM, V4, stated, I told you wrong. The culture request was made but not gotten and the doctor faxed back orders that the Nurse Practitioner will see this week. I have faxed over a request for steri-strips and a better dressing and a culture. On 6/29/22 at 9:35 AM, V4 was questioned why a phone call has not been made to the doctor instead of faxing, V4 stated, The office will just tell us that we need to fax and wait for a response. On 6/29/22 at 10:30 AM, V4 stated she had called the doctor's office, and they said the Nurse Practitioner will come and see her today. V4 stated she asked if she could get a culture, and the office said no the nurse practitioner wants to evaluate it first. On 6/29/22 at 10:41 AM, V49 (V50's Medical Assistant) stated, We have not been made aware of any issues (R40) has been having with her incision. (V50) is in surgery until 1:30 PM, I will have him call you when he gets out. R40's Health Status Note, dated 6/29/22 at 12:37 PM, documents, Residents hand has some purple discoloration noted to the left-hand top side, middle of the hand. (if you would look between the 2nd and 3rd finger and go up about 3cm (centimeters) and towards the ring finger, this is where the discoloration is noted). Residents radial pulse is still present. Resident continues to have 3 plus pitting [CONDITION(S)] in it and has limited range of motion. Area is red and appears shinny (sp) and taught. On 6/29/22 at 12:48 PM, V4 stated, (R40's) hand is starting to bruise up by the incision now. She has a radial pulse. Her fingers are stiff but she can move them. On 6/29/22 at 12:50 PM, V18, CNA, stated, Her (R40) hand looks more red today. I know that it is swollen and the nurse is taking care of it. On 6/29/22 at 12:53 PM, V20, LPN, stated, The night shift nurse faxed I think her doctor here about the swelling and redness. I told the evening nurse to keep an eye out for the response. She was picking at it. I was monitoring her swelling. No, I did not reach out to the doctor because the night nurse had faxed the doctor. We can reach out by fax or phone if it is urgent. On 6/29/22 at 1:00 PM, V41, LPN, stated, If there is a change of condition, I will complete a SBAR (Situational Background Assessment Recommendation) and fax it to the doctor. Some doctors prefer the fax and if you call their office their nurses won't even let you talk to them. V40 likes faxes so you fax and wait for a response. On 6/29/22 at 1:35 PM, V50, R40's Surgeon, stated, I was not made aware of (R40's) change of condition. I expect the nurses to call me if there is a problem not (V40, R40's Primary Doctor / Medical Director). She is my patient this is my problem. I have been going there for [AGE] years and they have never had problems calling me before. If I would have known, I would have seen her in the clinic or seen her there. This will heal it is just going to take more time. The [CONDITION(S)] has caused the wound to dehiscence (open up). She is going to need antibiotics for the infection and probably wound clinic to heal the wound now. On 6/29/22 at 2:13 PM, V39, RN, stated, I did not reach out to the surgeon the other nurse did and we were waiting on a response. I faxed (V40) to update him but did not get a response. On 7/6/22 at 10:00 AM, V6, Regional Nurse, stated the nurses should have called the doctor and not faxed him when problems with her pain and incision started. On 7/6/22 at 2:16 PM, V40, Medical Director, stated he expects the nursing staff to notify someone at the first sign of infection. The Facility's Abuse, Prevention and Prohibition Policy, dated 2/2021, documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It continues, Definitions: Neglect means failure to provide goods and services necessary to avoid physicial harm, pain, mental anguish, or emotional distress.

Based on interview, observation, and record review, the facility failed to act on a change of condition for 1 of 18 residents (R40) reviewed for nursing care in the sample of 51. This failure resulted in R40 experiencing increasing pain with swelling, and R40's surgical wound becoming infected and opening up. Findings Include: 1. R40's Health Status Note, dated 6/23/22 at 1:30 PM, documents, Resident returned to facility after surgery via transportation driver. VS (Vital Signs) stable and no c/o (complaint of) voiced, denies any pain at this time. New orders for follow up appointment with (V50) at (local hospital) on July 12th at 4:00 PM. New order to leave dressing on left hand for 24 hours then remove it. Will continue to monitor. R40's Health Status Note, dated 6/23/22 at 7:57 PM, documents, Drsg (dressing) intact to left hand, fingers edematous, slightly reddish purple, moving fingers freely. Up adlib (at liberty) ambulating independently. No acute distress, no s/s (sign and symptoms) pain/discomfort. R40's Discharge Instructions from the local hospital for Excisions, dated 6/23/22, documents, Incisional Care: Look at the appearance of incisions each day and watch for signs of infection, including: redness, swelling, heat, green/yellow or foul-smelling drainage, fever 101 or higher, or severe pain not controlled by prescribed medication. If you suspect an infection, call your doctor. It also documents, You can reach your doctor at one of the follow numbers. For urgent problems, go to the nearest emergency room . V50's name and number was checked. R40's Health Status Note, dated 6/24/22 at 6:23 AM, documents, Resident c/o pain to left hand PRN (as needed) Tylenol given per MD (Medical Doctor) orders, stitches intact with noted [CONDITION(S)] to top of left hand and fingers on left hand, no redness noted. Will continue to monitor. R40's Health Status Note, dated 6/24/22 at 3:53 PM, documents, Sutures intact to left hand, picks at area at times. No s/s infection noted. R40's Health Status Note, dated 6/25/22 at 9:04 AM, documents, Resident recently had procedure to hand and has stitches in place. Hand is swollen and warm to touch. Resident unable to keep hand elevated to help with swelling. Resident complaining about tape to hand - resident does not have tape to hand. R40's Health Status Note, dated 6/25/22 at 12:47 PM, documents, Resident complaining about hand hurting, writer attempted to administer Tylenol prn as ordered and resident spit medication out and threw it on the floor. Resident complaining that she is cold. Writer took resident to room and put on sweater, sat in recliner with two blankets. R40's Health Status Note, dated 6/25/22 at 4:45 PM, documents, Picking at left hand sutures causing bleeding to area, dry protective drsg applied for protection, continues to pick and tries to remove drsg. Fingers remain edematous, warm to touch. Afebrile. R40's Health Status Note, dated 6/26/22 at 5:10 PM, documents, Writer has re applied 2 dressings to L (left) anterior hand sutures. Resident has picked at sutures until they are bleeding. L hand is red/swollen and irritated. Resident continues to pick at sutures and hand. Will apply another dressing and wrap in kerlix to see if this helps from resident picking at surgical incision. Will continue to monitor. R40's Health Status Note, dated 6/27/22 at 5:00 AM, documents, Resident noted to have [CONDITION(S)] and redness to L dorsal hand. Sutures are CDI (clean, dry, and intact). MD notified. Awaiting response. On 6/27/22 at 6:43 AM, R40 exited her room. R40's left hand gauze dressing was pulling up leaving the top of her hand exposed. The top of R40's left hand had sutures, the area was swollen and red. R40's fingers were swollen. At that time, R40 stated, My tummy hurts. My hand hurts. I need help. On 6/27/22 at 8:08 AM, R40 was sitting at the dining room table. R40 was unwrapping the gauze bandage on her left hand. R40 was picking at the sutures. R40 stated, My hand hurts. This tape hurts. At that same time, V5, Certified Nursing Assistant (CNA), V37, CNA, and V38, Activity Director, were in the dining room passing out breakfast trays. No one acknowledged R40, or tried to redirect her from picking at her bandage. On 6/27/22 at 8:18 AM, V20, Licensed Practical Nurse (LPN), stopped her medication pass to redress R40's hand. R40 stated, My hand hurts. Don't touch my hand. My hand hurts. On 6/27/22 at 8:55 AM, R40 was walking in hallway stating that her hand hurts. On 6/27/22 at 10:28 AM, V20 stated, (R40) had like a horn growing out of the top of her hand. It is a large incision and has sutures. At this time, R40 came walking down the hall with the left hand gauze pulled up and the top of her hand bleeding. R40 stated, My hand hurts. On 6/27/22 at 10:30 AM, V20 stated, The night shift nurse faxed the surgeon to let him know and we are waiting to hear back from him. V20 told R40 she will get her some Tylenol to help. V20 took R40 to her room to cleanse and redress R40's left hand. R40 continued to say her hand hurt. V20 cut the remaining bandage off with scissors, R40's hand and fingers were very swollen. The top of her hand had an incision approximately 2 inches long, starting at the top of the hand, going past the knuckle to her inner finger. V20 cleansed the wound with normal saline, applied a gauze pad, and wrapped the hand in gauze. R40's Health Status Note, dated 6/27/22 at 3:39 PM, documents, Sutures intact to left hand, hand/fingers remain edematous and red, will not leave protective drsg on. Call out to (V50, Surgeon) regarding suture removal and the [CONDITION(S)]/redness of hand, awaiting return call. R40's Health Status Note, dated 6/28/22 at 4:13 AM, documents, L hand remains edematous and reddened. Sutures appear removed at this time. Resident will not allow dressing to cover incisional wound. Area cleansed. Scant amount of sanguineous drainage noted. On 6/28/22 at 8:45 AM, R40 was walking in the dining room. R40's left hand had no bandage on it. R40's top of her hand had a small amount of drainage coming form the wound. The incision was scabbed over. R40's hand and fingers were more swollen than on 6/27/22. R40's hand remains red. R40 was telling V16, CNA, not to bump her hand and that her hand hurts. R40's Health Status Note, dated 6/28/22 at 9:53 AM, documents, Resident continues to pick top of left hand at surgical site, area red, and edematous. Writer wrapped left hand with dressing and cling, resident said get that off, then removed dressing and began picking left hand again. (V40, Doctor) notified and awaiting response from MD. R40's Health Status Note, dated 6/28/22 at 10:26 AM, documents, New order received from (V40, MD) to cover top of left hand with gauze, then cover with Geri sleeve or glove. R40's Health Status Note, dated 6/28/22 at 10:48 AM, documents, (V40) MD updated on resident's surgical site to top of left hand, red, edematous, with serosanguineous drainage noted. Resident's temp 98.7 at this time. Awaiting on MD response. On 6/28/22 at 10:49 AM, V39, Registered Nurse (RN), stated, (R40) is a picker, she won't leave anything on her hand which isn't surprising because it is swollen. I spoke with the doctor and he said to wrap it and to cover the dressing with a brace or 'arm sleeve' to keep her from picking at it. I just dressed the wound. V39 stated, The wound has some drainage on it so I am going to reach out to the doctor to see if I can get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V39 stated she was notifying (V40, Medical Director). R40's Health Status Note, dated 6/28/22 at 2:19 PM, documents, Left hand remains red and edematous, continues to pick at surgical site, removes protective drsg once on. R40's Health Status Note, dated 6/29/22 at 3:41 AM, documents, Resident's L hand remains edematous and reddened. Scant amount of drainage noted. Resident has not c/o pain or discomfort thus far this shift. Continue to monitor for worsening of condition. R40's Health Status Note, dated 6/29/22 at 8:30 AM, documents, Resident is out in the dining room at this time, resident has picked off current bandage on left hand. Hand evaled (evaluated) at this time. Residents hand is red and swollen 3 plus pitting. Resident states that it hurts when touched. Residents hand cleaned and new dressing applied per MD order. Resident does have limited range of motion in her left hand related to swelling. Residents hand is not hot to touch.Will address with MD (V40) per fax to see if we can get a culture and a different dressing because resident picks this one off. Resident is unable to remember to leave dressing alone related to disease process. On 6/29/22 at 8:50 AM, R40 had removed the dressing from her left hand. R40's left hand and fingers were very swollen. The top of the hand was red. The redness from the hand was migrating down the fingers. The bottom of the incision that did run down the inner 4th finger has now pulled up to the knuckle and has opened up with drainage noted. The incision on the top of the hand had the the sutures intact, and they were scabbed over. R40 was asked to move her fingers. R40 could not move the 4th finger and could only move the other 4 fingers slightly, due to [CONDITION(S)] and pain. On 6/29/22 at 8:50 AM, V4, RN, stated, We have gotten a culture of her hand and are waiting on results. I have given her Tylenol. The bottom of the incision has opened up, there is a little drainage, the other sutures are scabbed over. Her hand and fingers are swollen. R40's Health Status Note, dated 6/29/22 at 9:05 AM, documents, Note faxed to MD (V40) office regarding hand dressing and culture needed. awaiting fax back. R40's Health Status Note, dated 6/29/22 at 9:05 AM, documents, Called MD (V40) office at this time, at 0937, asked to speak with a nurse regarding hand and vaginal bleeding. 0938-- (V71, V40's office staff), on the phone. Writer explained situation regarding residents hand and vaginal bleeding. (V71) states that (V72, Nurse Practitioner) will be in today to eval (evaluate) resident. Writer asked what time (V72) will be here because i feel like it is very important with residents hand and bleeding. (V71) states she will be in this afternoon. Writer asked if we could go ahead and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (V71) states (V72) wants to see it before anything else is done. On 6/29/22 at 9:30 AM, V4, stated, I told you wrong. The culture request was made, but not gotten, and the doctor faxed back orders that the Nurse Practitioner will see this week. I have faxed over a request for steri-strips and a better dressing and a culture. On 6/29/22 at 9:35 AM, V4 was questioned why a phone call has not been made to the doctor instead of faxing, V4 stated, The office will just tell us that we need to fax and wait for a response. On 6/29/22 at 10:30 AM, V4 stated she had called the doctor's office, and they said the Nurse Practitioner will come and see her today. V4 stated she asked if she could get a culture, and the office said no, the Nurse Practitioner wants to evaluate it first. On 6/29/22 at 10:41 AM, V49 (V50's Medical Assistant) stated, We have not been made aware of any issues (R40) has been having with her incision. (V50) is in surgery until 1:30 PM, I will have him call you when he gets out. R40's Health Status Note, dated 6/29/22 at 12:37 PM, documents, Residents hand has some purple discoloration noted to the left-hand top side. middle of the hand. (if you would look between the 2nd and 3rd finger and go up about 3cm (centimeters) and towards the ring finger, this is where the discoloration is noted). Residents radial pulse is still present. resident continues to have 3 plus pitting [CONDITION(S)] in it and has limited range of motion. Area is red and appears shinny (sp) and taught. On 6/29/22 at 12:48 PM, V4 stated, (R40's) hand is starting to bruise up by the incision now. She has a radial pulse. Her fingers are stiff but she can move them. On 6/29/22 at 12:50 PM, V18, CNA, stated, Her (R40) hand looks more red today. I know that it is swollen and the nurse is taking care of it. On 6/29/22 at 12:53 PM, V20, LPN, stated, The night shift nurse faxed I think her doctor here about the swelling and redness. I told the evening nurse to keep an eye out for the response. She was picking at it. I was monitoring her swelling. No, I did not reach out to the doctor because the night nurse had faxed the doctor. We can reach out by fax or phone if it is urgent. On 6/29/22 at 1:00 PM, V41, LPN, stated, If there is a change of condition, I will complete a SBAR (Situational Background Assessment Recommendation) and fax it to the doctor. Some doctors prefer the fax and if you call their office their nurses won't even let you talk to them. V40 likes faxes so you fax and wait for a response. On 6/29/22 at 1:35 PM, V50, R40's Surgeon, stated, I was not made aware of (R40's) change of condition. I expect the nurses to call me if there is a problem not (V40, R40's Primary Doctor / Medical Director). She is my patient this is my problem. I have been going there for [AGE] years and they have never had problems calling me before. If I would have known, I would have seen her in the clinic or seen her there. This will heal it is just going to take more time. The [CONDITION(S)] has caused the wound to dehiscence (open up). She is going to need antibiotics for the infection and probably wound clinic to heal the wound now. On 6/29/22 at 2:13 PM, V39, RN, stated, I did not reach out to the surgeon the other nurse did and we were waiting on a response. I faxed (V40) to update him but did not get a response. On 7/6/22 at 10:00 AM, V6, Regional Nurse, stated the nurses should have called the doctor and not faxed him when problems with her pain and incision started. On 7/6/22 at 2:16 PM, V40, Medical Director, stated he expects the nursing staff to notify someone at the first sign of infection.

Based on interview, observation, and record review, the facility failed to provide adequate supervision to prevent falls, and failed to operate a mechanical lift in a safe manner in 3 of 6 residents (R19, R38, R226) reviewed for falls in the sample of 51. This failure resulted in R38 and R226 sustaining falls which resulted in fractures. 1. R226's face sheet, undated, documents a diagnosis of [CONDITION(S)] and Muscle Weakness. R226's Minimum Data Set (MDS), dated [DATE], documents R226 has severe cognitive impairment, requires an extensive assistance of two staff for toileting and has had falls prior to admission and after admission. R226's care plan, dated 6/10/22, documents R226 is at risk of falls. R226's fall risk assessment, dated 6/10/22, documents R226 is at risk of falls. R226's progress note, dated 6/24/22 at 2:11PM, documents, Certified Nurses Assistant (CNA) brought resident to bathroom, resident was agitated and walked on through the next bathroom door to the adjoining room. Resident then attempted to punch CNA, and resident fell to the floor. CNA yelled for writer/nurse. Writer arrived in room and noted resident sitting on the floor. Writer asked resident if he was having pain and he responded his hip and neck hurt. Staff did not move resident. 911 called. Emergency Medical Technicians (EMT) arrived and resident lifted with sheet to stretcher. Resident transferred to local hospital via ambulance. R226's hospital history and physical, dated 6/25/22, documents diagnosis of a Left Femoral Neck Fracture. On 6/28/22 at 11:47AM, V41, Licensed Practical Nurse (LPN), stated R226 was very agitated, and he had just punched a task aide and threw furniture all around the room. V41 stated he started yelling he needed to go pee, so she told V60, CNA, to go ahead and take him to the bathroom. V41 stated she went out to get his medication, [MEDICATION(S)], ready hoping with him going to the bathroom, it would calm him down enough to take the medication. V41 stated R226 went into the bathroom and kept going into the next residents room, and when V60 tried to redirect him back to the bathroom, R226 was kicking and trying to hit V60, and he fell . V41 was questioned if it was safe for V60 to take R226 to the bathroom alone, and V41 stated, That is all the staffing we had that day would allow. On 6/29/22 at 11:39AM, V41, LPN, stated when R226 fell on [DATE], there was only 1 CNA attempting to toilet him. V41 is unsure of what assistance level was required for R226 with toileting. On 6/30/22 at 11:05AM, V1, Administrator, stated he would expect staff to use the recommended number of staff needed for transfers, toileting, etc. 2. R38's Care Plan, dated 3/17/22, documents, (R38) is at risk for falls related to gait/balance problems and history of falls. Interventions: 'Call Don't Fall' sign, call light is within reach and encourage the resident to use it for assistance as needed, educate the resident/family/caregivers about calling for assistance prior to cares and what to do if a fall occurs, ensure personal items are within reach, ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, place walker within reach. On 6/21/22, intervention added: Re-educate resident importance of using call light for assistance. It continues (R38) YOUNITE Story - Care/ADL (Activities of Daily Living) Preferences: (R38) prefers to go to bed at 8:00 PM, usually wakes up early in the morning to use the bathroom and then will go back to bed for about an hour. It continues (R38) has an ADL Self Care Performance Deficit related to impaired balance. Interventions: Ambulation assist walking with resident in her room to and from the bathroom using a gait belt and wheeled walker providing stand by assist to limited assist as needed based on resident's performance and ability, requires one staff participation to use toilet, requires one staff participation with transfers. It continues (R38) has limited physical mobility. Interventions: requires stand by assistance with a walker to ambulate as desired. R38's Fall Risk Data Collection, dated upon admission on 6/1/21, documents R38 was a low fall risk. R38's Fall Risk Data Collection, dated 3/13/22, R38's date of fall, documents R38 was a low fall risk. R38's Fall Risk Data Collection, dated 3/26/22, R38's return to the facility after hospitalization from a fall, documents R38 was a high fall risk. R38's Fall Risk Data Collection, dated 6/21/22, R38's date of fall, documents R38 was a high fall risk. R38's Progress Note, dated 3/13/22 at 3:40 AM, documents, The resident is experiencing a change in condition. See SBAR (Situation, Background, Assessment, Recommendation) assessment for further information and family/physician notification. The change in condition the resident is currently experiencing is non witnessed fall. R38's Progress Note, dated 3/13/22 at 3:43 AM, documents, Resident yelling out help. CNA entered room and observed resident sitting on the floor. Writer entered room and observed resident sitting on the floor in the corner by bathroom door. [NAME] standing behind resident. Resident states she was bending over to pick up a piece of clothing and lost her balance and fell to her bottom. ROM (Range of Motion) WNL (Within Normal Limits) and no complaints of pain. resident was able to stand to feet and skin check completed at this time with no areas noted. resident ambulated with walker to bed without difficulty. Vital signs 112/52-56-16-97.8. neuro assessment initiated. Doctor made aware. will update POA (Power of Attorney) in AM hours. R38's Progress Note dated 3/13/22 at 10:08 AM, documents, Resident noted to have fall on night shift last evening. Neuro checks continued, vitals stable and WNL, no complaint of pain or discomfort at this time. Does states she is a little sore on left rear. No redness or bruising noted at this time. R38's Progress Note, dated 3/15/22 at 7:05 PM, documents, Resident complained of pain in right hip and lower right rib regions. Tylenol provided PRN (as needed) throughout day. Resident requesting x-ray. Resident able to move all extremities, and able to ambulate with walker. Aware we will update doctor in the morning. R38's Progress Note, dated 3/16/22 at 10:22 AM, documents, New Order received from Doctor's office per Nurse, x-ray right hip and right rib area. Orders called to (radiology company), states will call with time they will be here. Call placed to update POA/Son of new order, no answer, left message to call facility. HIPPA (Health Insurance Portability and Accountability Act) compliance maintained. Awaiting return call at this time. R38's Progress Note, dated 3/21/22 at 6:40 AM, documents, Called POA per resident's request. Resident continues to complain of pain. Resident is refusing to be repositioned, changed, or attempt to walk with assistance to go to the bathroom. POA states he was in yesterday and she would only get up one time. He attempted to encourage her that she needed to get up, but resident complained of pain and would not. Will update MD (Medical Doctor) when office opens that resident is still complaining of pain. POA states he will be in later today. Resident is in bed but slouched down towards the bottom of the bed and will not let staff pull her up in bed. Call light within reach. R38's Progress Note, dated 3/21/22 at 9:11 AM, documents, The resident is experiencing a change in condition. See SBAR assessment for further information and family/physician notification. The change in condition the resident is currently experiencing is resident had a fall on 3/13/22, complaining of increasing pain to pelvic/back. R38's Progress Note, dated 3/21/22 at 9:12 AM, documents, Doctor's office called and stated that resident should go to the ER (emergency room ) to be evaluated. R38's Progress Note, dated 3/21/22 at 9:16 AM, documents, Called (local ambulance service) to come and get resident and take to the hospital for evaluation. R38's Progress Note, dated 3/21/22 at 9:34 AM, documents, Ambulance arrived and took resident to the hospital to be evaluated. Paperwork given to EMS (Emergency Medical Service). R38's Progress Note, dated 3/21/22 at 1:48 PM, documents, Received phone call from (local ER) that the resident is going to be coming back. She did have a few acute fractures. Son did not want anything done nor did he want her to have any scripts for pain control. Sending someone to go and pick her up. R38's Progress Note, dated 3/21/22 at 2:20 PM, documents, POA present when resident returned. Resident informed writer that resident has a fractured tailbone. No paperwork from hospital showing any fractures. Called (local hospital), spoke with staff to request result of radiology reports faxed to facility. R38's MDS, dated [DATE], documents R38 is cognitively intact and requires extensive assistance from one staff member for transfers. R38 requires limited assistance from one staff member for ambulation, dressing, toilet use, personal hygiene and bathing. R38 is always continent of both her bowel and bladder. R38's Progress Note, dated 6/21/22 at 4:53 PM, documents, Writer called to resident's room by CNA @ 1620. Resident noted to be lying on the floor by her closet. Resident sitting upright, shoes on. Floor clean, quiet environment. Writer asked resident if she was in pain. Resident states, Yes, I think something is broke. Writer asked resident if she was able to move her legs. Resident states she is unable to move left leg. Left leg bent, resident unable to show exact location of pain other than left leg. Resident left on the floor, with CNA beside her. POA called at 4:30 PM. 911 called at 4:31 PM, informed both crews are out at this time, will be here as soon as they can. Report called to Nurse at (local ER) at 4:33 PM. Nurse at Doctors office notified. Regional nurse, (V6) present and aware. Local Ambulance Service arrived and transported resident via stretcher to LocaL ER at 4:47 PM. R38's Progress Note, dated 6/24/22 at 2:13 PM, documents, Received a call from (staff at local hospital) to call report that resident is coming back to facility today. Fracture to left hip, had nailing on 6/22/22 with incisions noted to left upper thigh. WBAT (weight bearing as tolerated). Two assist for transfers. Isolation droplet sinus related to random virus and ESBL (Extended-spectrum beta-lactamase) to urine. Carbohydrate controlled 75 gram diet. Accu checks Ac (before meals) and HS (before bed) with SSI (sliding scale insulin). Urinary catheter discontinued this morning and resident is voiding without difficultly. Order for [MEDICATION(S)] and script is being sent. Currently on [MEDICATION(S)]. Transport was at hospital at end of call to bring her to facility. On 7/5/22 at 10:45 AM, R38 was lying in bed, wheelchair was at the foot of her bed. There was no walker seen in her room. There was a call don't fall sign on the restroom door. R38 had personal items lying everywhere, on her bedside table, the night stand, and the window sill. On 7/6/22 at 12:30 PM, R38 was lying in bed with hospital gown on, no walker was seen in her room; personal belongings located in several places in her room; wheelchair at foot of her bed. On 7/05/22 at 11:00 AM, R38 stated, I remember when I fell last month. I was in my closet because I wanted to wear a specific shirt. I pulled on the shirt and it came off the hanger and I fell backwards. I landed on a metal rail on the floor and had to be operated on. I fell a few months ago when I was trying to pick up clothes by the bathroom door. I lost my balance and fell . I didn't bother them because they are so busy and there is not enough help. On 7/5/22 at 10:35 AM, V3, LPN, stated, I was here when (R38) fell on [DATE], and I was her nurse that day. I was just in her room, and she was sitting on the side of the bed with her feet down. I left to go to a quick meeting and when I came back, (V8, CNA) told me that (R38) was found on the floor. (R38) said she was going to change her blouse. On 7/06/22 at 1:26 PM, V29, CNA, stated (R47) was always moving around in her room with her walker. She usually is very good at using her call light for help but the times when she fell , she did not use it. (R47) liked to sit on the side of her bed to eat. Since she broke her hip, we just sit her up and put her food on tray table across her. On 7/7/22 at 11:05 AM, V48, CNA, stated (R38) usually will try and go to the restroom by herself, and if she feels like she needs some assistance, she will put her call light on. That night, (R38) must have gotten up herself and when I walked by her room, she was on the floor. The staffing for our shift is always short staffed. There is always just me, (V67, CNA), and (V68, CNA) working with one to two Nurses for the entire building. It is hard to get to everyone with just a few of us working. The Facility's Schedule and Daily Assignment sheets provided by V6, Regional Nurse, dated 3/12/22, documents during the date and time of R38's fall (3/13/22 at 3:40 AM), there was only one LPN and three CNA's on duty in the facility with a census of 66 residents. 3. R19's MDS, dated [DATE], documents R19 is cognitively intact and requires extensive assistance from two staff members for transfers. R19 requires extensive assistance from one staff member for bed mobility, dressing, toilet use, personal hygiene and bathing. R19 is always incontinent of urine and always continent of bowel. R19's Care Plan, dated 6/27/22, documents, (R19) has an ADL Self Care Performance Deficit Limited Mobility. Interventions: requires Mechanical lift and assist of two for transfers. It continues, (R19) has limited physical mobility. Interventions: is non weight bearing, is totally dependent on staff for ambulation/locomotion. On 6/27/22 at 12:25 PM, V29, CNA, brought the full body mechanical lift device into R19's room, attached the sling under R19 to the lift device, and then lifted R19 off her bed. There was no verification of the strap/loops attached prior to lifting R19 from her bed. R19 was left swinging in the air above her bed while V8, CNA, moved around the bed to get R19's wheelchair, which was located at the foot of her bed. V29 was operating the lift device, and pulled R19 out and away from her bed, while being moved approximately three to four feet to her wheelchair. R19 was left swinging freely in the air during the move until lowered into the wheelchair. No one was holding onto R19 during this transfer until the final lowering into her wheelchair. On 6/30/22 at 10:45 AM, V8, CNA, stated, If we are using the (full body mechanical lift device), after we put the resident in the sling, we will lift them and pull the resident back away from bed, make sure the wheels are locked on both the wheelchair and lift device. If the resident needs to be adjusted to a sitting position, I will use the handles on the back of the sling to move the resident into the wheelchair. On 6/30/22 at 11:00 AM, V23, CNA, stated, When getting a resident up using a (full body mechanical lift device), we will lift them off the bed and pull the lift from under the bed and move the resident to the wheelchair and lowered. One person can hold the handle on the back of the sling to guide the resident to the chair. On 7/07/22 at 9:00 AM, V6, Corporate Nurse, stated, I would expect the staff to keep a hold on the resident at all times while using the full body mechanical lift device. They should not be letting the resident free swing while in the lift. The Facility's Total Dependent Lift Employee Checklist, undated, documents Check Care Plan, Gather Equipment, Wash hands, Place sling under resident and around legs, Position lift near resident and lower the four-point tilting frame, Connect clips to tilting frame, Verify placement of (full body mechanical lift) loops. The Hoyer Installation and Instruction Manual, dated 2002, documents Before Lifting: 1. Make sure that all straps are attached to the carry bar. 2. Make sure the person being lifted is comfortable. 3. Make sure the sling is not caught on an obstruction. 4. Lift until the buttocks of the person being lifted clear the arm supports or the top of the bed before moving the person. Guide the legs past any obstacle. It continues The Hoyer lift is not intended to be a transport device. Person in the lift should not be moved more than a few feet. The Fall Policy, dated 9/17/19, documents The purpose of the Fall Management Program is to develop, implement, monitor and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that foster resident independence and quality of life. The Fall Management Program promotes safety, prevention and education of both staff and residents.

Based on interview and record review, the facility failed to monitor and provide interventions to prevent significant weight loss for 1 of 3 residents (R20) reviewed for weight loss and nutrition in the sample of 51. This failure resulted in R20's severe weight loss of 10% in 3 months, and severe weight loss of 11.7% in 6 months. Findings include: R20's weight log documents R20's weights as follows: 12/1/2021 130.0 Lbs (pounds); 1/2/2022 123.0 Lbs; 2/9/2022 121.8 Lbs; 2/13/2022 121.8 Lbs; 3/9/2022 117.0 Lbs; 4/1/2022 117.0 lbs; 5/1/22 125.6 lbs; 6/15/2022 114.8 lbs. R20's Nutrition Record does not document meals for 5/31/22 dinner, 6/1/22 dinner, 6/2/22 to 6/9/22 all meals, 6/10/22 breakfast & lunch, 6/11, 6/12 no meals documented, 6/13/2022 breakfast & lunch, 6/14 no meals documented, 6/15 lunch. R20's Dietary Note, dated 1/13/2022 at 11:06 AM, documents, Note Text: RD (Registered Dietician) NOTE: Resident with Regular diet, adequate for nutrition needs, weight at 123#, < (less than) IBW (ideal body weight) Range, this is usual weight for resident when reviewing weight hx (history). decrease noted 5.4% x 30 days, Ice Cream is given 1xday- 101 yo (year old) advanced age r/t (related to) weight changes as well. Resident is Covid+ and weight changes expected to continue r/t illness. Rec (recommend) MPS for nutrition/weight support. Refer PRN ( as needed). R20's Dietary Note, dated 4/8/2022 at 9:56 AM, documents, Note Text: RD NOTE: Resident with weight changes past 6 months, 117#, <IBW Range. Regular diet is adequate for 101 yo, on IceCream also. intake is good at meals per records. Dementia dx (diagnosis) noted. D/T (due to) Weight decline, REC House Supplement 60cc (cubic centimeters) 2x day. Refer PRN. R20's Dietary Note, dated 6/21/2022 at 12:28 PM, Note Text: RD NOTE: Resident 101 yo with 8% decrease this month, current weight at 115#, <IBW Range, stable with April weight, diet is adequate for nutrition needs, also on Ice-cream for addtl (additional) nutrition/caloric support. intake is ~50% at meals. REC house supplement for nutrition, Refer PRN On 6/29/22 at 12:33 PM, V51, Registered Dietician, stated, Per guidelines, 8% weight loss in one month is considered significant. I can't say whether (R20) would have lost weight if she had received the Med Pass. I would expect staff to encourage a resident to eat who has had significant weight loss. After I visit the facility, I send a full report to the DON (Director of Nursing), Administrator, and Dietary Manager. It may also go to someone in corporate, but I'm not sure about that. I review weights twice per month, but I'm physically in the facility once per month. On 6/29/22 at 12:50 PM, V34, Dietary Manager, stated, I get a report from the Dietitian once a month. It goes to me and the ADON (Assistant Director of Nursing). Usually the ADON notifies the doctor, but last month, we didn't have the ADON, so I sent the report to all the nurses so they could contact the doctor. If there is a new doctor order, the nurses will let me know. Sometimes, nurses will refer to the Dietitian, and I will let the Dietitian know to see them. If a resident needs encouragement, extra fluids, etc. I write it on the 'notes' section of their meal ticket. The CNAs (Certified Nursing Assistants) or nursing are responsible for carrying that out. I order the Med Pass, Magic Cups and ice cream. I am not sure if nursing is still ordering Boost or Ensure, but they used to. I only pass the Magic Cups and ice cream. The nurses take care of Med Pass. On 6/29/22 at 12:43 PM, V53, CNA, stated, The checkmark means the residents were asked if they wanted a snack. We chart in (Point Click Care) whether or not they accepted the supplement. We do not document how much they ate or if they ate at all. V54 stated, I think we only document percentages at meals. On 6/29/2022 at 1:00 PM, V52, RN, at V64's (R20's Primary Care Physician) office, stated the facility did not notify them of R20's weight loss or recommendations from the Dietician. V52 stated it is the expectation the facility notify V64, R20's Primary Physician, and/or the office of R20's weight loss and recommendations. V52 stated when notified of a significant weight loss, the doctor reviews the previous weights, condition, age, consults the family, and reviews any recommendations. V52 stated at that time, interventions would be put in place, and in this case it would have been the supplements. V52 stated they did not get that opportunity, because they were not notified of any weight loss until June 28th. V52 stated the interventions are put in place to stabilize and help prevent further weight loss. V52 stated, She should have been on the supplements. On 7/5/2022 at 1:20 PM, V3, LPN, stated R20 has had significant weight loss. V3 stated if there was a recommendation from the Dietician, then the recommendation should have been followed. V3 stated interventions are put in place to prevent future weight loss and stabilize the resident. V3 stated not putting interventions in place contributed to R20's weight loss. On 7/5/2022 at 1:43 PM, V56, R20's Guardian, stated she was not aware of R20's weight loss and supplement until yesterday (7/4/2022). V56 stated she brings in snacks, and the problem is they are not in her reach. V56 stated her mom has a short term memory problem, and would not remember to ask for them. V56 stated her mom would allow staff to provide encouragement and assistance for her during the meal. V56 stated her mom can do some things for herself, but requires help at times. V56 stated she would expect to receive calls. On 7/6/2022 at 2:17 PM, V40, Medical Director, stated with a resident who is having a weight loss and with multiple comorbidities, he would expect the physician to be notified of the weight loss and the Dietician recommendations. V40 stated he would expect interventions would have been put in place. V40 stated interventions are put in place to stabilize and prevent more weight loss. V40 stated the resident should have been placed on the supplements. V40 stated not having the intervention in place contributed to R20's weight loss. The facility's Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol. Assessment and Recognition 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time. 2. As part of the initial assessment, the staff and physician will review the individual's current nutritional status and identify individuals with recent weight loss and significant risk for impaired nutrition 3. The threshold for significant unplanned and undesired weight loss will be based on the following criteria a. 1 month-5% weight loss is significant; greater than 5% is severe. c. 6 months-10% weight loss is significant; greater than 10% is severe.

Based on observation, interview, and record review, the facility failed to address pain for infected, swollen surgical incision, and provide treatment to prevent skin irritation for 2 of 3 (R40, R72) reviewed for nursing care in the sample of 51. This failure resulted in R40 not having her new pain addressed for 6 days. Findings Include: 1. R40's Health Status Note, dated 6/23/22 at 1:30 PM, documents, Resident returned to facility after surgery via transportation driver. VS (Vital Signs) stable and no c/o (complaint of) voiced, denies any pain at this time. New orders for follow up appointment with (V50) at (local hospital) on July 12th at 4:00 PM. New order to leave dressing on left hand for 24 hours then remove it. Will continue to monitor. R40's Health Status Note, dated 6/23/22 at 7:57 PM, documents, Drsg (dressing) intact to left hand, fingers edematous, slightly reddish purple, moving fingers freely. Up adlib (at liberty) ambulating independently. No acute distress, no s/s (sign and symptoms) pain/discomfort. R40's Discharge Instructions from the local hospital for Excisions, dated 6/23/22, documents, Incisional Care: Look at the appearance of incisions each day and watch for signs of infection, including: redness, swelling, heat, green/yellow or foul-smelling drainage, fever 101 or higher, or severe pain not controlled by prescribed medication. If you suspect an infection, call your doctor. It also documents, You can reach your doctor at one of the follow numbers. For urgent problems, go to the nearest emergency room . V50's name and number was checked. R40's Health Status Note, dated 6/24/22 at 6:23 AM, documents, Resident c/o pain to left hand PRN (as needed) Tylenol given per MD (Medical Doctor) orders, stitches intact with noted [CONDITION(S)] to top of left hand and fingers on left hand, no redness noted. Will continue to monitor. R40's Health Status Note, dated 6/24/22 at 3:53 PM, documents, Sutures intact to left hand, picks at area at times. No s/s infection noted. R40's Health Status Note, dated 6/25/22 at 9:04 AM, documents, Resident recently had procedure to hand and has stitches in place. Hand is swollen and warm to touch. Resident unable to keep hand elevated to help with swelling. Resident complaining about tape to hand - resident does not have tape to hand. R40's Health Status Note, dated 6/25/22 at 12:47 PM, documents, Resident complaining about hand hurting, writer attempted to administer Tylenol prn as ordered and resident spit medication out and threw it on the floor. Resident complaining that she is cold. Writer took resident to room and put on sweater, sat in recliner with two blankets. R40's Health Status Note, dated 6/25/22 at 4:45 PM, documents, Picking at left hand sutures causing bleeding to area, dry protective drsg applied for protection, continues to pick and tries to remove drsg. Fingers remain edematous, warm to touch. Afebrile. R40's Health Status Note, dated 6/26/22 at 5:10 PM, documents, Writer has re applied 2 dressings to L (left) anterior hand sutures. Resident has picked at sutures until they are bleeding. L hand is red/swollen and irritated. Resident continues to pick at sutures and hand. Will apply another dressing and wrap in kerlix to see if this helps from resident picking at surgical incision. Will continue to monitor. R40's Health Status Note, dated 6/27/22 at 5:00 AM, documents, Resident noted to have [CONDITION(S)] and redness to L dorsal hand. Sutures are CDI (clean, dry, and intact). MD notified. Awaiting response. On 6/27/22 at 6:43 AM, R40 exited her room. R40's left hand gauze dressing was pulling up leaving the top of her hand exposed. The top of R40's left hand had sutures, the area was swollen and red. R40's fingers were swollen. At that time, R40 stated, My tummy hurts. My hand hurts. I need help. On 6/27/22 at 8:08 AM, R40 was sitting at the dining room table. R40 was unwrapping the gauze bandage on her left hand. R40 was picking at the sutures. R40 stated, My hand hurts. This tape hurts. At that same time, V5, Certified Nurse Aide (CNA), V37, CNA, and V38, Activity Director, were in the dining room passing out breakfast trays. No one acknowledged R40 or tried to redirect her from picking at her bandage. On 6/27/22 at 8:18 AM, V20, Licensed Practical Nurse (LPN), stopped her medication pass to redress R40's hand. R40 stated, My hand hurts. Don't touch my hand. My hand hurts. On 6/27/22 at 8:55 AM, R40 was walking in hallway stating that her hand hurts. On 6/27/22 at 10:28 AM, V20 stated, (R40) had like a horn growing out of the top of her hand. It is a large incision and has sutures. At this time, R40 came walking down the hall with the left hand gauze pulled up and the top of her hand bleeding. R40 stated, My hand hurts. On 6/27/22 at 10:30 AM, V20 stated the night shift nurse faxed the surgeon to let him know and we are waiting to hear back from him. V20 told R40 she will get her some Tylenol to help. V20 took R40 to her room to cleanse and redress R40's left hand. R40 continued to say her hand hurt. V20 cut the remaining bandage off with scissors. R40's hand and fingers were very swollen. The top of her hand had an incision approximately 2 inches long, starting at the top of the hand, going past the knuckle to her inner finger. V20 cleansed the wound with normal saline, applied a gauze pad and wrapped the hand in gauze. R40's Health Status Note, dated 6/27/22 at 3:39 PM, documents, Sutures intact to left hand, hand/fingers remain edematous and red, will not leave protective drsg on. Call out to (V50, Surgeon) regarding suture removal and the [CONDITION(S)]/redness of hand, awaiting return call. R40's Health Status Note, dated 6/28/22 at 4:13 AM, documents, L hand remains edematous and reddened. Sutures appear removed at this time. Resident will not allow dressing to cover incisional wound. Area cleansed. Scant amount of sanguineous drainage noted. On 6/28/22 at 8:45 AM, R40 was walking in the dining room. R40's left hand had no bandage on it. R40's top of her hand had a small amount of drainage coming form the wound. The incision was scabbed over. R40's hand and fingers were more swollen than on 6/27/22. R40's hand remains red. R40 was telling V16, CNA, not to bump her hand and that her hand hurts. R40's Health Status Note, dated 6/28/22 at 9:53 AM, documents, Resident continues to pick top of left hand at surgical site, area red, and edematous. Writer wrapped left hand with dressing and cling, resident said get that off, then removed dressing and began picking left hand again. (V40, Doctor) notified and awaiting response from MD. R40's Health Status Note, dated 6/28/22 at 10:26 AM, documents, New order received from (V40, MD) to cover top of left hand with gauze, then cover with Geri sleeve or glove. R40's Health Status Note, dated 6/28/22 at 10:48 AM, documents, (V40) MD updated on resident's surgical site to top of left hand, red, edematous, with serosanguineous drainage noted. Resident's temp 98.7 at this time. Awaiting on MD response. On 6/28/22 at 10:49 AM, V39, Registered Nurse (RN), stated, (R40) is a picker, she won't leave anything on her hand which isn't surprising because it is swollen. I spoke with the doctor and he said to wrap it and to cover the dressing with a brace or 'arm sleeve' to keep her from picking at it. I just dressed the wound. V39 stated, The wound has some drainage on it so I am going to reach out to the doctor to see if I can get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V39 stated that she was notifying (V40, Medical Director). R40's Health Status Note, dated 6/28/22 at 2:19 PM, documents, Left hand remains red and edematous, continues to pick at surgical site, removes protective drsg once on. R40's Health Status Note, dated 6/29/22 at 3:41 AM, documents, Resident's L hand remains edematous and reddened. Scant amount of drainage noted. Resident has not c/o pain or discomfort thus far this shift. Continue to monitor for worsening of condition. R40's Health Status Note, dated 6/29/22 at 8:30 AM, documents, Resident is out in the dining room at this time, resident has picked off current bandage on left hand. Hand evaled (evaluated) at this time. Residents hand is red and swollen, 3 plus pitting. Resident states that it hurts when touched. Residents hand cleaned and new dressing applied per MD order. Resident does have limited range of motion in her left hand related to swelling. Residents hand is not hot to touch. Will address with MD (V40) per fax to see if we can get a culture and a different dressing because resident picks this one off. Resident is unable to remember to leave dressing alone related to disease process. On 6/29/22 at 8:50 AM, R40 had removed the dressing from her left hand. R40's left hand and fingers were very swollen. The top of the hand was red. The redness from the hand was migrating down the fingers. The bottom of the incision that did run down the inner 4th finger has now pulled up to the knuckle and has opened up with drainage noted. The incision on the top of the hand has the the sutures intact and they were scabbed over. R40 was asked to move her fingers, R40 could not move the 4th finger and could only move the other 4 fingers slightly due to [CONDITION(S)] and pain. On 6/29/22 at 8:50 AM, V4, RN, stated, We have gotten a culture of her hand and are waiting on results. I have given her Tylenol. The bottom of the incision has opened up, there is a little drainage, the other sutures are scabbed over. Her hand and fingers are swollen. R40's Health Status Note, dated 6/29/22 at 9:05 AM, documents, Note faxed to MD (V40) office reguarding hand dressing and culture needed. Awaiting fax back. R40's Health Status Note, dated 6/29/22 at 9:05 AM, documents, Called MD (V40) office at this time, at 0937, asked to speak with a nurse reguarding hand and vaginal bleeding. 0938-- (V71, V40's office staff), on the phone. Writer explained situation reguarding residents hand and vaginal bleeding. (V71) states that (V72, Nurse Practitioner) will be in today to eval (evaluate) resident. Writer asked what time (V72) will be here because I feel like it is very important with residents hand and bleeding. (V71) states she will be in this afternoon. Writer asked if we could go ahead and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (V71) states (V72) wants to see it before anything else is done. On 6/29/22 at 9:30 AM, V4, stated, I told you wrong. The culture request was made but not gotten and the doctor faxed back orders that the Nurse Practitioner will see this week. I have faxed over a request for steri-strips and a better dressing and a culture. On 6/29/22 at 9:35 AM, V4 was questioned why a phone call has not been made to the doctor instead of faxing, V4 stated, The office will just tell us that we need to fax and wait for a response. On 6/29/22 at 10:30 AM, V4 stated she had called the doctor's office, and they said the Nurse Practitioner will come and see her today. V4 stated she asked if she could get a culture, and the office said no, the Nurse Practitioner wants to evaluate it first. On 6/29/22 at 10:41, V49 (V50's Medical Assistant) stated, We have not been made aware of any issues (R40) has been having with her incision. (V50) is in surgery until 1:30 PM, I will have him call you when he gets out. R40's Health Status Note, dated 6/29/22 at 12:37 PM, documents, Residents hand has some purple discoloration noted to the left-hand top side, middle of the hand. (if you would look between the 2nd and 3rd finger and go up about 3cm (centimeters) and towards the ring finger, this is where the discoloration is noted.) Residents radial pulse is still present. Resident continues to have 3 plus pitting [CONDITION(S)] in it and has limited range of motion. Area is red and appears shinny (sp) and taught. On 6/29/22 at 12:48 PM, V4 stated, (R40's) hand is starting to bruise up by the incision now. She has a radial pulse. Her fingers are stiff but she can move them. On 6/29/22 at 12:50 PM, V18, CNA, stated, Her (R40) hand looks more red today. I know that it is swollen and the nurse is taking care of it. On 6/29/22 at 12:53 PM, V20, LPN, stated, The night shift nurse faxed I think her doctor here about the swelling and redness. I told the evening nurse to keep an eye out for the response. She was picking at it. I was monitoring her swelling. No, I did not reach out to the doctor because the night nurse had faxed the doctor. We can reach out by fax or phone if it is urgent. On 6/29/22 at 1:00 PM, V41, LPN, stated, If there is a change of condition, I will complete a SBAR (Situational Background Assessment Recommendation) and fax it to the doctor. Some doctors prefer the fax and if you call their office their nurses won't even let you talk to them. V40 likes faxes, so you fax and wait for a response. On 6/29/22 at 1:35 PM, V50, R40's Surgeon, stated, I was not made aware of (R40's) change of condition. I expect the nurses to call me if there is a problem not (V40, R40's Primary Doctor / Medical Director). She is my patient this is my problem. I have been going there for [AGE] years and they have never had problems calling me before. If I would have known, I would have seen her in the clinic or seen her there. This will heal it is just going to take more time. The [CONDITION(S)] has caused the wound to dehiscence (open up). She is going to need antibiotics for the infection and probably wound clinic to heal the wound now. On 6/29/22 at 2:13 PM, V39, RN, stated, I did not reach out to the surgeon the other nurse did and we were waiting on a response. I faxed (V40) to update him but did not get a response. On 7/6/22 at 10:00 AM, V6, Regional Nurse, stated the nurses should have called the doctor and not faxed him when problems with her pain and incision started. On 7/6/22 at 2:16 PM, V40, Medical Director, stated he expects the nursing staff to notify someone at the first sign of infection. 2. R72's Care Plan, dated 5/25/22, documents R72 has actual impairment to skin integrity r/t (related to) impaired mobility. Shearing to right buttock, Rash to sacrum and buttocks. It also documents Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. R72's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . every shift. 6/23/2022 Cleanse right buttock with soap and water. Pat dry. Apply z-guard to right buttock sheared area BID (twice a day) and PRN (as needed) until resolved every day and night shift for wound healing. R20's Medication Record, dated June 2022, documents blanks for the 6/28/2022 day for the Z guard treatment. On 6/28/2022 at 12:15 PM, R72 was lying in bed, leaning to the right side against bed rail, with frown on face and call light on floor next to bed, out of reach of R72. On 6/28/2022 at 12:40 PM, V26, Certified Nurse Assistant (CNA), and V29, CNA, assisted R72 with incontinent care. R72 was incontinent of bowel. V26 and V29 assisted R72 onto his side. R72 noted to have facial grimacing and moaned with movement. V26 cleansed bowel from R72 buttocks. R72 had facial grimacing and tightening of his body during care. R72 yelled out it hurt. R72's buttocks were fire engine red in color, and had multiple open areas to buttocks and sacrum. V26 stated she knew it hurt, and apologized for causing him pain. On 6/28/2022, R72 stated he needed help; he needed to be changed. R72 stated his bottom hurt and it [CONDITION(S)] when he goes to the bathroom. R72 stated he is in a lot of pain. When asked if he called for anyone, R72 stated he couldn't, and he didn't have a way to. When asked if he used his call light, R72 stated he did not have one. R72 stated when he has a bowel movement, it [CONDITION(S)]. R72 stated he is in severe pain. R72 stated he has been waiting for some time, and been in pain the entire time. On 6/30/2022 at 10:00 AM, V6, Regional Nurse, stated if the nurse administered the medication, then it should be charted. On 6/30/2022 at 1:50 PM, V43, Social Service Director, stated R72 is alert and able to make his needs known. On 7/7/2022 at 10:10 AM, V27, LPN, stated R72 is receiving (skin protectant paste) as a barrier. V27 stated the stool would cause some pain when it touches the open areas. V27 stated the barrier is there to decrease the contact of the stool in the wounds and assist with healing. V27 stated he is not sure it would increase his pain when not on, but it would help prevent the stool from getting in the areas. On 7/7/2022 at 10:53 AM, V6, Regional Nurse, stated the facility does not have a pain policy.

Based on observation, interview, and record review, the Facility failed to implement Infection Control Measures in order to prevent the spread of COVID-19 as evidenced by: not isolating COVID-19 positive residents from negative residents; not isolating unvaccinated residents during COVID-19 outbreak; allowing COVID-19 positive residents to intermingle with other residents; not encouraging the use of masks/social distancing of residents; improper usage of Personal Protective Equipment (PPE); not posting signage for staff/residents/visitors education on appropriate isolation procedures; not implementing required environmental cleaning; and not implementing an effective infection control surveillance and tracking system during a COVID-19 outbreak. These failures resulted in an Immediate Jeopardy (IJ) which began on [DATE] when V33, Housekeeper, tested positive for COVID-19 and the facility did not perform contact tracing and place all unvaccinated residents in quarantine. R18 was the first resident who tested positive for COVID-19 on [DATE]. R18 expired from COVID-19 on [DATE]. 25 residents tested positive for COVID-19 and 4 expired from COVID-19 or complications from COVID-19. Due to these residents' comorbidities and vulnerability, these failures increased their risk for severe illness from COVID-19 and possible death for all 72 residents living in the facility. The Immediate Jeopardy was identified on [DATE]. On [DATE], V1, Administrator, was notified of the Immediate Jeopardy. The surveyor confirmed by observations, record review and interview that the Immediate Jeopardy was removed on [DATE] but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: 1.The Facility's COVID Positive Tracking sheet, provided by the facility on [DATE], documented the following staff and residents tested positive for COVID-19 on these dates: V33, Housekeeper, tested positive on [DATE]; R18 tested positive on [DATE]; R19 tested positive on [DATE]; R12 tested positive on [DATE]; R34, R13, and R16 tested positive on [DATE]; R22, R21, R3, and R20 tested positive on [DATE]; R30, R31, R25, R32, R17, and R33 tested positive on [DATE]; R29 tested positive on [DATE]; and R35 tested positive on [DATE] at the hospital. The New COVID Positive Sheet, dated [DATE], provided by the facility documented R6, R36, R37, R38, R39, R40, and R41 tested positive. On [DATE] at 2:45 PM, V2, Director of Nursing (DON)/Infection Preventionist, stated the residents listed on the Form titled, The New COVID Positives [DATE] were tested for their routine whole facility outbreak testing. V2 stated the PCRs (Polymerase Chain Reaction-lab test) were completed on [DATE], and the results came back [DATE]. V2 stated none of the residents on the list had symptoms. Of the 25 residents who tested positive for COVID-19 from [DATE] through [DATE], the following residents died from COVID-19 or complications from COVID-19: R18's Death Certificate, dated [DATE], documents R18 died on [DATE] with cause of death as, [CONDITION(S)]/Disease. R19's Death Certificate, dated [DATE], documents R19 died on [DATE] with cause of death as, COVID Pneumonia. R12's Death Certificate, dated [DATE], documents R12 died on [DATE] with cause of death as, [CONDITION(S)] Coronavirus 19. R3's Death Certificate, dated [DATE], documents R3 died on [DATE] with cause of death as, [CONDITION(S)] Coronavirus 19. 2. On [DATE] upon the initial tour of the facility at approximately 8:00 AM, the 200 hall was the designated COVID unit (Red zone). There was a Yellow zone (precautionary isolation) located at the beginning of the 200 hall and the Red zone was located behind a plastic barrier. The Memory Care Unit was located on the 100 hall. The Facility's 100 Hall Vaccinated/Unvaccinated Roster, dated [DATE], documents 20 residents reside on the Memory Care Unit. 6 of those residents (R17, R25, R30, R31, R32, R33) are positive for COVID-19. The Facility's COVID Positive Tracking sheet, provided by the facility on [DATE], documented R17, R25, R30, R31, R32, and R33 tested positive on [DATE]. The New COVID Positive Sheet [DATE], provided by the facility documented R6 and R41 on the Memory Care Unit tested positive on [DATE]. On [DATE] at 4:15 PM, V22, Registered Nurse (RN), stated 6 residents tested positive for COVID-19 on [DATE] on the Memory Care Unit (100 Hall). V22 stated the residents that tested positive will have to move to the COVID unit (200 hall). On [DATE] at 4:21 PM, V12, Licensed Practical Nurse (LPN), stated, I am now the nurse for 200 and 300 hall. The residents (R17, R25, R30, R31, R32, R33) started testing positive on the 100 hall at about 4:00 PM (today). They are all back there with masks on until we can move them. The ones that are negative are in the dining room so we can keep them separate. On [DATE] at 4:45 PM, V12, LPN, and V22, RN, assisted residents (R17, R25, R30, R31, R32, R33) from the 100 hall Memory Unit to the 200 hall (designated COVID unit) with N95 masks on both residents and staff, but no other PPE. On [DATE] at 8:52 AM, V19, RN stated, Those residents (R17, R25, R30, R31, R32, R33) who were moved to the 200 hall on [DATE] are not back here (200 hall/Designated COVID Unit). They moved them all back to the Memory Care Unit. On [DATE] at 9:10 AM, V2, DON/Infection Preventionist, stated, It is in our action plan (page 24) that we can leave the dementia residents on the unit (Memory Care) so now we have two COVID units. We are to try to keep them in their rooms with masks on. I don't necessarily have a spread sheet to track (Respiratory Line List). Should I have a better system? Yes. This is how corporate told me to do it. It is very hard to get through to the local health department or have them call me back. At this time, The Facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities was requested. On [DATE] at 1:00 PM, V13, R4's husband, exited the Memory Care Unit from the double doors and entering the main floor. V13 was still in full PPE and asked the surveyor, Do I need to remove this? There were no staff nearby to educate/instruct V13 on the proper PPE doffing techniques. On [DATE] at 2:00 PM, V2 stated, Family members come in. I don't know how we would educate them. There should be signs. 3. On [DATE] at 10:30 AM, R41 and R32 were observed in their room on the Memory Care Unit. They remained roommates throughout the day. The Facility's 100 Hall Vaccinated/Unvaccinated Roster, dated [DATE], documented R32 tested positive for COVID-19 and R41 is negative. The New COVID Positives [DATE] Sheet documents R41 was now positive. On [DATE] from 11:15 AM and throughout the day, R24 and R25 shared a room. The Facility's 100 Hall Vaccinated/Unvaccinated Roster, dated [DATE], documented R25 was positive for COVID-19 and R24 was not. The Facility's 100 Hall Vaccinated/Unvaccinated Roster, dated [DATE], documented R48 and R30 are roommates. The Form documents R30 was positive for COVID-19 and R48 was not. On [DATE] at 11:45 AM, V9, LPN, stated residents that are positive are sharing rooms with COVID-19 negative residents. V9 stated it is impossible to keep residents in their rooms or sitting away from each other. On [DATE] at 11:15 until 1:00 PM, V33, Housekeeper, was mopping rooms on the Memory Care Unit where there was a mixture of COVID-19 positive residents and COVID-19 negative residents, and also cleaning the common hallway and dining area on the memory unit with the same mop head and the same mop water without the benefit of changing water, solution or mop head between surface exposures on the unit. V33 began cleaning R24's (COVID-19 negative) and R25's (COVID-19 positive) room who are roommates. V33 proceeded to R6's and R26's (both COVID-19 negative) room to clean. V33 proceeded to R27's and R28's room (both COVID-19 negative). V33 went to R17's (COVID-19 positive) and R3's room (COVID-19 positive). V33 proceeded to R17's room (COVID-19 positive) and ended V33's cleaning with R43's and R44's room (both COVID-19 negative). On [DATE] at 1:00 PM, V33 exited the Memory Care Unit through the back the door to the outside. V33 did not remove V33's PPE, walked down the sidewalk, and reentered the facility on the 200 hall (Red/Yellow Zone). At that time, V33 entered R14's room to clean. R14 was in the yellow zone (COVID Observation area) due to new admission status. V33 cleaned R14's room with the same mop water and mop head that was used on the Memory Care Unit which residents are both COVID positive and negative. On [DATE] at 1:30 PM, V20, LPN, and V31, Certified Nursing Assistant (CNA), entered R14's room in the Yellow zone (precautionary isolation). Outside of R14's room were isolation precaution signs displaying the need to use gown, goggles/face shield, N95 and gloves. V20 and V31 were wearing a mask and face shield, however, they were not wearing gloves or gowns when they entered R14's room. They obtained vital signs and provided R14 with water. On [DATE] at 2:10 PM, V33 stated mop water and mop heads get changed every 4 rooms. V33 stated, I was never fully trained for housekeeping. V33 further stated, I clean all the rooms the same, no different protocols or precautions when cleaning rooms on the Memory Unit. V33 stated V33 does not clean cleaning tools on V33's cart from room to room. V33 also stated V33 does the common areas like the main hallway and the dining area as V33 goes along, between going in and out of rooms. On [DATE] at 11:15AM to 1:00 PM, there was no signage posted regarding isolation precautions for R32, R33, R31, R30, R17, R25 who were all identified by facility as COVID-19 positive. All of these residents reside on the Memory Care unit. On [DATE] at 11:45 AM, V9, LPN, stated there has never been precaution signage on resident doors on the Memory Care unit. On [DATE] from 11:15 AM until 1:00 PM, none of the residents on the Memory Care unit were seen wearing any type of source control/face masks. The following staff were on the Memory Care unit during this time and did not encourage residents to socially distance or wear face mask: V9 (LPN), V11, Certified Nurse's Aide (CNA), V23 and V24 (Maintenance). On [DATE], R32 was wandering about the unit. At 12:25 PM, R32 (COVID positive) and R25 (unvaccinated and COVID positive) were sitting at same table without masks and not socially distanced at least six feet apart. R33 (COVID positive) and R27 (vaccinated and COVID negative) were sitting at same dining table not socially distanced. Throughout this observation, R33 and R27 were holding hands, watching TV and walking down hallways together. On [DATE] at 12:45 PM, V25, Housekeeper, was on the memory unit handling residents' lunch containers without gloves, improper use of an N95 (only one strap was being used), placing containers into trash bag pushing them down with ungloved hands, without hand hygiene at the end of task. On [DATE] at 9:30 AM, R33 (COVID positive) and R6 (vaccinated and COVID negative) were sitting in same living room common area in close proximity without masks. V9, LPN, intervened during an altercation between R33 and R6. After coming into contact with R6 (COVID-19 positive), V9 did not change V9's gown. On [DATE] at 11:45 AM, V9 stated the residents won't wear their masks even when encouraged to and many of times continuing to ask them to put them on causes a behavior. V9 stated positive and negative COVID residents all sit in the same day area/dining area and at the same tables as one another. V9 stated some residents you can't move their seating or it will cause a behavior, and some residents want to sit with certain groups or residents. V9 stated for example (R32) and (R25), they always sit at the same table. V9 also stated (R33) and (R27) are everywhere together and trying to separate them is nearly impossible. On [DATE] at 9:00 AM, on the Memory Care Unit, V11, CNA, was not using PPE properly; the gown was not tied, exposing V11's clothing on the backs and the sides. V11 was wearing a surgical mask, not a N95. On [DATE] at 9:45 AM, V11, stated, Yes, I have an N95. I just haven't had the chance to put it on. On [DATE] at 10:30AM, V26, RN, stated all employees should be wearing an N95 all of the time, and V26 was also instructed if you entered the Memory Unit, you are not to leave and go to any other part of the building during the shift. On [DATE] at 10:30AM, V2, DON/Infection Preventionist, stated the staff are treating all residents like they are COVID-19 positive. V2 stated all rooms of COVID-19 positive residents should have precaution isolation signage outside of their rooms. V2 stated the residents that are vaccinated and have roommates that are vaccinated are kept in their same rooms even if their roommate tests positive. V2 stated the only time residents are moved is when a positive resident has an unvaccinated roommate, then they would separate those residents. V2 stated staff are to change their PPE after having contact with a COVID-19 positive resident if their PPE/gown is soiled. V2 stated the facility doesn't have a policy, but the follow standards of practice; they have an action plan and follow CDC guidelines. V2 stated there are no barriers on the memory care unit and masks should be encouraged, and social distancing should be encouraged. V2 stated the first positive in the building was on [DATE], which was a Dietary employee. V2 stated all employees should be wearing a face shield or goggles and an N95 at all times in the building and if in the Red Zone (COVID positive residents) 200 hall, Yellow Zone (precautionary isolation) 200 hall or on the Memory Care Unit 100 hall, staff should be wearing full PPE, N95, face shield/goggles, gown and gloves. V2 stated the facility has plenty of PPE and if they get low or run out, V2 would get it from a sister home. V2 stated staff have received PPE requirement education. 4.The Facility's Unvaccinated Residents and Transition Times List, undated, documents R14, R20, R22, R29, R30, R31, R46, and R47 are all unvaccinated residents. There was no documentation provided by the facility that these residents were placed on quarantine during the facility COVID-19 outbreak. On [DATE] at 2:31 PM, V2, DON/Infection Preventionist, stated, The transition time means they are new admits and on precautionary isolation for 10 days if they are not vaccinated. Our outbreak began on [DATE] when (V33, Housekeeping) tested positive. Contract tracing was not documented anywhere. The unvaccinated residents did their time in isolation (on admission). We are currently still in outbreak status. They (unvaccinated residents) have not remained in isolation this whole time. Over the weekend we had 3 more deaths, (R20, R31, and R35). On [DATE] at 3:15 PM, V2 stated, I don't believe it is in our action plan to quarantine the unvaccinated residents. We followed our action plan. The Facility's LTC (Long Term Care) Respiratory Surveillance Line List, dated [DATE], documented, No employees to report. It does not document V33 as having any symptoms or testing positive. The Line List, dated [DATE] and [DATE], document symptoms for V38, CNA, but no documentation any testing was done. The Line List for [DATE] does not include any information for V32. The Line List has no documentation V38 (CNA) tested positive on [DATE]. The Line List has no documentation R18 tested positive on [DATE]. The Facility's COVID-19 Outbreak Timeline undated, documents, On Thursday [DATE], informed by staff nurse that an employee had positive rapid COVID test. A PCR was completed, and employee was sent home to quarantine. This document does not specify who the employee is. The Facility had no documentation they conducted any type of contact tracing to determine who R18 (the first positive resident) may have had close contact with prior to R18 testing positive for COVID-19 on [DATE]. There was no documentation of contact tracing for V33 who tested positive on [DATE] or V32 who tested positive on [DATE]. On [DATE] at 3:15 PM, V2, DON/Infection Preventionist, stated, I can go through the contact tracking in my head. The first employee to test positive was the housekeeping gal (V33), and she works all over the building. She would have been around her boss and the other housekeeper. I guess she had called in a couple days and I didn't know it. She came to work with symptoms and her nurse did a rapid on her. The second was (V32, CNA) and she usually works the 400 hall. The Facility's COVID-19 Outbreak Timeline undated, documents, On Friday [DATE], informed by staff nurse that an employee had positive rapid COVID test. A PCR was completed and employee was sent home to quarantine. Residents were transferred to COVID unit. It documents that 2 residents tested positive. This document does not specify who the employee or residents were. It documents, Contacted (local health department) and updated with outbreak status. There were discrepancies discovered on the COVID Positive Tracking document, dated [DATE]. For example, R32 was listed as testing positive on [DATE] via a rapid test. The Facility's LTC Respiratory Surveillance Line List, dated [DATE], does not list R32 as testing positive or having symptoms. On [DATE] at 1:45 PM, V3, Assistant Director of Nursing (ADON), stated, (R32) isn't positive. I don't know why he is on that list (COVID Positive Tracking). Now I am confused. We just tested him. At this time, V3 provided a generic list and stated, this is how we keep track when we test them. I am sure this is from [DATE] and (R32) was negative. There were 6 residents. R28 was included on this list as testing positive, but not on the COVID Positive Tracking List provided on [DATE]. On [DATE] at 10:40 AM, V2, DON/Infection Preventionist, stated V2 documents symptoms on The Facility's LTC (Long Term Care) Respiratory Surveillance Line List. V2 stated V2 runs a report of the COVID assessments daily and fills the line list out according to the report of symptoms. V2 stated the Facility's LTC Respiratory Surveillance Line List should also include positive residents and staff and it should be completed accurately. V2 stated if the resident is unvaccinated and exposed, they should go into transition (precautionary isolation- Yellow zone). V2 stated V2 was not sure why the Facility's LTC Respiratory Surveillance Line List was blank for [DATE] and no symptoms were listed. On [DATE] at 10:47 AM, V2 stated the Line list is how V2 tracks symptoms, a running log of positives. V2 stated V2 was sending it to IDPH and somehow, V2 lost the file. V2 stated, I've been scrambling to find it. It was our timeline-tracker documented when they became positive which was lost. V2 stated this included room changes related to COVID-19 positive results. V2 stated on [DATE], the facility began whole house routine outbreak testing for employees and staff. V2 stated they did rapid tests because they didn't have PCR's (Polymerase Chain Reaction-lab test). V2 stated, Staff's testing results are on the timeline that is lost. V2 stated V2 just recreated COVID Positive Tracking sheet on [DATE]. On [DATE] at 10:25 AM, V30, Corporate Nurse, stated staff should promote residents to wear their masks and to social distance the best they can. V30 stated the memory unit has its own dedicated housekeeper that goes nowhere else in the building. V30 stated changing PPE every time it's been exposed to a COVID resident is not feasible. On [DATE] at 1:50 PM, V2 stated the residents that are unvaccinated were quarantined if they were new admits. V2 stated on the Yellow unit (COVID observation unit), staff should be wearing full PPE (gloves, goggles/face shield, N95, and gown) when entering these resident rooms, all staff should put on full PPE before entering. V2 stated when staff are entering R14's room, full PPE should be being worn while R14 resides in the Yellow unit area. On [DATE] at 8:15 AM, V39, Local Health Department Nurse, stated V39 was not made aware of any COVID positive cases at the facility until Tuesday [DATE] at 5:00PM, and the list she received from V1, Administrator, documented the first COVID-19 positive as [DATE]. V39 stated V39 had no messages V39 was aware of from the facility, and V39 is also reachable via email. V39 also stated if the facility was doing rapid tests, they weren't reporting them to the Health Department. V39 stated with an outbreak, the recommendation to the facility would be to increase testing to every 3 days, get PCR's, keep unvaccinated residents in a private room on the Yellow zone, staff to use full PPE (gloves, gowns, face shield/goggles, N95), test residents every 3 days, and track symptoms for 10 to 14 days of start of outbreak. V39 stated new admits should be 14 days of isolation with full PPE to be worn by staff. On [DATE] at 10:00AM, V3 stated, COVID positive residents should have Droplet Precaution signs outside of each of their rooms and a tier cubby with all the PPE outside their rooms. V3 stated that gown, gloves, goggles/face shield, N95 should be worn when having resident connect with COVID-19 residents. V3 stated V3 would expect staff to change their PPE after contact with a COVID-19 positive resident and before caring for another resident. The Facility's ACTION PLAN-COVID 19, updated [DATE], documents under the section entitled A Proactive Approach to Keep Residents, Staff and Visitors Safe documents 3. Require source control (mask, face covering or respirators that correctly cover the mouth and nose; 4. Physical distancing at least six feet between persons, in accordance with CDC guidance; 5. Instructional signage throughout the facility and proper visitor and staff education on COVID-19 signs and symptoms, infection control precautions, visitation, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designate areas, hand hygiene. The Plan documents 7. Cleaning and disinfecting high frequency touched surfaces, equipment or areas in the facility often; 8. Appropriate use of Personal Protective Equipment (PPE); and 9. Effective cohorting of residents (e.g., separate areas dedicated to COVID-19 care- Transition area and Recovery area). The Plan documents Residents are required to wear a well-fitting cloth facemasks or medical grade mask-procedure or surgical (if tolerated) at all times when exiting their rooms, when leaving the community grounds, when around others outside of their room, when entering a congested communal area with the property and or when staff enter their rooms. The Facility's ACTION PLAN-COVID 19, updated [DATE], documents under the section entitled A Proactive Approach to Keep Residents, Staff and Visitors Safe documents In performing cleaning or sanitation services int the Transition or Recovery Areas, housekeeping staff must wear PPE: N95 respirator or higher, secondary face covering, proper eye protection consisting of face shield or goggles, gowns (disposable or reusable) and gloves at all times on the unit. PPE should also be applied when entering these areas, removed accordingly when exiting each room and areas. The Plan documents Staff will follow manufacturer's instructions for all cleaning and disinfection products and will use products that are EPA approved for use against the virus that cause COVID-19. The Facility's ACTION PLAN-COVID 19, updated [DATE], documents under the section entitled A Proactive Approach to Keep Residents, Staff and Visitors Safe documents Communal dining may resume without interruption while adhering to infection control practices, social distancing measures and mask wearing to ensure all resident have access to we-prepared food in a timely, safe manner. Face covering or mask over nose and mouth for all residents, regardless of vaccination status, to be worn at all times while indoors during communal dining and to the from the dining rea and when around other visitors, staff or unvaccinated residents. The Facility's ACTION PLAN-COVID 19, updated [DATE], documents under the section entitled For residents that reside in Skilled Memory Care for Residents who have been tested and are laboratory confirmed COVID-19 positive: 1. Every attempt will be made to have the resident remain on the unit; 2) If possible, place in a private room; 3) If the unvaccinated resident attempts to wander outside of their room, ensure a facemask is put on the resident prior to leaving their room and perform hand hygiene; 4) Ensure the unvaccinated residents maintains a 6-foot social distancing from other residents 5) If the unvaccinated resident touches any objects or surfaces while out of their room, clean surfaces and objects with a n EPA approved disinfectant. The Facility's ACTION PLAN-COVID 19, updated [DATE], documents under the Section Confirmed COVID-19 Positive (Recovery Area) Move COVID-19 Positive resident to designated Recovery Area (private available, otherwise Cohort with others with like symptoms or diagnosis. The Plan documents Immediately place resident on droplet precautions. The Plan documents 1. Signage shall be placed at the entrance of the Recovery Area instructing staff that they must wear PPE: N95 respiratory or higher, secondary face covering, proper eye protection consisting of face shield or goggles, gowns (disposable or reusable) and gloves at all time on the unit. PPE should also be applied when entering the area and prior to patient encounter. The Plan documents Signage shall be placed at the exit of the Recovery Area identifying the general population area and instructing staff that they are leaving the isolation zone. Staff are to remove and discard gowns glove and secondary masks before exiting. The Centers for Disease Control and Prevention (CDC) Recommendations, updated [DATE], Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documents Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission or who have: Not been fully vaccinated; or Suspected or confirmed [CONDITION(S)]-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with [CONDITION(S)]-CoV-2 infection for 14 days after their exposure, including those residing or working in areas of a healthcare facility experiencing [CONDITION(S)]-CoV-2 transmission (i.e., outbreak); or Moderate to severe immunocompromise; or Otherwise had source control and physical distancing recommended by public health authorities. The Centers for Disease Control and Prevention (CDC) Recommendations, updated [DATE], Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documents Place a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom. Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with [CONDITION(S)]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shifts. Only patients with the same respiratory pathogen should be housed in the same room. Limit transport and movement of the patient outside of the room to medically essential purposes. The Centers for Disease Control and Prevention (CDC) Recommendations, updated [DATE], Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documents HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The Centers for Disease Control and Prevention (CDC) Recommendations, updated [DATE], Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documents Dedicated medical equipment should be used when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. All non-dedicated, non-disposable medical equipment used for that patient should be cleaned and disinfected according to manufacturer's instructions and facility policies before use on another patient. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for [CONDITION(S)]-CoV-2 in healthcare settings, including those patient-care areas in which aerosol generating procedures are performed. The CDC guidance, updated [DATE], Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes documents Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection. HCP caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). Ideally, a resident with suspected [CONDITION(S)]-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending. The CDC guidance, updated [DATE], Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes documents New Infection in Healthcare Personnel or Resident. Alternative, broad-based approach: If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-level or group-level (e.g., unit, floor, or other specific area(s) of the facility). Broader approaches might also be required if the facility is directed to do so by the jurisdiction's public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission. Perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately (but not earlier than 2 days after the exposure, if known) and, if negative, again ,d+[DATE] days later. Unvaccinated residents and HCP: Unvaccinated residents should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves and gown. They should not participate in group activities. The Facility's Resident Census and Conditions of Residents, printed [DATE], documents there are 72 residents living in the facility. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the Immediacy: The Administrator and the Director of Nursing were educated by the Director of Clinical Operations on the following: *They must review all residents to determine who may require transmission based contact-droplet infection control precautions due to suspected COVID or COVID-19 positive. Residents identified as requiring transmission based contact-droplet infection control precautions due to suspected COVID or COVID-19 positive will be provided transmission based c [TRUNCATED]

Based on interview, observation and record review, the facility failed to implement fall prevention interventions after falls for 3 of 3 residents (R1, R2, R3) reviewed for falls in the sample of 9. This failure resulted in R2 falling, on two separate occasions, suffering a left radius fracture and refracture of the left hip and pelvic fracture, requiring R2 to be sent out for emergent care. Findings include: 1. R2's face sheet, undated, documents R2 has a diagnosis of Fracture of the Left Femur, Fracture of the Left Wrist and Hand, Unsteadiness on Feet, Abnormalities of Gait and Mobility and Muscle Weakness. R2's Fall Risk Data Collection, dated 11/10/21, documents R2 is at high risk for falls. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact; requires an extensive assist with bed mobility, transfers; is dependent with toileting; balance is unsteady and has a history of falls. R2's Care Plan, dated 11/10/21, documents R2 is at risk for falls and is to have the following fall interventions in place: Call don't fall sign, call light within reach, personal items within reach, gripper strips beside bed, mat on floor beside bed when resident is in bed and a scoop mattress. On 12/1/21 at 10:45am, R2 stated she fell at home and broke left hip, prior to coming to the facility. R2 stated she has fallen twice since she's been at the facility and has re-broken her left hip and left wrist. R2 stated she doesn't know what happened or what caused her to fall. On 12/1/21 at 10:45am, R2 was observed in room, in bed, with a splint on left wrist. R2's personal items were on a bedside table to the left of R2. R2 stated she is unable to use her left hand/wrist due to a fracture, therefore is unable to reach the items to the left of her. There was no Call don't fall sign, no gripper strips at bedside or a floor mat in place during the observation. On 12/1/21 at 11:20am, V3, Certified Nursing Assistant (CNA), provided incontinent care for R3. After providing care, V3 left R2's call light clipped to the left outer side of R2's mattress, out of R2's reach. On 12/2/21 at 8:25am, R2 was observed in her room in bed. The Call don't fall sign, gripper strips at bedside nor the floor mat to bedside, were in place. R2's progress note, dated 11/10/21 at 3:10pm, documents R2 was found on the floor in room. R2 was lying on back approximately 10 steps from the bed. When questioned, R2 stated the Orthopedic doctor told me I could walk, and my hip isn't broke any longer because the doctor fixed it. R2 was noted to have a hematoma to the back of head with a small open area. R2 was complaining of pain to the left wrist and arm with swelling and bruising noted. R2 was sent to the emergency room for further evaluation and treatment. R2's X-Ray report of the left wrist, dated 11/10/21, documents a Subtle [MEDICATION(S)] linear lucency distal radial metaphysis, could be a non-displaced fracture. R2's Hospital History and Physical, dated 11/10/21, documents a diagnosis of Radius Fracture. R2's progress note, dated 11/19/21 at 12:10am, documents R2 was observed sitting on the floor beside the bed facing the closet, with both legs extended in front of her, towards the foot of the bed. R2 was complaining of pain and stiffness in the left hip, left shoulder, upper left back and mid lower back. Resident sent to the emergency room for further evaluation and treatment. R2's CT of the pelvis, dated 11/19/21, documents minimally displaced acute fractures involving the posterior aspect of the proximal left femur around the prosthesis stem. R2's CT of the head/brain, dated 11/19/21, documents a punctate subdural hematoma. On 12/1/21 at 11:30am, V5, Registered Nurse (RN), stated R2 has a fractured pelvis, is alert and oriented and knows to use her call light. V5 states R2 fell and broke her hip because she wouldn't wait for anyone to help her. On 12/2/21 at 9:00am, V2, Director of Nurses (DON), stated R2 fell the first night she was at the facility (11/10/21), broke her wrist and R2 wasn't using her call light or it had been on for very little time. (R2) got up without assistance. R2 told V2 that she thought she could get up on her own because the doctor fixed her hip. V2, DON, stated R2 fell on [DATE] and had a new fracture to the left hip and a hairline fracture to the pelvis. V2 stated R2 had the call light on. V2 stated R2 said that it took the girls too long so she got up on her own. V2 stated she checked the call light log and R2's call light had been on for less than two minutes. The call light log was requested at that time. On 12/2/21 at 3pm, V2 stated she was unable to access/print the call light log. On 12/2/21 at 3:45pm, V10, Licensed Practical Nurse (LPN), stated R2 is non-compliant with fall precautions. V10 stated she worked on 11/19/21, R2's call light went off and she (V10) was at the nurse's station and immediately went to R2's room. V10 stated R2 was observed on the floor and didn't wait for help. V10 stated R2's call light was on for less than 2-3 minutes before V10 entered her room. 2. R1's Face Sheet, undated, documents R1 has a diagnosis of Cerebral Infarction and Muscle Weakness. R1's Fall Risk Data Collection, dated 7/30/21, documents R1 is at high risk for falls. R1's MDS, dated [DATE], document R1 has moderate cognitive impairment; requires an extensive assistance of two with bed mobility, transfers and toileting; balance is unsteady. R1's Care Plan, dated 6/28/21, documents R1 is at risk for falls with the following interventions: Call don't fall sign. R1's progress note, dated 9/15/21 at 10:14pm, documents R1 was heard yelling help and upon entering R1's room, was observed on the floor, back against the wheelchair and chair alarm underneath. No injuries were noted. R1's progress note, dated 9/20/21 at 12:51pm, documents R1 slipped out of wheelchair while attempting to grab a fork off of the ground. R1's progress note, dated 11/24/21 at 9:30am, documents R1 experienced a fall. R1's progress note dated 11/24/21 at 10:29am, documents R1 was found lying on the floor in the bathroom. Seemed to be trying to take self to the bathroom as resident was incontinent of bowel. No injuries noted except a small laceration to right ear. R1's SBAR (Situation, Background, Assessment, Response) Communication Form, dated 11/24/21 at 9:30am, documents a chair alarm is to be in place. On 12/1/21 at 2:15pm, R1 was observed in room, up in wheelchair. The Call don't fall sign nor the chair alarm was in place. R1 was pleasantly confused . R1 states he has experienced no falls. On 12/2/21 at 8:20am and 10:20am, R1 was observed up in wheelchair and the chair alarm was not in place. On 12/2/21 at 12:50am, V8, CNA, stated R1 uses call light and has had recent falls, but was unable to provide any details of the falls. 3. R3's Face Sheet, undated, documents R3 has a diagnosis of Symptoms and Signs of Cognitive Functions and Awareness, Abnormalities of Gait and Mobility, Weakness. R3's Fall Risk Data Collection, dated 10/1/21, documents R3 is at low risk for falls. R3's MDS, dated [DATE], documents R3 has severe cognitive impairment; requires an extensive assistance of one with bed mobility, toileting and transfers; requires supervision with ambulation; balance is unsteady. R3's progress note, dated 11/3/21 at 12:45am, documents R3 was on the floor in closet . without clothes on, urine and bowel movement was on the floor. Bruising was noted to the right elbow and R3 complained of pain to the right side of head. No bumps or bruising noted to R3's head. R3's progress note, dated 11/21/21 at 3:50pm, documents R3 was in the bathroom, taking clothes off, staff heard a yell and upon observation, R3 was observed lying on side. Feet located toward sink, with nightgown and incontinence brief off. A 3 centimeter (cm) by 0.3cm skin tear to the upper posterior left arm and a 0.5cm by 0.5cm skin tear to the upper posterior left arm was noted. Resident is always taking clothes off throughout the day. R3's Care Plan, dated 10/1/21, documents R3 is at risk for falls with the following interventions: assist to bathroom after meals, gripper socks, gripper strips at bedside and keep bathroom light on. The care plan fails to list new fall interventions for R3's falls on 11/3/21 or 11/21/21. On 12/2/21 at 9am, V2, DON, stated the fall interventions are listed on the resident's care plans and she would expect fall interventions to be in place. On 12/2/21 at 1:50pm, V12, CNA, and V13, CNA, both state they would look at the resident's care plans to see what fall interventions were to be in place. The Fall Policy, dated 9/17/19, documents Residents found to be at high risk for falls are placed on the Fall Program and interventions are implemented to meet individual needs. Following any falls, the facility staff completes an Occurrence Report. Details of the fall will be recorded and potential causal factors identified and investigated. Interventions will be implemented and care plan updated.

Based on interview, record review and observation, the facility failed to adequately identify/assess residents for risk of contracture and failed to develop and provide complete range of motion (ROM) services for 2 of 5 residents (R2, R6) reviewed for range of motion services in the sample of 18. This failure resulted in R2 developing limited range of motion within the past six months which are painful on movement and a decline in mobility. Findings include: 1. On 9/13/17 at 10:56 AM, R2 was in bed when E16, Certified Nurse Aide (CNA), and R10, Licensed Practical Nurse (LPN), entered the room to provide incontinent care and get him up for lunch. R2's knees were drawn up at almost a 45 degree angle. As E17 and E10 rolled him side to side, he grabbed at his legs and said ow repeatedly. When requested to straighten out his legs by E10, or to assist him to straighten out his legs, R2 was unable to do so. R2 was then transferred to his wheelchair with the use of a full body mechanical lift. R2's Minimum Data Set (MDS), dated [DATE], identifies him to have no limitations with no services or Range of Motion exercises in place. On 9/15/17 at 12:57 PM, when asked why R2's MDS identified no limitations, E3, Restorative Nurse, stated that he has just recently had a decline and that he was still walking in February when he was on the Memory Unit. When asked why he was not getting services, E3 was unable to say. R2's MDS, dated [DATE], confirms that R2 was ambulating in February 2017 as he is coded as requiring minimal assist of one staff to walk about his room and in the hallway at that time. Physical Therapy Notes, dated 3/24/17, documents R2 was able to ambulate on the unit with front wheeled walker, and transfers sit to stand with stand by assist. On 9/15/17 at 1:35 PM, neither E10, LPN, or E29, LPN/MDS coordinator, could not state why R2 has had such a decline. E3 provided a quarterly restorative assessment, dated 6/21/17 and 8/2/17, which identify no range of motion deficits and no services warranted. A Physical Therapy Screen, dated 8/15/17, also identifies no limitations or changes in his range of motion. The Facility's undated Restorative Nursing policy documents, A restorative program is a program to assure a resident does not deteriorate or diminish in their abilities (walking, transferring, eating, range of motion, toileting) unless circumstances make the decline unavoidable. The policy documents Restorative Programs may include range of motion - passive and active. The Facility's undated PROM (Passive Range of Motion) Restorative Examples policy documents the goal to be resident will maintain ROM and flexibility of extremities within next 90 days. The steps document staff to perform PROM to all extremities twice daily 7 days per week, will range each extremity 5 reps (repetitions), encourage resident to communicate any pain/discomfort during process, completion of Contracture Assessment quarterly by nursing to monitor for change in needs, and completion of Contracture Profile by Therapy every 6 months to monitor change in condition and review program monthly. 2. R6's MDS, dated [DATE], documents her to have long/short term memory deficits with severe cognitive impairment. The MDS documents R6 requires extensive assist of two for bed mobility and transfer. The MDS documents R6 has no range of motion limitations (ROM), but to receive Passive Range of Motion (PROM) seven days a week. The Care Plan, dated 8/9/17, fails to reflect any ROM needs for R6. On 9/14/17 at 2:10 PM, E17, Certified Nurse Aide (CNA), was asked if she did PROM's on R6 and replied yes. E17 was then requested to do ROM on R6. E17 told R6 that she was going to exercise her arm and lifted her right arm in a flexion/extension exercise doing 10 repetitions. R6 was unable to raise her arm any higher than shoulder height without exhibiting some discomfort (grimacing and resistance). E17 then lifted R6's hand and moved her right wrist back and forth (circumduction) after opening and closing her fingers a few times (Adduction/abduction). No further exercises were done before E17 covered R6 up confirming she was done and left the room. On 9/15/17 at 12:57 PM, E3, Restorative Nurse, stated E17 did not do complete ROM on R6 according to their policy. E3 stated R6 has had an overall decline in the past several months. E3 was unable to provide a quarterly review on 9/15/17. A Physical assessment dated [DATE] documents R6's Right arm ROM to be within normal limits. The Range of Motion Exercises policy, dated 10/2010, documents staff are to move each joint through its range of motion three times unless otherwise instructed. The policy documents staff are to move each joint gently, smoothly and slowly through it's range of motion, remembering to stop before the point of pain. The policy documents staff are to record in the medical record, how the resident tolerated the exercise, how long the exercise was conducted, if the resident participated in any way or any changes in ability were noted, and any problems/complaints by the resident.

Based on interview, observation, and record review, the facility failed to have adequate justification for use of antipsychotic medications, failed to have a comprehensive assessment of behaviors, and failed to do a quantitative/qualitative analysis to reduce medications when applicable for 3 of 4 residents (R2, R8, R12) reviewed for Antipsychotic medication use in the sample of 18. This failure resulted in R8's decline in overall activities of daily living, level of alertness and gradual weight loss. Findings include: 1. The September 2017 physician's orders [REDACTED]. The POS documents R8's [MEDICATION NAME] was increased on 7/14/17 from BID to TID. The Care Plan, dated 8/29/17, documents R8 is on Antipsychotic medications for Dementia with behavioral disturbances and anxiety. There is no plan for reduction, and specific behaviors identified include refusing care and striking staff. R8's September 2017 Behavioral tracking sheets identify Behavior #1 as spitting out medication, #2 striking at staff when being redirected, and #3 elopement/wandering risk. Tracking sheets for July, August and September 2017 fail to document any of these behaviors as occurring. There is no tracking for striking at staff and refusing care. R8's July 2017 Tracking for 7/14/17 when R8's [MEDICATION NAME] was increased shows none of these behaviors as occurring and on 7/24/17, when the [MEDICATION NAME] was added, again shows no behaviors as occurring. Labs tests however, dated 7/14/17, show R8's urinalysis (UA) documenting a Urinary tract infection [MEDICAL CONDITION] identified on 7/14/17 and reoccurring almost every 4-6 weeks since December 2016. R8's psychological evaluation, dated 5/20/17, documents R8 was sent out to the hospital for this evaluation. Lab results of U/A's show a UTI on 5/2/17 and 5/25/17. On 7/13/17, the Nurse Practitioner documented put up looking for clothes, sleep ok, no mania, no [MEDICAL CONDITION], compliant, no c/o (complaint of pain), restless, tries to get up nonstop, hard to redirect off topic. An increase in [MEDICATION NAME] was ordered to 25 mg TID. On 9/12/17 at the noon meal, R8 was partially fed her lunch and then at 1 PM was in bed asleep. R8 was cooperative and quiet during lunch. Progress Notes, dated 9/5/17 and 9/11/17, show R8 fell from her wheelchair. The fall on 9/11/17 resulted in a large hematoma left forehead. On 9/13/17 at 9:15 AM, R8 was transferred to the toilet with extensive assist of E16 and E17, Certified Nurses Aides (CNA's). R8 barely bore weight and shuffled her feet as she was moved from the wheelchair to the toilet. R8 was incontinent of bowel and bladder. R8 was awake, but mumbled when spoken to and appeared sluggish. R8 had a large purple/blue hematoma on her left side of the forehead from a fall on 9/11/17. R8 was cooperative and quiet during the care and transfers. On 7/14/17 at 10 AM, E20, Social Worker (SW), was asked to provide a comprehensive assessment including analysis on R8's behaviors and stated that she would provide tracking and the care plan, but had nothing else in terms of an assessment. E20 stated R8 was on the Memory/Dementia unit until just recently when she showed an overall decline and could no longer participate in activities on the unit, and the decision was made to move her off. E20 stated R8 has had no behaviors lately. On 9/14/17 at 10:50 AM, E19, Registered Nurse (RN), stated R8 has not had behaviors for a long time and lately has been lethargic, very sleepy lately, adding that they were going to do a CAT (Computerized Axial Tomography) scan to see if it was due to her fall. E19 stated R8 has really declined lately. E19 also stated the physician discontinued the [MEDICATION NAME] and [MEDICATION NAME]. Progress Noted, dated 9/14/17 12:19 PM, E19 documented Faxed MD (medical Director) about resident's continued lethargy. Also asked for a review of medications due to resident being on [MEDICATION NAME] and [MEDICATION NAME]. MD faxed back to D/C (discontinue) [MEDICATION NAME] and Hold [MEDICATION NAME] for the time being. Also, a CAT scan has been ordered. On 9/14/17 at 2 PM, R8's physician order [REDACTED]. On 9/15/17 as of 10:30 AM, the physician or pharmacist had not been notified regarding the [MEDICATION NAME] warning to not discontinue abruptly. At 11:20 AM on 9/15/17, E25, RN, stated the pharmacist was contacted and gave recommendations to decrease the [MEDICATION NAME] to one time daily times (x) one week, then one every other day x one week, then D/C with the recommendation being forwarded to R8's physician. E25 stated the physician agreed with the pharmacy recommendation. The Minimum Data Set (MDS), dated [DATE], identifies R8 as having long/short term memory deficits with severe cognitive impairment. The MDS documents R8 needs extensive assist of two staff for bed mobility, transfers, hygiene/toileting and was continent of bowel and occasionally incontinent of bladder. R8's OBRA screening, dated 9/15/15, identifies no serious mental illness. The CAT scan results, dated 9/14/17, came back with no findings as a result of the fall. R8's monthly weight record shows a gradual decline from 1/6/17 at 173.4 pounds to 163.8 pounds on 8/30/17. Progress notes, dated 7/14/17, document R8 being taken for walks about the unit, showing a decline observed in her needing extensive assist of 2 CNA's just to transfer on 9/13/17. Progress note, dated 7/28/17, documents CNA reported res (resident) has slept entire shift (2-10), continually incontinent, not eaten or drank, becomes agitated when woke up. Progress Notes following the addition of [MEDICATION NAME] on 7/24/17 and the increase in [MEDICATION NAME] on 7/14/17 show no monitoring for effectiveness and/or adverse consequences of [MEDICAL CONDITION] medications. There is no notification to the physician that R8 was exhibiting adverse symptoms including lethargy, decreased activities of daily living including ambulation and eating. The facility's [MEDICAL CONDITION] Medication Use policy, dated 1/2017, documents the residents will only receive [MEDICAL CONDITION] medication when necessary to treat specific conditions for which they are indicated and effective. The policy also documents prior to starting [MEDICAL CONDITION] medications, consents will be obtained. The policy documents [DIAGNOSES REDACTED]. The policy documents staff will observe, document, regarding the effectiveness and nursing staff shall monitor for side effects and adverse consequences of [MEDICAL CONDITION] medication with side effects and adverse consequences reported to the medical practitioner. 2. The MDS, dated [DATE] identifies R2 as being a [AGE] year old male admitted to the facility on the Memory/Dementia Unit on 2/8/17. The MDS documents R2 has long/short term memory deficits with severe cognitive impairment and currently requires extensive assist for bed mobility and extensive assist of two staff for all other activities of daily living except eating. The MDS documents R2 is frequently incontinent of urine and bowel. The MDS documents no behaviors for R2. The POS for 2/24/17 documents R2 was started on [MEDICATION NAME] 12.5 mg daily with an increase to BID on 7/13/17. R2's OBRA screen, dated 3/17/17, identifies no history of severe mental health issues. R2's Admission Sheet identifies [DIAGNOSES REDACTED]. The Care Plan, dated 6/8/17, documents R2 has a behavior problem evidenced by yelling/cursing at staff, [DIAGNOSES REDACTED]. Interventions include administer Antipsychotic medications as ordered, monitor for side effect/effectiveness, and monitor and report to MD including shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, loss of appetite and weight, muscle cramps and fatigue in part. A psychiatric note, dated 7/13/17, documents R2 to yell out frequently when he has needs, can get agitated easily and R2's [MEDICATION NAME] was increased to 12.5 twice daily. The Progress Notes from 7/5/17 through 7/13/17 when R2's [MEDICATION NAME] was increased fail to document any behaviors as occurring. The Progress notes following the increase document on 7/14/17 at 2:49 PM, R2 yelled out for the past couple hours with food and fluids offered. There is no documentation as to what non-pharmacological interventions were attempted that failed prior to the increase in the [MEDICATION NAME]. Behavioral tracking sheets identify yelling and wandering as a problem. Observations on 9/13/17 at 11:31 AM and 9/14/17 at 11:45 AM show R2 to be confused, often mumbling and unable to respond appropriately when spoken to. R2 yelled ow repeatedly when care was provided and/or moving him about in bed. R2 would also push staff's hands away at times. R2 was transferred using a full mechanical lift. On 9/15/17, E20, SW, was unable to provide a comprehensive assessment toward R2's behaviors and failed to have justification for use of the [MEDICATION NAME]. E20 was also unable to provide a qualitative/quantitative analysis of R2's behaviors and was unable to say how many episodes he was currently having. On 9/14/17 at 12:57 PM, E3, Restorative Nurse, stated R2 has had a major decline in the past few months and that in February 2017, he was still ambulating. On 9/14/17 at 12 noon, E19, RN, stated R2 usually only has behaviors when care is provided and will try to swat at the girls, usually when getting him up. E19 stated a reduction was recommended by the pharmacist which the family refused on 9/7/17. 3. On 9/14/2017 at 4:05 PM, E1, Administrator, stated The social worker had the Medical Director write (R12's) physician to try to inform him of the facility's [MEDICAL CONDITION] medication policy and his reply. R12's OBRA Initial Screen, dated 8/31/2015, documents in part, Based upon all information and data available to me for this person there is a reasonable basis for suspecting DD (developmental Disabilities) or MI (Mental Illness)- NO. R12's 9/2017 Physician order [REDACTED]. R12's Medication Order Listing Report documents in part, 11/25/2015 [MEDICATION NAME] tablet 2.5 mg at bedtime for sleep, 1/05/2016 [MEDICATION NAME] tablet 5 mg every 6 hours for agitation, 1/05/2016 [MEDICATION NAME] tablet 7.5 mg for at bedtime for sleep, 1/12/2016 [MEDICATION NAME] tablet 5 mg every 6 hours needed for [MEDICAL CONDITION], 5/10/2016 [MEDICATION NAME] tablet 5 mg every 6 hours as needed for [MEDICAL CONDITION], 7/21/2016 [MEDICATION NAME] tablet 10 mg at bedtime for [MEDICAL CONDITION], 9/15/2016 [MEDICATION NAME] 10 mg at bedtime related to major [MEDICAL CONDITION], single episode, 9/2/2017 [MEDICATION NAME] 10 mg by mouth at bedtime related to psychological and behavioral factors associated with disorders or disease classified elsewhere. R12's Medication Administration Record, [REDACTED]. [MEDICATION NAME] 10 mg administered. R12's care plan, dated 11/27/2015 revised 10/05/2016, documents in part, (R12) uses [MEDICAL CONDITION] medication [MEDICATION NAME] for [MEDICAL CONDITION]. Interventions: Monitor for/record occurrence of target behavior symptoms and document per facility protocol. R12's Behavior Tracking for 12/22/2016 through 9/13/ 2017 documents in part, Behavior 1: cursing at staff with or without triggers, Behavior 2: (R12) will refuse to do her restorative exercise. From 12/22/2016 through 9/13/2017 no behavior is documented on the tracking record for R12. A letter to Z5, R12's physician, dated 8/10/2017, documents in part, A recent audit showed the following resident(s) have antipsychotic medications prescribed that are noncompliant with company policy. Antipsychotic medications shall generally be used only for the following conditions/[DIAGNOSES REDACTED]. a. [MEDICAL CONDITION] b. Schizo-affective disorder c. Schizophreniform disorder d. [MEDICAL CONDITION]'s disorder e. [MEDICAL CONDITION] In a note to the facility, dated 8/11/2017, Z5 documents in part We are in compliance. No changes.

Based on interview and record review the facility failed to comprehensively assess and implement progressive interventions to address consistent abnormal bowel elimination patterns for a demented resident for 1 of 3 resident (R4) reviewed for constipation in the sample of 14. This resulted in R4 having significant behavioral issues related bowel elimination requiring hospitalization . Findings include: 1. R4 was admitted to the facility on [DATE] with diagnoses, in part, of: Dementia with behavioral disturbance and lack of coordination. R4's Minimum Data Set ((MDS) dated [DATE] documents R4 is severely cognitively impaired. R4's MDS dated [DATE] documents R4 requires extensive assistance with two staff members for toileting. R4's Care Plan, dated 2/18/16, documents R4 cannot see. The Care Plan further documents R4 has an Activity of Daily Living Self Care (ADL) Performance deficit. Toilet: (R4) requires one staff participation to use toilet. There is no documentation on R4's Care Plan regarding R4's difficulty with bowel evacuation. R4's Hospital emergency room (ER) History and Physical documents on 5/23/16, Chief Complaint: Altered Mental status. History of Present Illness: [AGE] year old male brought from the nursing home because of altered mental status with confusion and violent behavior. This started after staff at the nursing was giving him an enema for severe constipation. Review of System (ROS) Psychiatric: positive for agitation. Physical Exam: Constitutional: The patient was awake, ill-appearing and poorly responsive. The patient was in moderate distress. Disposition: Admit. R4's Documentation Survey Report dated February 2016 documents no bowel movements for 7 days on 2/17/16 through 2/23/16. R4's Report dated March 2016 documents no bowel movement for 7 days, 3/17/16 through 3/23/16, and again for 5 days, 3/26/16 through 3/30/16. R4's Report for April 2016 documents no bowel movement for 4 days, 4/8/16 through 4/11/16. R4's May 2016 Report documents no bowel movement for 6 days, 5/11/16 through 5/16/16. R4's February, March, April and May 2016 Medication Administration Records (MARs) did not document any routine medication for bowel issues. R4's MAR indicated [REDACTED]. R4's February MARs do not document administration of any medications to facilitate bowel movements. R4's March MAR indicated [REDACTED]unknown documented as the results during 3/17/16-3/23/16 when R4 did not have a bowel movement. R4 was given Milk of Magnesia on 3/29/16 with results documented as ineffective during the time period between 3/26/16 and 3/30/16, when R4 did not have a bowel movement. R4's medical record had no documentation that the facility contacted Z2, R4's physician, of R4's inability to have a bowel movement during these times. The MAR indicated [REDACTED]. R4's April MAR indicated [REDACTED]. R4's medical record had no documentation that the facility contacted Z2 regarding R4's inability to have a bowel movement. R4's May MAR indicated [REDACTED] documented as the results during 5/11/16-5/16/15 when R4 did not have a bowel movement. A [MEDICATION NAME] suppository was documented as given on 5/14/16 with unknown documented as the results during this same time period. R4's medical record had no documentation that the facility contacted Z2 regarding R4's inability to have a bowel movement. R4's Nursing Notes, dated 5/23/16 documents Called to (R4) room by Certified Nurse Assistant (CNA), (R4) up on toilet screaming for help, very agitated unable to have BM (bowel movement), upon giving PRN (as needed) enema (R4) became very combative, kicking, screaming, grabbing staff stating I'm going to break your arm forcefully flailing himself around, grabbed staff trying to bite them. Assisted by CNA and another nurse, (R4) was given a shower due to BM being all over (R4). (R4) returned to bed, staff trying multiple interventions to calm (R4), PRN [MEDICATION NAME] given but (R4) spit it at nurse, self inflicted s/t (skin tear) noted to left forearm, multiple attempts to reapproximate with steri strips, (R4) continued to hit, kick and cuss staff, third nurse called to room while writer phoned (E1, Director of Nursing, DON), and on call for permission to send to emergency room due to no PRN IM (intramuscular) available, ordered received and wife notified and agrees with transfer, ambulance phoned. On 6/6/16 at 3:05 PM, E5, CNA, stated R4 was blind and needed assistance from staff for ADL's. E5 stated R4 didn't have much of bowel movements and that R4 had a hard time with bowel movements. E5 stated R4's behaviors would increase when he (R4) needed to have a bowel movement and then R4 would calm down after having bowel movement. On 6/6/16 at 3:07 PM, E6, Restorative Registered Nurse, RN, stated R4 was legally blind and went to the restroom and would use a urinal. E6 stated she doesn't think R4 had any issues with his bowels and would go regularly. On 6/6/16 at 3:00 PM, E4, Licensed Practical Nurse, LPN, stated R4 sometimes had hallucination and was hard to re-direct. E4 stated she was unsure what R4's triggers for behaviors were. E4 stated R4 was blind and completely dependent on staff. E4 further stated R4 required medication for bowel movements and the facility protocol was if residents did not have bowel movement for 3 days, the computer system would alert staff. On 6/6/16 at 3:30 PM, E7, CNA, stated R4 required 2 people for tolieting. E7 stated R4 had trouble with having a bowel movement and R4 talked about his bowels a lot. On 6/7/16 at 8:00 AM, E1, Administrator, confirmed R4 had bowel trouble. On 6/7/16 at 8:55 AM, E13, CNA, stated R4 was unable to see and required a lot of assistance. E13 stated R4 was very frustrated at times and would require short directions from staff. E13 stated R4 would become combative at times. E13 stated R4 did not have regular bowel movements and would show up on the bowel list the facility generates. E13 stated Z1, R4's wife, said they pushed fluids at home and he was always constipated and having bowel problems. E13 stated R4 would be up and down and noticed behaviors decreased after successful bowel evacuation. E13 stated she knew R4 received milk of Magnesia or [MEDICATION NAME] which was not successful and would have to take multiple doses of those medications. E13 stated CNAs report to nursing staff if residents have had results with medications for bowels. On 6/7/16 at 9:52 AM, E10, Social Service Director, stated staff called the emergency roiagnom on [DATE] due to R4's increased behaviors. E10 stated R4 was having a hard time having a bowel movement and R4 got all riled up. E10 stated R4 was scratching and biting staff. E10 stated R4 was sent out to the emergency room . On 6/7/16 at 1:44 PM, E17, CNA, stated R4 was up and down on the toilet on 5/23/16 because he had to go to the bathroom. E17 stated R4 had loose watery stool running down his leg and all over bathroom and R4's bedroom. E17 stated R4 would grunt and push with no result and would state I need to take a sh**. E17 stated E12 had to give R4 a fleets enema and R4 laid still while the fleets enema was administered. E17 stated R4 had quite a bit of stool all over him and E11 and E12 took R4 to the shower room and BM was dripping everywhere down the hall. E17 stated she did not accompany E11 and E12 to the shower room with R4 and she stay to clean up R4's bathroom, bedroom and hallway. On 6/7/16 at 10:52 AM, E11, LPN, stated she was on duty the night of 5/23/16 when R4 was sent to the ER. E11 stated upon entering R4's bathroom, she noticed liquid BM all over R4's bedroom and bathroom. E11 stated R4 was very agitated, yelling and swinging his arms. E11 stated R4 is blind and was grabbing and punching. E11 stated she did not listen to R4's bowels during the incident of 5/23/16 and did not believe E12, LPN, did either. E11 stated E12 felt R4's stomach when R4 was in the bathroom and that R4 was tender. E11 stated she couldn't tell if R4 was in pain and he was not able to verbally confirm pain. E11 stated she and E12 got R4 into bed and E12 left room to get an enema for R4. E11 stated R4 had liquid stool so she thought he was constipated. E11 stated she did a rectal exam on R4 and felt hard formed stool. E11 stated R4 continued to yell, kick and curse during this time. E11 stated R4 allowed E12 to administer the enema. E11 stated R4 had feces everywhere and all over himself so E11 and E12 got a shower chair and took R4 to the shower. E11 stated R4 continued to kick and scream, yelling profanities, fighting staff and even bit E12 on the hand during his shower. E11 stated R4 yelled during the shower I'm going to break your arm and I'm going to kill you. E11 stated once E11 and E12 were done giving R4 a shower, they took him back to bed. E11 stated E12 gave R4 a PRN [MEDICATION NAME] and R4 spit it out at E11. E11 stated she stayed with R4 while E12 went to call Z2 for R4 to be sent to the hospital. E11 stated R4 had behaviors in the facility but nothing like the night of 5/23/16. E11 stated his behaviors were hard to track and she felt this behavior was because R4 could not have a bowel movement and he was anxious. E11 stated she could usually talk R4 down, or take him to the bathroom to help decrease behaviors. E11 stated R4 had bowel issues at home and that Z1 had to give him medicine to help with having a bowel movement. E11 stated R4 came to the facility with his own Milk of magnesia. E11 stated the facility had orders to give R4 Milk of Magnesium and that the facility protocol was that residents were flagged if they did not have a bowel movement in 3 days. E11 stated R4's Milk of magnesia was ineffective, then R4 had a suppository ordered that would sometimes work. E11 stated R4 had enemas order as well but thought R4 had only received an enema a couple of time since his admission. E11 stated the facility's policy/procedure is to run a BM report around 10:00 PM and the residents that have not had a BM for 3 days will be flagged. E11 stated the nursing staff double checks with the CNA's and then give those residents Milk of Magnesia and wait 12 hours, then a suppository if no results with the Milk Of Magnesia. E11 stated she is unsure how long you wait after giving the suppository if there are no results and that R4 was the only residents she has seen with an enema order. E11 stated she would call the residents doctor if no BM after 12 hours with a suppository and no results. E4 stated she was unsure why R4 went more than 3 days without a BM. On 6/7/16 at 9:20 AM, E12 stated she was the nurse caring for R4 on 5/23/16. E12 stated R4 had behaviors and they varied. E12 stated sometimes R4 would become aggressive and sometimes he was friendly. E12 stated R4 was blind and had confusion and hallucinations at times. E12 stated she would notice a decrease in R4's behaviors after a successful bowel movement. E12 stated on 5/23/16, E17 came and got E12. E12 went to R4's room and R4 was on the toilet. E12 stated R4 was agitated due to needing to have a BM. E12 stated R4 can't have a BM on his own without having PRN medication given. E12 stated R4 was antsy and couldn't sit still. E12 stated R4 was anxious and up and down on the toilet. E12 stated R4 was kicking and yelling at staff stating I can't get it out- I need to go to the bathroom! E12 stated there was loose stool all over R4's room from the bed to the bathroom and all over the toilet. E12 stated R4 was yelling trying to take a sh**. E12 stated E11 and E17 assisted R4 back to his bed and E11 did a digital rectal exam and felt hard formed stool. E12 stated R4 continued kicking and screaming during this time. E12 stated she went and got an enema and tried to give it to R4 and R4 was wound for sound'. E12 stated the enema was successful and there was fecal matter and loose stool all over R4. E12 stated she and E11 put R4 in a shower chair and took R4 to the shower room. E12 stated R4 still continued kicking and screaming during this time and in the shower room. E12 stated R4 got a hold of her wrist and R4 state I'll break your arm and I'll kill you son of a bi*****. E12 stated R4 bit her on the wrist during R4's shower. E12 stated after showering R4, E11 and E12 laid R4 down and E12 stated she gave R4 a PRN [MEDICATION NAME] which R4 spit out at E11. E12 stated she called to send R4 out of the facility. E12 stated R4 was kicking, scratching, hitting and didn't know what else to do. E12 stated R4 would get PRN medications for bowel movements and it starts with Milk of Magnesia, then suppository, then enema. E12 stated she was unsure if anyone listened to R4's bowels on 5/23/16 and stated she did not. E12 stated she was unsure is R4 had pain as R4 could not specify pain. E12 stated she felt R4's abdomen and it was hardened but wasn't too obvious. E12 stated R4 is the only person we have been giving enemas too. E12 stated she does not have a good answer as to why R4 went more than 3 days without a bowel movement during his stay at the facility or why the doctor was not notified of these times. E12 stated she would call a residents physician after an enema with unsuccessful results-if its too that point and that doesn't work then there is something more going on. E12 stated she is not sure about the facility policy is there no BM after 3 days. E12 further stated she hasn't usually encountered someone who hasn't gone to the bathroom. E12 stated she did not consider giving R4's PRN anxiety medications before the enema. E12 stated it was a last resort and they (anxiety medication) generally don't even work. On 6/7/16 at 11:20 AM, E2, Director of Nursing, DON, stated she had no reports of bowel issues for R4. E2 stated she expects staff to call the doctor after 3 days of no bowel movement. E2 sated that is the facility's protocol. E2 stated they do not have any documentation or policy in writing on 3 days, it's just what the facility does. E2 stated she expects nursing staff to follow through if giving a medication to help with facilitating a bowel movement. E2 stated she expects staff to call the doctor if no success within 8 hours of giving medications to help with bowel movements. E2 further stated she expected staff to call the doctor after 3 days of no bowel movement. E2 stated she would expect staff to have progressive interventions to facilitate bowel movements, utilize the ordered medications, and even get R4 on a daily regimen instead of PRN medications. E2 stated the computer system flags residents that did not have a BM for 3 days and nursing is to address this. E2 stated she did not know why or how R4 had multiple days of exceeding the 3 days without a bowel movement with the system the facility uses. The Facility's Policy Bowel Disorders-Clinical Protocol dated April 2013, documents: 1. As part of the initial assessment the staff and physician will help identify individuals with previously identified lower Gastrointestinal tract conditions an symptoms. This should include a review of gastrointestinal problems during any recent hospitalization , results of previous [MEDICATION NAME] studies, endoscopies, et. 2. Examples of lower gastrointestinal tract conditions and symptoms include: d. Pain with defecation, f. alteration in bowel movements, h. Residents taking anti-diarrhea medications or medications related to bowel motility. 3. In addition the nurse shall assess and document/report the following: a. Vital signs, b. quantitative and qualitative description of diarrhea, c. change in mental status or level of consciousness, d. presence of fecal impaction, f. abdominal assessment, g. digital rectal examination, i. current medications.

Based on interview and record review, the Facility neglected to properly perform the [MEDICATION NAME] maneuver in compliance with Facility policy and current standards of practice; and neglected to provide Cardio [MEDICAL CONDITION] Resuscitation (CPR) for one resident (R2) in the sample of 21, who was choking on food and became unresponsive. This neglect resulted in R2 expiring in the Facility due to an Airway Obstruction. This has the potential to affect 20 residents (R1, R3-R21) in the sample who were identified as having swallowing problems with a potential for choking and who currently reside in the Facility. This failure resulted in an Immediate Jeopardy which was identified to have begun on [DATE]. While the Immediate Jeopardy was removed on [DATE], the Facility remains out of compliance at Severity Level 2 as the Facility continues to educate staff and update the staff on Emergency Policies and Procedures for Choking. 1. The Facility's Emergency Procedure for Choking policy documents: The purpose of this procedure is to prevent choking by expelling the foreign body airway obstruction. Conscious Resident - Standing or sitting: 1. Ask the resident if he/she is choking. REMEMBER, a choking victim cannot speak or breath and needs your help immediately. 2. Ask the resident to cough or speak if at all possible to determine if his or her airway is obstructed. 3. If able to cough, instruct and encourage the resident to continue coughing to dislodge or expel any foreign object. 4. Call for help, but stay with the resident. 5. Quickly assure the resident that you are going to stay and assist him or her. 6. If the resident cannot cough, only then should abdominal thrusts be performed as follows: a. Stand behind the resident. b. Wrap your arms around the resident's waist. c. Make a fist with one hand. d. Place the thumb side of your fist against the resident's upper mid-abdomen, below the ribcage and above the navel. e. Grasp your clenched fist with your other hand. f. Press your fist into the resident's upper abdomen with a quick upward thrust. g. Do not squeeze the ribcage. Contain the force of the thrust to your hands. h. Repeat the thrusts until the foreign body is expelled or the resident loses consciousness. Unconscious Resident - Lying Down (or when unable to reach around the resident). 1. Ease the resident gently as possible to the floor. 2. Call for help if assistance is not readily present but do not leave the resident unattended. 3. Position the resident on his or her back with the arms to his/her side. 4. Perform abdominal thrusts as follows: a. Facing the resident, kneel down and straddle the resident's upper thighs with your body. b. Place the heel of one hand on the resident's upper mid-abdomen, below the rib cage and above the navel and with fingers pointed toward the resident's chest. c. Place the other hand directly over the positioned hand. d. Bring your shoulders forward over your hands. e. Use your body weight to press your hands into the resident's upper abdomen with a quick upward thrust. 5. Perform the finger sweep maneuver to check for a foreign body as follows: a. Keep the resident's face up. b. Perform the tongue-jaw lift to open the resident's mouth. (Note: moving the lower jaw moves the tongue off the throat and opens the airway.) c. Perform the finger sweep using your index finger as a hook. 1. Insert your index finger into the resident's mouth along side of the cheek and across the base of the tongue. 2. Try to remove any foreign objects. 3. Avoid pushing foreign objects deeper into the throat. 4. Turn the resident's head to one side if needed to sweep an object from the mouth. 6. Alternate steps 4 and 5 until the object is expelled. Arrange for the resident to be evaluated by a physician immediately after the foreign body airway obstruction has been removed. 7. If unable to clear the foreign body from obstructing the airway, arrange emergency transport of the resident to the nearest acute care medical facility. 8. Proceed with CPR immediately if the resident has no pulse or respirations. The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individuals who performed the procedure. 3. The exact time the choking began. 4. The exact time of any unconsciousness. 5. All assessment data obtained during the procedure. 6. The time the procedure was started and stopped. 7. The resident's response to the procedure. 8. The signature and title of the person recording the data. The American Red Cross First Aid Recommendations for Choking document: 1. Have someone call 911. 2. Obtain consent from the victim. 3. Lean the person forward and give 5 back blows with the heel of your hand. 4. Give 5 quick, upward abdominal thrusts. 5. Continue alternating back blows and abdominal thrusts until: the obstructing object is forced out. The person can breathe or cough forcefully on his own or the person becomes unconscious. The American Red Cross documents the following recommendations to follow for the unconscious choking adult: Try 2 rescue breaths. Each rescue breath should last about 1 second. If breaths do not go in, tilt the head farther back. Try 2 rescue breaths again. If the chest does not rise - give 30 chest compressions in about 18 seconds. Look for an object in the airway. Remove if one is seen. Try 2 rescue breaths. Repeat until EMS responders arrive or the obstruction is removed and the patient begins to breathe on his/her own. The Facility Occurrence Investigation and R2's Nurses Notes, dated [DATE] 5:40 PM, per Licensed Practical Nurse (LPN), E11, document I was called to the dining room, with resident coughing. (E7) CNA (Certified Nurses Aide) told me that (R2) was choking on a hamburger and I attempted to get resident to spit it out, resident would not and kept chewing what was left in her mouth at this time. (R2) began to wheeze and I attempted a finger sweep with no results and [MEDICATION NAME] performed with no results. (R2) taken back to room, with oxygen applied and another finger sweep attempted with no results. I returned to the desk and called 911 and (R2's) POA (Power of Attorney). I went back to resident's room and (E9, RN, Registered Nurse, Nurse Manager) was in with (R2). (E9) states that (R2) had no pulse, but still had some shallow breathing. Ambulance arrive, and placed monitor on resident and stated that (R2) was 'gone.' When the POA was notified, the POA said that she would meet (R2) and the ambulance at the hospital. Earlier in the shift, (R2) was not feeling well and I had notified (Z1), her physician about this. (Z1) ordered lab (laboratory) work to be done. Lab work was obtained and sent to hospital, with the order to continue to monitor (R2) at this time. (Z1's) office had called back and wanted (R2) to be started on an antibiotic for a Urinary Tract Infection. The antibiotic was started at 5:35 PM without any difficulty swallowing. At 6:15 PM, the hospital called and said that (R2) had a critical hemoglobin of 7.7. The Occurrence Report documents a statement dated [DATE] at 7:46 PM, made by E7: I was feeding (R2) the regular food that I was given for her. I was feeding her tiny bites. (R2) started to choke and gasp for air. I told (E8) CNA, to run and get (E11). (E11) came in and asked me what was wrong and I told (E11) that (R2) was choking and couldn't breathe. We tried digging the food our of her mouth but, couldn't get it. Her lips started turning blue/purple. On [DATE], at 2:25 PM, E7 stated that he was in the dining room helping feed residents supper on [DATE]. E11, LPN, told E7 that R2 needed to be fed promptly. E7 said that E11 stated you need to help (R2) eat - she's a feeder. E7 said that R2 had seemed a bit tired that day and normally ate independently. E7 said that he and R2 had been talking and laughing at the supper table. R2 had french fries and a hamburger cut into fourths on her plate. E7 said he gave R2 a small piece of hamburger and told her to chew. E7 then gave R2 another piece of hamburger from the edge of the burger and R2 began acting weird - she started coughing and gasping. E7 said that he patted R2 on the back a couple of times and told E8, CNA, to go and get the nurse, E11. E7 said that E11 gently patted R2 on the back and said Can you spit it up? E7 said that R2 did not respond and would not open her mouth. R2 was gasping, coughing and began turning blue. E11 attempted one abdominal thrust while R2 was sitting in her wheelchair. E7 said I think something was stuck in (R2's) airway. E7 said that E11 then wheeled R2 to R2's room with R2 sitting in her wheelchair and E10, CNA, holding R2's feet up. E7 went to get the blood pressure cuff and stethoscope. E7 said four staff members hoisted R2 into her bed and E7 then left R2's room. E7 said that after the event occurred with R2 on [DATE], the Facility inserviced him concerning aspiration. E7 said that as of [DATE] he has not been inserviced by the Facility on what to do if someone is choking and did not know what to do if someone is choking. E10 stated in an interview on [DATE] at 2:05 PM that he was standing in the hallway when he saw E11, LPN, rush R2 to her room. E10 said I saw that something was wrong so I grabbed (R2's) legs, and helped (E11) get (R2) to her room. Four of us put (R2) to bed - (E8, E11, E21) and myself. We could not get (R2's) pulse and her blood pressure was very irregular and thready. (R2) was gasping for air - they were short, shallow breaths. I didn't know that (R2) had choked, but (E11) told me while were in the hallway. (E11) left (R2's) room to call the ambulance. (E8, E21) and I were trying to get (R2) to respond. (E9) came into (R2's) room and checked (R2's) pulse. (E9) thought (R2) might have a weak pulse, but wasn't sure. We put an oxygen mask on (R2) as she took her final gasp of air. I didn't see anything in her mouth. Nobody did the [MEDICATION NAME] maneuver nor did anyone initiate CPR (Cardio [MEDICAL CONDITION] Resuscitation). The ambulance took about 15 minutes to get there. The EMT's (Emergency Medical Technician's) said there was nothing they could for (R2) as she was gone. E10 said that he has not been given any training by the Facility on what to do if someone is choking. E10 said I don't think that they should have taken (R2) to her room and laid her down. I think they should have started life saving measures in the dining room. On [DATE] at 1:53 PM, E11 said that during the supper meal on [DATE], E8 walked up to the Nurses Station and said E11 was needed in the Dining Room. I got up and walked to the Dining Room. I did not know there was a rush. I went into the Dining Room, (E7) called me over and said that (R2) was choking. (R2) was breathing. I told (R2) to spit out the food. (R2) kept chewing so I tried to get the food out of her mouth. I tried putting my fingers in her mouth, but (R2) was clamping down with her teeth. (R2) started wheezing. I reached around and did the [MEDICATION NAME] maneuver while she sat in the wheelchair. I only did one abdominal thrust. (R2) kept chewing. I told (E7) that we needed to get (R2) back to her room. We got (R2) to her room and she was unresponsive. (R2) was still breathing, but wheezing, and with shallow breaths. I tried to do a finger sweep, but didn't feel anything. (E9) came in and took over so I left to call 911. I told (E9) that I had done the [MEDICATION NAME] one time. (R2) was a DNR (Do Not Resuscitate) so we didn't do anything else. (R2) quit breathing right before the ambulance came. (E9) said that (R2) had taken a little gasp and stopped breathing. The EMT's came in and I told them that (R2) had choked. The EMT's said that (R2) was already 'gone' and they left. It was 6:13 PM. I called (Z1, R2's physician), and he said it sounded like (R2) aspirated. (E9) told me that (R2) was 'gone' when we put her into bed. I have been trained by the Facility after this happened, but no one has ever told me to do the [MEDICATION NAME] Maneuver more than one time. I didn't know that you should do CPR on someone who is choking if they have a DNR. On [DATE] at 1:36 PM, E9 said that he had been outside the Facility on break during the evening meal on [DATE]. E9 said that he came into the building as he heard an urgent page on the overhead. E9 said that staff had taken R2 to her room and placed her into bed. E9 said I went into (R2's) room and saw that she was unresponsive. (R2's) eyes were fixed and she had agonal breathing. There were 4 or 5 people standing around in (R2's) room. One of the CNA's was trying to take (R2's) blood pressure. (E11) left (R2's) room to call someone, maybe the ambulance, (R2's) Physician or (R2's) POA. I tried to get (R2's) pulse so I went and got the Pulse Oximeter Machine. We had oxygen going on R2. Her color was dusky, but she had a faint pulse. It was difficult to assess her heart sounds as she was obese. The EMT's got there about 10 minutes later. The EMT's said 'Why did you call us? This lady is gone!' (R2) was a DNR so we did not attempt resuscitation. She had been very depressed - she had said that she wanted to die. E9 said that he did not record any of what occurred with R2 in writing. E9 could not remember who was present in the room with R2. E9 said that he would not attempt CPR on a resident who has a DNR even if they become unresponsive due to choking. E8 was interviewed on [DATE] at 2:51 PM. E8 said that staff would always encourage R2 to eat and that she would eat ice cream all day long. E8 said that staff normally did not feed R2. E8 said I was passing trays in the dining room when I heard (E11) tell (E7) to feed (R2). Then, I saw (E11) go over to (R2) and stick her fingers in (R2's) mouth. (R2) was biting down. (E11) did the [MEDICATION NAME] maneuver to (R2) one time. By that time, (R2) was slouched over and had no expression on her face. I told (E11) that (R2's) lips were turning blue. (R2) was gasping for air. I went to get oxygen from (E23, LPN) and she said to ask (E22, LPN) as she was going on-break. (E22) was on the telephone so I had to wait for her to finish her call. (E22) handed me the keys for the oxygen room and I got the portable oxygen. By that time, staff were bringing (R2) down the hall. (R2's) lips were purplish/blue and she was pale. Somebody said that we needed to get the sit-to-stand lift to get (R2) into bed. Instead, we manhandled her into bed. We put oxygen on her and (R2) was gasping. We found out she was a DNR so we didn't do anything else. We tried 4 - 5 times to get (R2's) pulse or blood pressure and couldn't get one. (E9) couldn't get one either. The EMT's came and said that (R2's) face was fixed already. We told the EMT's that she choked. E8 said that she had not been trained by the Facility on what to do when someone is choking. E8 said that she could not remember what to do when someone is choking. E8 said that she guessed that you see if there is something in the persons mouth if they are choking. On [DATE] at 1:55 PM, E22 stated that I was not aware until the inservice training I received today, that you do the [MEDICATION NAME] Maneuver on someone who is choking and is a DNR followed by CPR. E18, CNA, stated in an interview on [DATE] at 9:45 AM, that if she saw someone choking Hopefully, help would be there. I would lay them on the ground at that location. E2, Director of Nursing (DON), stated in an interview on [DATE] at 10:00 AM, that Facility nurses receive training on the [MEDICATION NAME] Maneuver and CPR from the American Heart Association. E2 said that the CNA's can obtain training on CPR on the computer, but they are not mandated by the Facility to complete the training. E2 said that CNA's do not receive any hands-on training for the [MEDICATION NAME] Maneuver or CPR. On [DATE] at 1:44 PM, E2 said that during the Facility investigation into R2's death, she did not realize that staff had only performed one abdominal thrust in an attempt to clear R2's airway however, she was aware that staff did not start CPR. E2 stated that currently there are 20 residents in the facility, R1 and R3 through R21, who are identified as having swallowing problems and are potentially at risk for choking. Z1, R2's physician, was interviewed by telephone on [DATE] at 11:15 AM. Z1 said that R2 had previously had a major stroke and anyone who has had a stroke is at risk for choking. Z1 said that Facility staff should have done the [MEDICATION NAME] Maneuver repeatedly on R2 to clear the obstruction in R2's airway and implemented life saving measures. Z1 said I would have expected a real, repeated effort to clear (R2's) airway. My understanding is that staff did not follow through because (R2) was a DNR, and they should not have stopped. Choking to death is not a good way to die. R2's State Certificate of Death Worksheet, with a certification date of [DATE], documents that R2's primary cause of death was Airway Obstruction. The approximate interval between onset and death is documented as 10 minutes. R2's secondary cause of death is documented as Swallowing Dysfunction with an interval between onset and death of 2 years. The Immediate Jeopardy began on [DATE] at 5:40 PM when R2 choked during the evening meal and staff did not respond appropriately. E1, Administrator, was notified of the Immediate Jeopardy on [DATE] at 12:00 PM. On [DATE] the surveyor determined through record review and interview that the Facility took the following actions to remove the Immediacy: 1. On [DATE], E1, Administrator and E2, DON, initiated an investigation regarding circumstances surrounding the event related to R2 on [DATE]. 2. Between [DATE] and [DATE], E2 and/or E12, Wound Care Nurse Manager, E19, Restorative Nurse, E25, MDS/Care Plan Nurse and E9, Weekend Nurse Supervisor, educated nursing staff, including Licensed Nurses and CNA's, on reporting immediately to the charge nurse, any resident having any difficulty with eating such as choking, pocketing food, or any not previously noted difficulty with meal consumption. 100% of nursing staff have been re-educated with the exception of approximately six staff that will not be allowed to return to duty until they have been educated. Remaining staff, including all department managers, dietary, housekeeping and activities will be in-serviced by [DATE]. Staff which are on vacation will be inserviced before returning to work. 3. Speech therapy staff were re-educated by their supervisor on [DATE] on immediately communicating any recommendation for diet changes due to swallowing issues to the Facility nurses and to the resident's physician. 4. On [DATE], nursing staff, including Licensed Nurses and CNA's were educated on the Emergency Procedure for Choking, including initiating CPR if the resident becomes unresponsive as a result of the choking event, even if the resident has an order for [REDACTED]. 5. The DON reassessed all residents on [DATE], that are currently identified with swallowing difficulties to ensure that any potential difficulties with meal consumption were being addressed. Only one resident was identified as having an episode of coughing and that was discussed with the Speech Therapist. All of the remaining residents will have a screen completed for swallowing difficulties, by therapy staff, by [DATE]. Any issues identified will be communicated to the physician for additional orders and the care plan will be updated where indicated. 6. All new staff hires after [DATE] will be educated on emergency procedures including emergency procedures for choking. All new employees hired will continue to be educated during orientation on reporting any difficulty with meal consumption to the nurse if/when identified. 7. E1 and the Medical Director met on [DATE], reviewed and discussed the occurrence and corrective action. The Medical Director concurred with the corrective action that has been implemented. 8. On [DATE], the Quality Assurance (QA) Committee met and a Plan of Action was developed and will remain in place until the QA Committee feels, based on interviews and observations, that the staff have incorporated the education received into the day-to-day care and service. 9. Effective [DATE], Nurse Managers, including the DON, Assistant Director of Nursing (ADON), Wound Care Nurse Manager, Restorative Nurse Manager and Weekend RN Supervisor, will monitor random meals, at least four times a week, to identify residents at risk for choking. Observations will include questioning staff on what to do if a resident has difficulty with meal consumption. The Nurse Managers will question at least one staff member per day on the Emergency Procedure for choking. The plan will be reviewed weekly by the QA Committee and monthly in the QA Meeting and will remain in effect for at least 90 days to ensure the action is incorporated into the care of service.

Based on record review and interview, the Facility failed to provide appropriate actions to clear a resident's airway when found choking on food; and failed to provide Cardio [MEDICAL CONDITION] Resuscitation (CPR) when becoming unresponsive after choking on food for 1 of 21 residents (R2) reviewed for choking in the sample of 21. This failure resulted in R2 expiring in the Facility due to an Airway Obstruction. This has the potential to affect 20 residents (R1, R3 thru R21) in the sample who were identified as having swallowing problems with a potential for choking who currently reside in the Facility. This failure resulted in an Immediate Jeopardy which was identified to have begun on [DATE]. While the Immediate Jeopardy was removed on [DATE], the Facility remains out of compliance at Severity Level 2 as the Facility continues to educate staff and update the staff on Emergency Policies and Procedures for Choking. Findings include: 1. The Facility Occurrence Investigation and R2's Nurses Notes, dated [DATE] 5:40 PM, per E11, Licensed Practical Nurse (LPN), document, I was called to the dining room, with resident coughing. (E7, Certified Nurses Aide) CNA told me that (R2) was choking on a hamburger and I attempted to get resident to spit it out, resident would not and kept chewing what was left in her mouth at this time. (R2) began to wheeze and I attempted a finger sweep with no results and [MEDICATION NAME] performed with no results. (R2) taken back to room, with oxygen applied and another finger sweep attempted with no results. I returned to the desk and called 911 and (R2's) POA (Power of Attorney). I went back to resident's room and (E9, Registered Nurse, RN/ Nurse Manager) was in with (R2). (E9) stated that (R2) had no pulse, but still had some shallow breathing. Ambulance arrived, and placed monitor on resident and stated that (R2) was 'gone.' When the POA was notified, the POA said that she would meet (R2) and the ambulance at the hospital. Earlier in the shift, (R2) was not feeling well and I had notified (Z1) her physician about this. (Z1) ordered laboratory work to be done. Lab work was obtained and sent to hospital, with the order to continue to monitor (R2) at this time. (Z1's) office had called back and wanted (R2) to be started on an antibiotic for a Urinary Tract Infection. The antibiotic was started at 5:35 PM without any difficulty swallowing. At 6:15 PM, the hospital called and said that (R2) had a critical hemoglobin of 7.7. The Occurrence Report documents a statement dated [DATE] at 7:46 PM, made by E7: I was feeding (R2) the regular food that I was given for her. I was feeding her tiny bites. (R2) started to choke and gasp for air. I told (E8, CNA) to run and get (E11). (E11) came in and asked me what was wrong and I told (E11) that (R2) was choking and couldn't breathe. We tried digging the food our of her mouth but, couldn't get it. Her lips started turning blue/purple. On [DATE], at 2:25 PM, E7 stated that he was in the dining room helping feed residents supper on [DATE]. E11 told E7 that R2 needed to be fed promptly. E7 said that E11 stated You need to help (R2) eat - she's a feeder. E7 said that R2 had seemed a bit tired that day and normally ate independently. E7 said that he and R2 had been talking and laughing at the supper table. R2 had french fries and a hamburger cut into fourths on her plate. E7 said he gave R2 a small piece of hamburger and told her to chew. E7 then gave R2 another piece of hamburger from the edge of the burger and R2 began acting weird - she started coughing and gasping. E7 said that he patted R2 on the back a couple of times and told E8, CNA, to go and get the nurse, E11. E7 said that E11 gently patted R2 on the back and said Can you spit it up? E7 said that R2 did not respond and would not open her mouth. R2 was gasping, coughing and began turning blue. E11 attempted one abdominal thrust while R2 was sitting in her wheelchair. E7 said I think something was stuck in (R2's) airway. E7 said that E11 then wheeled R2 to R2's room with R2 sitting in her wheelchair and E10, CNA, holding R2's feet up. E7 went to get the blood pressure cuff and stethoscope. E7 said four staff members hoisted R2 into her bed and E7 then left R2's room. E7 said that all of the resident's who need to be fed by staff sit in one area of the dining room - that is how the CNA's know that someone is a feeder. E7 said that R2 was not sitting in that area and the only reason that E7 was feeding R2 on [DATE] was because E11 told E7 to feed R2. E10, CNA, stated in an interview on [DATE] at 2:05 PM that he was standing in the hallway when he saw E11 rush R2 to her room. E10 said I saw that something was wrong so I grabbed (R2's) legs, and helped (E11) get (R2) to her room. Four of us put (R2) to bed - (E8, E11, E21) and myself. We could not get (R2's) pulse and her blood pressure was very irregular and thready. (R2) was gasping for air - they were short, shallow breaths. I didn't know that (R2) had choked, but (E11) told me while were in the hallway. (E11) left (R2's) room to call the ambulance. (E8, E21) and I were trying to get (R2) to respond. (E9) came into (R2's) room and checked (R2's) pulse. (E9) thought (R2) might have a weak pulse, but wasn't sure. We put an oxygen mask on (R2) as she took her final gasp of air. I didn't see anything in her mouth. Nobody did the [MEDICATION NAME] maneuver nor did anyone start CPR (Cardiopulmonary Resuscitation). The ambulance took about 15 minutes to get there. The EMT's (Emergency Medical Technicians) said there was nothing they could for (R2) as she was gone. E10 said that he has not been given any training by the Facility on what to do if someone is choking. E10 said I don't think that they should have taken (R2) to her room and laid her down. I think they should have started life saving measures in the dining room. On [DATE] at 1:53 PM, E11 said that during the supper meal on [DATE], E8 walked up to the Nurses Station and said E11 was needed in the Dining Room . I got up and walked to the Dining Room. I did not know there was a rush. I went into the Dining Room, (E7) called me over and said that (R2) was choking. (R2) was breathing. I told (R2) to spit out the food. (R2) kept chewing so I tried to get the food out of her mouth. I tried putting my fingers in her mouth, but (R2) was clamping down with her teeth. (R2) started wheezing. I reached around and did the [MEDICATION NAME] maneuver while she sat in the wheelchair. I only did one abdominal thrust. (R2) kept chewing. I told (E7) that we needed to get (R2) back to her room. We got (R2) to her room and she was unresponsive. (R2) was still breathing, but wheezing and with shallow breaths. I tried to do a finger sweep, but didn't feel anything. (E9) came in and took over so I left to call 911. I told (E9) that I had done the [MEDICATION NAME] one time. (R2) was a DNR (Do Not Resuscitate) so we didn't do anything else. (R2) quit breathing right before the ambulance came. (E9) said that (R2) had taken a little gasp and stopped breathing. The EMT's came in and I told them that (R2) had choked. The EMT's said that (R2) was already 'gone' and they left. It was 6:13 PM. I called (Z1, R2's Physician) and he said it sounded like (R2) aspirated. (E9) told me that (R2) was 'gone' when we put her into bed. I have been trained by the Facility after this happened but no one has ever told me to do the [MEDICATION NAME] Maneuver more than 1 time. I didn't know that you should do CPR on someone who is choking if they have a DNR. On [DATE], at 2:20 PM, E11 said that R2 had not eaten on [DATE]. E11 said My intent was for (E7) to sit with (R2), but he started feeding her. E9, RN, Nurse Manager, said on [DATE] at 1:36 PM, that he had been outside the Facility on break during the evening meal on [DATE]. E9 said that he came into the building as he heard an urgent page on the overhead. E9 said that staff had taken R2 to her room and placed her into bed. E9 said I went into (R2's) room and saw that she was unresponsive. (R2's) eyes were fixed and she had agonal breathing. There were 4 or 5 people standing around in (R2's) room. One of the CNA's was trying to take (R2's) blood pressure. (E11) left (R2's) room to call someone, maybe the ambulance, (R2's) physician or (R2's) POA. I tried to get (R2's) pulse so I went and got the Pulse Oxymeter Machine. We had oxygen going on (R2). Her color was dusky, but she had a faint pulse. It was difficult to assess her heart sounds as she was obese. The EMT's got there about 10 minutes later. The EMT's said 'Why did you call us? This lady is gone!' (R2) was a DNR so we did not attempt resuscitation. She had been very depressed - she had said that she wanted to die. E9 said that he did not record any of what occurred with R2 in writing. E9 could not remember who was present in the room with R2. E9 said that he would not attempt CPR on a resident who has a DNR even if they become unresponsive due to choking. E8, CNA, was interviewed on [DATE] at 2:51 PM. E8 said that staff would always encourage R2 to eat and that she would eat ice cream all day long. E8 said that staff normally did not feed R2. E8 said I was passing trays in the dining room when I heard (E11) tell (E7) to feed (R2). Then, I saw (E11) go over to (R2) and stick her fingers in (R2's) mouth. (R2) was biting down. (E11) did the [MEDICATION NAME] maneuver to (R2) one time. By that time, (R2) was slouched over and had no expression on her face. I told (E11) that (R2's) lips were turning blue. (R2) was gasping for air. I went to get oxygen from (E23, LPN) and she said to ask (E22, LPN) as she was going on break. (E22) was on the telephone so I had to wait for her to finish her call. (E22) handed me the keys for the oxygen room and I got the portable oxygen. By that time, staff were bringing (R2) down the hall. (R2's) lips were purplish/blue and she was pale. Somebody said that we needed to get the sit-to-stand lift to get (R2) into bed. Instead, we manhandled her into bed. We put oxygen on her and (R2) was gasping. We found out she was a DNR so we didn't do anything else. We tried 4 - 5 times to get (R2's) pulse or blood pressure and couldn't get one. (E9) couldn't get one either. The EMT's came and said that (R2's) face was fixed already. We told the EMT's that she choked. E8 said that she had not been trained by the Facility on what to do when someone is choking. E8 said that she could not remember what to do when someone is choking. E8 said that she guessed that you see if there is something in the persons mouth if they are choking. E24, Speech Therapist, stated on [DATE] at 9:38 AM, that she had started working with R2 in early [DATE]. E24 said that she first started seeing R2 for cognition as she seemed confused and was talking about her dead husband. During R2's evaluation, E24 noticed that R2 was sitting poorly in her wheelchair with her head tilted back. E24 gave R2 water and she coughed a little. E24 said that she had previously worked with R2 for swallowing. E24 said that she then asked some of the CNA's how R2 ate and they said that R2 occasionally choked on her food. E24 said that R2 would take large bites and needed to be cued to take smaller bites. E24 said that R2's food needed to be cut up and placed towards R2's right side due to her previous Cardio Vascular Accident ([MEDICAL CONDITION]). E24 said I told (R2) that we needed to downgrade her diet and give her ground meat, and (R2) said she didn't like it. I told her either we needed to downgrade her diet or work with (R2) to eat regular food. I did tell some of the CNA's (I don't remember who) to REALLY cut up her food but, it was not documented. I usually write up a plan when I finish working with a resident. I saw her three times a week so, I probably saw (R2) about 6 times for swallowing problems. It can take one to two months to complete the process and make recommendations. (R2) fed herself - I don't know why she was being fed that meal. Z1, R2's Physician, was interviewed by telephone on [DATE] at 11:15 AM. Z1 said that R2 had previously had a major stroke and anyone who has had a stroke is at risk for choking. Z1 said that Facility staff should have done the [MEDICATION NAME] Maneuver repeatedly on R2 to clear the obstruction in R2's airway and implemented life saving measures. Z1 said I would have expected a real, repeated effort to clear (R2's) airway. My understanding is that staff did not follow through because (R2) was a DNR, and they should not have stopped. Choking to death is not a good way to die. R2's Ambulance Service Patient Care Report documents [DATE], Call Received at 6:01 PM. Arrived on scene at 6:04 PM. We were called out by 911 for a woman choking and moving very little air. Upon arrival, we found (R2) laying in bed with a CNA and nurses around the bed. They said that they just got her back into bed after choking in the dining room. There was a CNA hooking the oxygen mask over (R2's) face, about ,[DATE] inches above her face and 2 liters of oxygen running. (R2) was not breathing and did not have a pulse in her arm or at the carotid. (R2's) eyes were already fixed and had mucous starting to form. The nurse said that (R2) was a DNR. The monitor was put into place and it confirmed in all three leads that her rhythm was asystole. The charge nurse called the coroner. R2's Facility Facesheet documents that she was originally admitted to the facility on [DATE] with diagnoses, in part, of Dense Left [MEDICAL CONDITION] due to [MEDICAL CONDITION], Dysphagia, [MEDICAL CONDITION] and Cognitive Deficit. R2's most recent Minimum Data Set (MDS), dated [DATE], documents that has a Brief Interview for Mental Status (BIMS) score of 13, which means that she was cognitively intact; and required supervision with setup help for eating. R2's clinical records document a physician's orders [REDACTED]. R2 also has a physician's orders [REDACTED]. R2's Speech Therapy Plan of Care, dated [DATE], documents Reason for Referral: Dysphagia. This [AGE] year old female with a history of [MEDICAL CONDITION] year has been experiencing increased difficulty with her cognitive abilities. Nursing reporting that patient has been confused and asking about her late husband as if he were still alive. Patient has also been demonstrating choking episodes during meals. These have reportedly involved patient coughing, loosing her voice and her face turning red. ST (Skilled Speech Therapy) services are necessary for patient to decrease her risk for aspiration and improve her cognitive skills. Without ST, patient is at risk for worsening confusion and risk for aspiration and choking. Rehabilitation Outcome Measure: Swallowing - moderate to severe. R2's current Facility Plan of Care, dated [DATE], does not document R2's swallowing problems. E2, Director of Nursing (DON) confirmed in an interview on [DATE] at 10:00 AM that the Facility did not develop a plan of care for R2's swallowing problems. E2 said that she inserviced staff on [DATE] concerning residents experiencing aspiration, swallowing problems and pocketing food. E2 said that the inservice did not include what to do if a resident is choking. R2's State Certificate of Death Worksheet, with a certification date of [DATE], documents that R2's primary cause of death was Airway Obstruction. The approximate interval between onset and death is documented as 10 minutes. R2's secondary cause of death is documented as Swallowing Dysfunction with an interval between onset and death of 2 years. The Facility's Emergency Procedure for Choking policy documents: The purpose of this procedure is to prevent choking by expelling the foreign body airway obstruction. Conscious Resident - Standing or sitting: 1. Ask the resident if he/she is choking. REMEMBER, a choking victim cannot speak or breath and needs your help immediately. 2. Ask the resident to cough or speak it at all possible to determine if his or her airway is obstructed. 3. If able to cough, instruct and encourage the resident to continue coughing to dislodge or expel any foreign object. 4. Call for help, but stay with the resident. 5. Quickly assure the resident that you are going to stay and assist him or her. 6. If the resident cannot cough, only then should abdominal thrusts be performed as follows: a. Stand behind the resident. b. Wrap your arms around the resident's waist. c. Make a fist with one hand. d. Place the thumb side of your fist against the resident's upper mid-abdomen, below the ribcage and above the navel. e. Grasp your clenched fist with your other hand. f. Press your fist into the resident's upper abdomen with a quick upward thrust. g. Do not squeeze the ribcage. Contain the force of the thrust to your hands. h. Repeat the thrusts until the foreign body is expelled or the resident loses consciousness. Unconscious Resident - Lying Down (or when unable to reach around the resident). 1. Ease the resident gently as possible to the floor. 2. Call for help if assistance is not readily present but do not leave the resident unattended. 3. Position the resident on his or her back with the arms to his/her side. 4. Perform abdominal thrusts as follows: a. Facing the resident, kneel down and straddle the resident's upper thighs with your body. b. Place the heel of one hand on the resident's upper mid-abdomen, below the rib cage and above the navel and with fingers pointed toward the resident's chest. c. Place the other hand directly over the positioned hand. d. Bring your shoulders forward over your hands. e. Use your body weight to press your hands into the resident's upper abdomen with a quick upward thrust. 5. Perform the finger sweep maneuver to check for a foreign body as follows: a. Keep the resident's face up. b. Perform the tongue-jaw lift to open the resident's mouth. (Note: moving the lower jaw moves the tongue off the throat and opens the airway.) c. Perform the finger sweep using your index finger as a hook. 1. Insert your index finger into the resident's mouth along side of the cheek and across the base of the tongue. 2. Try to remove any foreign objects. 3. Avoid pushing foreign objects deeper into the throat. 4. Turn the resident's head to one side if needed to sweep an object from the mouth. 6. Alternate steps 4 and 5 until the object is expelled. Arrange for the resident to be evaluated by a physician immediately after the foreign body airway obstruction has been removed. 7. If unable to clear the foreign body from obstructing the airway, arrange emergency transport of the resident to the nearest acute care medical facility. 8. Proceed with CPR immediately if the resident has no pulse or respirations. The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individuals who performed the procedure. 3. The exact time the choking began. 4. The exact time of any unconsciousness. 5. All assessment data obtained during the procedure. 6. The time the procedure was started and stopped. 7. The resident's response to the procedure. 8. The signature and title of the person recording the data. The American Red Cross First Aid Recommendations for Choking document: 1. Have someone call 911. 2. Obtain consent from the victim. 3. Lean the person forward and give 5 back blows with the heel of your hand. 4. Give 5 quick, upward abdominal thrusts. 5. Continue alternating back blows and abdominal thrusts until: the obstructing object is forced out and the person can breathe or cough forcefully on his own, or until the person becomes unconscious. The American Red Cross documents the following recommendations to follow for the unconscious choking adult: Try 2 rescue breaths. Each rescue breath should last about 1 second. If breaths do not go in, tilt the head farther back. Try 2 rescue breaths again. If the chest does not rise - give 30 chest compressions in about 18 seconds. Look for an object in the airway. Remove if one is seen. Try 2 rescue breaths. Repeat until EMS responders arrive or the obstruction is removed and the patient begins to breathe on his/her own. E2 stated in an interview on [DATE] at 10:00 AM, that Facility nurses receive training on the [MEDICATION NAME] Maneuver and CPR from the American Heart Association. E2 said that the CNA's can obtain training on CPR on the computer but, they are not mandated by the Facility to complete the training. E2 said that CNA's do not receive any hands-on training for the [MEDICATION NAME] Maneuver or CPR. On [DATE] at 1:44 PM, E2 said that during the Facility investigation into R2's death, she did not realize that staff had only performed one abdominal thrust in an attempt to clear R2's airway however, she was aware that staff did not start CPR. E2 stated that currently there are 20 residents in the facility R1, and R3 through R21, who are identified as having swallowing problems and are potentially at risk for choking. The Immediate Jeopardy began on [DATE] at 7:40 PM when R2 choked during the evening meal and staff did not respond appropriately. E1, Administrator, was notified of the Immediate Jeopardy on [DATE] at 12:00 PM. On [DATE] the surveyor determined through record review and interview that the Facility took the following actions to remove the Immediacy: 1. On [DATE], E1, Administrator and E2, DON, initiated an investigation regarding circumstances surrounding the event related to R2 on R/,[DATE]. 2. Between [DATE] and [DATE], nursing staff, including Licensed Nurses and CNA's, were educated by E2 and/or E12, Wound Care Nurse Manager, E19, Restorative Nurse, E25, MDS/Care Plan Nurse and E9, Weekend Nurse Supervisor, on reporting any resident having any difficulty with eating such as; choking, pocketing food, or any not previously noted difficulty with meal consumption to the charge nurse when it is noted. 100% of nursing staff have been re-educated with the exception of approximately six staff that will not be allowed to return to duty until they have been educated. Remaining staff, including all department managers, dietary, housekeeping and activities will be in-serviced by [DATE]. Staff which are on vacation will be inserviced before returning to work. 3. Speech therapy staff were re-educated by their supervisor on [DATE] on immediately communicating any recommendation for diet changes to the Facility nurses and to the resident's physician. 4. On [DATE], nursing staff, including licensed nurses and CNA's were educated on the Emergency Procedure for Choking, including initiating CPR if the resident becomes unresponsive as a result of the choking event, even if the resident has an order for [REDACTED]. 5. E2, DON reassessed all resident on [DATE] that are currently identified with swallowing difficulties to ensure that any potential difficulties with meal consumption were being addressed. Only one resident was identified as having an episode of coughing and that was discussed with the Speech Therapist. All of the remaining residents will have a screen completed for swallowing difficulties, by therapy staff, by [DATE]. Any issues identified will be communicated to the physician for additional orders and the care plan will be updated when indicated. 6. All new hires after [DATE] will be educated on emergency procedures including emergency procedures for choking. All new employees hired will continue to be educated during orientation on reporting any difficulty with meal consumption to the nurse if identified. 7. E1, Administrator and the Medical Director met on [DATE], reviewed and discussed the occurrence and corrective action. The Medical Director concurred with the corrective action that has been implemented. 8. On [DATE], the Quality Assurance (QA) Committee met and a Plan of Action was developed and will remain in place until the QA Committee feels, based on interviews and observations, that the staff have incorporated the education received into the day-to-day care and service. 9. Effective [DATE], Nurse Managers, including the DON, Assistant Director of Nursing (ADON), Wound Care Nurse Manager, Restorative Nurse Manager and Weekend RN Supervisor, will monitor random meals, at least four times a week, to identify residents at risk for choking. Observations will include questioning staff on what to do if a resident has difficulty with meal consumption. The Nurse Managers will question at least one staff member per day on the Emergency Procedure for choking. The plan will be reviewed weekly by the QA Committee and monthly in the QA Meeting and will remain in effect for at least 90 days to ensure the action is incorporated into the care of service.

Based on record review and interview, the Facility failed to provide life saving measures according to accepted professional standards of care for 1 of 1 residents (R2) in the sample of 21 who began choking on food and as a result became unresponsive. This failure resulted in R2 expiring in the Facility due to an Airway Obstruction. Findings include: 1. The Facility Occurrence Investigation and R2's Nurses Notes dated [DATE] 5:40 PM per E11, Licensed Practical Nurse (LPN), document, I was called to the dining room, with resident coughing. (E7, Certified Nurses Aide) CNA told me that (R2) was choking on a hamburger and I attempted to get resident to spit it out, resident would not and kept chewing what was left in her mouth at this time. (R2) began to wheeze and I attempted a finger sweep with no results and [MEDICATION NAME] performed with no results. (R2) taken back to room, with oxygen applied and another finger sweep attempted with no results. I returned to the desk and called 911 and (R2's) POA (Power of Attorney). I went back to resident's room and (E9, Registered Nurse, RN/ Nurse Manager) was in with (R2). (E9) stated that (R2) had no pulse, but still had some shallow breathing. Ambulance arrived, and placed monitor on resident and stated that (R2) was 'gone.' When the POA was notified, the POA said that she would meet (R2) and the ambulance at the hospital. Earlier in the shift, (R2) was not feeling well and I had notified (Z1) her physician about this. (Z1) ordered laboratory work to be done. Lab work was obtained and sent to hospital, with the order to continue to monitor (R2) at this time. (Z1's) office had called back and wanted (R2) to be started on an antibiotic for a Urinary Tract Infection. The antibiotic was started at 5:35 PM without any difficulty swallowing. At 6:15 PM, the hospital called and said that (R2) had a critical hemoglobin of 7.7. R2's State Certificate of Death Worksheet, with a certification date of [DATE], documents that R2's primary cause of death on [DATE] was due to Airway Obstruction. The approximate interval between onset and death is documented as 10 minutes. R2's secondary cause of death is documented as Swallowing Dysfunction with an interval between onset and death of 2 years. On [DATE] at 1:53 PM, E11, LPN, said that during the supper meal on [DATE], E8, CNA, walked up to the nurses station and said E11 was needed in the Dining Room. E11 said I got up and walked to the Dining Room. I did not know there was a rush. I went into the Dining Room, (E7) called me over and said that (R2) was choking. (R2) was breathing. I told (R2) to spit out the food. (R2) kept chewing so I tried to get the food out of her mouth. I tried putting my fingers in her mouth, but (R2) was clamping down with her teeth. (R2) started wheezing. I reached around and did the [MEDICATION NAME] maneuver while she sat in the wheelchair. I only did one abdominal thrust. (R2) kept chewing. I told (E7) that we needed to get (R2) back to her room. We got (R2) to her room and she was unresponsive. (R2) was still breathing, but wheezing and with shallow breaths. I tried to do a finger sweep, but didn't feel anything. (E9) came in and took over so I left to call 911. I told (E9) that I had done the [MEDICATION NAME] one time. (R2) was a DNR (Do Not Resuscitate) so we didn't do anything else. (R2) quit breathing right before the ambulance came. (E9) said that (R2) had taken a little gasp and stopped breathing. The EMT's (Emergency Medical Technicians) came in and I told them that (R2) had choked. The EMT's said that (R2) was already 'gone' and they left. It was 6:13 PM. I called (Z1, R2's physician) and he said it sounded like (R2) aspirated. (E9) told me that (R2) was 'gone' when we put her into bed. I have been trained by the Facility after this happened, but no one has ever told me to do the [MEDICATION NAME] Maneuver more than one time. I didn't know that you should do CPR (Cardiopulmonary resuscitation) on someone who is choking if they have a DNR. On [DATE], at 2:25 PM, E7 stated that he was in the dining room helping feed residents supper on [DATE] and E11 told E7 that R2 needed to be fed promptly. E7 said that E11 stated you need to help (R2) eat - she's a feeder. E7 said that R2 had seemed a bit tired that day and normally ate independently. E7 said that he and R2 had been talking and laughing at the supper table. R2 had french fries and a hamburger cut into fourths on her plate. E7 said he gave R2 a small piece of hamburger and told her to chew. E7 then gave R2 another piece of hamburger from the edge of the burger and R2 began acting weird - she started coughing and gasping. E7 said that he patted R2 on the back a couple of times and told E8, CNA, to go and get the nurse, E11. E7 said that E11 gently patted R2 on the back and said Can you spit it up? E7 said that R2 did not respond and would not open her mouth. R2 was gasping, coughing and began turning blue. E11 attempted one abdominal thrust while R2 was sitting in her wheelchair. E7 said I think something was stuck in (R2's) airway. E7 said that E11 then wheeled R2 to R2's room with R2 sitting in her wheelchair and E10, CNA, holding R2's feet up. E7 went to get the blood pressure cuff and stethoscope. E7 said four staff members hoisted R2 into her bed and E7 then left R2's room. E7 said that after the event occurred with R2 on [DATE], the Facility inserviced him concerning aspiration. E7 said that he has not been inserviced on what to do if someone is choking and did not know what to do if someone is choking. On [DATE] at 2:05 PM, E10, CNA, said that he has not been given any training by the Facility on what to do if someone is choking. E10 said I don't think that they should have taken (R2) to her room and laid her down. I think they should have started life saving measures in the dining room. On [DATE], at 1:36 PM, E9 stated that he would not attempt CPR on a resident who has a DNR even if they become unresponsive due to choking. On [DATE] at 2:51 PM, E8 said that she had not been trained by the Facility on what to do when someone is choking. E8 said that she could not remember what to do when someone is choking. E8 said that she guessed that you see if there is something in the persons mouth if they are choking. On [DATE] at 1:55 PM, E22, LPN, stated I was not aware until the inservice training I received today that you do the [MEDICATION NAME] Maneuver on someone who is choking and is a DNR, followed by CPR. E18, CNA, stated in an interview on [DATE] at 9:45 AM, that is she saw someone choking Hopefully, help would be there. I would lay them on the ground at that location. E2, Director of Nursing (DON), stated in an interview on [DATE] at 10:00 AM, that Facility nurses receive training on the [MEDICATION NAME] Maneuver and CPR from the American Heart Association. E2 said that the CNA's can obtain training on CPR on the computer, but they are not mandated by the Facility to complete the training. E2 said that CNA's do not receive any hands-on training for the [MEDICATION NAME] Maneuver or CPR. On [DATE] at 1:44 PM, E2 said that during the Facility investigation into R2's death, she did not realize that licensed staff had only performed one abdominal thrust in an attempt to clear R2's airway, however, she was aware that staff did not start CPR. Z1, R2's Physician, was interviewed by telephone on [DATE] at 11:15 AM. Z1 said that R2 had previously had a major stroke and anyone who has had a stroke is at risk for choking. Z1 said that Facility staff should have done the [MEDICATION NAME] Maneuver repeatedly on R2 to clear the obstruction in R2's airway and implemented life saving measures. Z1 said I would have expected a real, repeated effort to clear (R2's) airway. My understanding is that staff did not follow through because (R2) was a DNR, and they should not have stopped. Choking to death is not a good way to die. The Facility policy Emergency Procedure - Cardiopulmonary Resuscitation documents that Preparation for Cardiopulmonary Resuscitation includes obtaining or maintaining American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. The Center for Medicare and Medicaid Services Survey and Certification Letter ,[DATE]-NH, Revised [DATE] documents CPR Certification: Staff must maintain current CPR certification for healthcare providers through a CPR provider whose training includes hands-on practice and in-person skills assessment; online-only certification is not acceptable. Proper technique should be evaluated by an instructor through in-person demonstration of skills. The American Red Cross First Aid Recommendations for Choking document: 1. Have someone call 911. 2. Obtain consent from the victim. 3. Lean the person forward and give 5 back blows with the heel of your hand. 4. Give 5 quick, upward abdominal thrusts. 5. Continue alternating back blows and abdominal thrusts until: the obstructing object is forced out. The person can breathe or cough forcefully on his own or the person becomes unconscious. The American Red Cross documents the following recommendations to follow for the unconscious choking adult: Try 2 rescue breaths. Each rescue breath should last about 1 second. If breaths do not go in, tilt the head farther back. Try 2 rescue breaths again. If the chest does not rise - give 30 chest compressions in about 18 seconds. Look for an object in the airway. Remove if one is seen. Try 2 rescue breaths. Repeat until EMS responders arrive or the obstruction is removed and the patient begins to breathe on his/her own.

Based on interview, observation and record review, the facility failed to provide preventative measures including turning/repositioning and appropriate preventative measures to prevent ulcer from occurring for 4 residents (R3, R4, R6 and R7) of 8 reviewed for pressure ulcer prevention in a sample of 20. This failure resulted in R7 developing an unstageable ulcer on her right bunion area and multiple ulcers under a left leg immobilizer. Findings include: 1. The Minimum Data Set, MDS, dated [DATE] (significant change), R7 has severe cognitive impairment and requires extensive assist for bed mobility and total assistance for transfers. The MDS also identifies R7 to be totally incontinent of bowel and bladder. The Incident/Accident log documents R7 sustained a fractured left femur during care on 4/5/14 and returned from the hospital with an immobilizer on her left leg. The The Braden Skin Risk assessment dated [DATE] identifies R7 as high risk for breakdown. The care plan dated 4/22/14 documents a pressure ulcer suspected deep tissue injury (SDTI) to right medial foot bunion area due to immobility, incontinence and nutritional status. Interventions include: pressure reducing mattress and alternating pressure overlay with heel guard boot (foam boots) at all times except during hygiene, pillows between legs, turn/reposition every 2 hours and as needed, float heels when possible among. Skin reports dated prior to 4/22/14 fail to reflect any pressure ulcers prior to 4/22/14 when the ulcer was first found. Nurses notes dated 4/22/14 at 1527 (3:27pm) identify the area as Dark purple in color with surrounding tissue red, Doctor notified and diagnosed as SDTI. Labs dated 4/23/14 show low [MEDICATION NAME] level but normal protein. The Weekly Pressure Ulcer Report dated 4/24/15 includes R7 and documents that her pressure ulcer at the time it was found measured 1.5cm (centimeters) x 2.5cm and was assessed to be a SDTI at the time. physician's orders [REDACTED]. On the report dated 5/1/14, R7's pressure ulcer measured 1.3cm x 1.2cm but was 100% eschar/necrotic. Treatment remained the same. On 5/8/14, measurements and treatment remained the same. On 5/13/14 during tour of the facility, R7's right bunion area was observed to be black/eschar. R7 had a foam boot on. There were multiple cloth incontinent pads on her bed. R7's bed had an air overlay mattress on that was rolled/bunched up at the foot of the bed that E13,Licensed Practical Nurse (LPN)/Wound Nurse the overlay had to be corrected. On 5/20/14 at 11:45am, R7's wound was again observed with E13, who confirmed that R7 developed the ulcer in the facility. E13 stated she was unsure as to why R7 would develop a pressure ulcer since she wears a foam boot all the time. E13 uncovered R7's foot. R7 had a foam boot on which E13 pulled back. R7's pressure ulcer was stuck to the foam inside the foot and was moist when E13 pulled the skin off the foam. E13 stated the pressure ulcer appeared to getting moist and that she hoped it was just slough off as she was pulling bits of skin off the ulcer. On 5/15/14 at 10am, R7 was laying in bed with a hospital gown on. She was observed to remain in the same position at 11am, 12pm, 12:30pm, 1pm, 1:20pm and a 1:27pm. She was slouched over to her left side and had slid down in the bed as the bed was elevated approximately 30 degrees. At 1:27pm, E12 Certified Nurses Aide brought her lunch tray and and without repositioning her, attempted to feed her lunch. On 5/20/14 at 2:25pm, E13 and E27 did a skin check on R7 and found two new areas of pressure under her left leg immobilizer inner thigh that had a larger deep red cast surrounding the open areas. E13 stated the immobilizer should be checked every shift as the Nurses are putting Sureprep on the bunion area every shift. On 5/21/14 at 1:49pm, E13 stated she did not measure the open areas under the immobilizer because it was a larger red area with several open areas inside it but that she did contact the physician and received a new order. A progress note written by E13 dated 5/20/14 at 2:48pm documents "writer assessed residents skin to L (left) leg under immobilizer. Noted reddened area with scattered denuded tissue where posterior side of immobilizer touches residents skin. E13 documents physician notified and new order received. A copy of the order was provided for "cleanse area to posterior l thigh under immobilizer and apply [MEDICATION NAME] and ABD and BID (twice daily) and PRN (as needed) if ABD and immobilizer and ABD becomes soiled AND every day and evening shift." Review of the care plan dated 4/22/14 fails to include R7's risk of breakdown from the left leg immobilizer and fails to include any interventions specific to pressure ulcers from friction/shearing caused by the constant wear of the immobilizer. The MDS dated [DATE] identifies R3 to require extensive assist of two staff for transfers and bed mobility and is always incontinent of bowel and bladder with no plan in place. The care plan dated 4/28/14 identifies R3 to be at risk for pressure ulcers due to history/immobility and can be noncompliant with turning/repositioning. Interventions include having pressure relieving device on bed and chair, alternating pressure overlay on bed, and follow policies/protocols for pressure ulcer prevention. On initial tour of the building 5/13/14 at 10:10am, R3 was identified by E13, LPN/wound nurse as having just had several ulcers healed on her buttock and coccyx area. On 5/14/14 at 10:50am, R3 was laying in bed and had been incontinent of bladder. E5 and E4 CNAs gathered supplies and donned gloves. R3's bed had three cloth incontinent pads on over the air overlay mattress. R3 was observed to have an open area dire 2. The MDS dated [DATE] identifies R3 to require extensive assist of two staff for transfers and bed mobility and ctly on her coccyx and deep creases across both buttocks and upper thighs. R3 was also noted to have open beefy red stripes inner thighs bilaterally which appeared to be from the plastic briefs. E5 provided poor incontinent care and R3 was transferred to her wheelchair via a mechanical lift after being dressed. E5 stated R3's brief is not taped due to being too tight on her when they do. The facility failed to develop interventions to address R3's non-compliance and/or the irritation caused by the plastic on the incontinent briefs. 3. R6's MDS, dated [DATE], documented severe cognitive impairment and total staff assistance of two plus persons physical assistance with mobility, hygiene and tolieting. R6's Care Plan, initiated 4-7-14, documented R6 was a potential for pressure ulcer development. It was also noted R6 had fragile skin. During observation R6's incontinent care 5-14-14 at 9:05a.m. E8 and E9, Certified Nursing Aides (CNA's), removed two thick bed pads, one of which was soiled with urine, from underneath R6 prior to care and placed two clean thick bed pads underneath R6 after incontinent care. R6's buttocks and upper and lower back observed lightly reddened and creased. Interview of E8 and E9, on 5-14-14 at 9:25a.m., E8 and E9 stated they were done with R6's incontinent care without ensuring his bed pad surfaces were smooth without observed uneven surfaces, raised edges and wrinkles against R6's skin. 4. On 05/13/14 at 9:40 AM, R4 was observed sitting in her wheelchair in her room. At 11:20 AM, R4 was in her wheelchair outside her room waiting for staff to come to transfer her to bed. At 11:45 AM, E14 and E15, CNA's, were observed during transfer and incontinent care for R4. E14 removed R4's incontinent brief and an area of light and dark brown drainage was noted on the brief. A suprapubic catheter was observed on the right mid abdomen with dressing intact, as well as a [MEDICAL CONDITION] bag was observed on the left lower abdomen intact. When R4 was rolled to the left side, light brown drainage was observed oozing out of her rectum, as well as R4's buttocks and lower back were reddened and heavily creased. R4 stated the oozing drainage is not new, but it had gotten much worse. There was an open area observed in between the buttocks in the crease 1 1/2 inches long. The open area was observed to have macerated edges with dark red center. There was no dressing on the open area. There was an open area on the mid back observed without a dressing. E14 was observed to perform incontinent care and noted that R4 was also having her menstrual cycle. There were two open areas in the folds of the inner thighs near the perineal area that were deeply reddened. The dressing to the left side was off the open area and the right side was intact. Both were soiled with red, brown drainage. E16, LPN stated to put the dressing back on the left side and leave both in place. R4 stated that she was supposed to have the dressings changed before lunch. E16 stated she would be doing the dressing changes after lunch. R4 was left lying on an incontinent pad without any dressings on the coccyx or mid back areas. R4 stated she can turn herself from side to side, but cannot remain on that side without assistance. She also stated that she does not get turned and repositioned on a routine basis, especially at night. On 05/13/14 at 2:00 PM, E16, LPN was observed during dressing changes for R4. E16 was observed to cleanse the slit-like openings in the inner thighs near the perineal area with wound wash and wiped with a dry 4 x 4 dressing then applied a silver [MEDICATION NAME] strip into the creases. No taping. R4 stated that both sides were very painful when touched. E16 was observed to do the treatments for the mid back by cleansing with wound wash and dry with 4 x 4 dressing and apply skin prep to the surrounding tissue and apply an [MEDICATION NAME] dressing. Then E16 was observed to use wound wash on the coccyx and dry with a 4 x 4 dressing, then apply an [MEDICATION NAME] dressing and apply A & D ointment on the surrounding skin. The Physician order [REDACTED]. The MDS, dated [DATE], documented R4 was alert and oriented with no cognitive impairment requiring total assistance of at least two staff for transfers; extensive assistance of at least two staff for bed mobility and toilet use; and extensive assistance of at least one staff for dressing, hygiene and bathing. The Care Plan, dated 02/28/14, documented limitations in bilateral shoulders and required assistance with Activities of Daily Living (ADL's). There was nothing on the Care Plan presented on 05/15/14 that identified pressure ulcers. On 05/13/14, The Braden Score for Pressure Ulcer Development was 14, moderate risk. The Braden Score for 04/29/14 was 12, high risk. A written statement from E16, LPN, dated 05/19/14, documented that E16 did not do the dressing changes at the time of the incontinent care on 05/13/14, due to it being shower day for R4. However, on 05/20/14, R4 stated her shower days are Wednesdays and Saturdays. R4 stated she did not receive a shower on the 05/13/14. 5. According to the facility policy entitled "Pressure Ulcer Prevention and Healing Program", the facility is to utilize a program focused on assessment,, planning, implementation, evaluation, and reassessment. Under Implementation, the policy indicates that staff will consider the risk and skin condition and interventions may include bathing, skin care, incontinence care, positioning, mobility and transfer, pressure, friction and shear reduction, nutrition and hydration approaches and restorative/rehab. Manufacturers recommendations for the mattress air overlay includes a statement regarding using appropriate linens which the company sent an email clarifying dated 5/16/14 stating "anything that fits the combined height of the mattress plus the overlay would be considered an appropriate linen." A further email clarification dated 5/16/14 at 3:39pm directly written toward the use of multiple cloth pads over the air overlay documents information received back from the manufacturing team - "Due to the alternating pressure feature of the overlay, some devices and products may not be appropriate for use with this device" and "adding multiple incontinence pads will reduce the alternating pressure efficacy, but it will not completely eliminate it."

Based on record review and interview, the facility failed to implement safety measures to prevent falls for 1 of 3 residents (R3) reviewed for falls. This failure resulted in R3 falling while he was left unsupervised on the toilet and sustaining a C1 fracture of the vertebrae on [DATE]. R3 expired on [DATE]. The findings include: On [DATE], according to the "Occurrence Report" dated [DATE], R3 was found laying on the bathroom floor. An abrasion was found on his left forehead and R3 was complaining of his head and neck hurting. The report documented there were no witnesses to the fall. R3's cognition was documented as "confused" before and after the incident. The report documented R3 hit his head on the sink causing the abrasion to his forehead when he attempted to transfer himself and fell . "Occurrence Report" dated [DATE] and [DATE] documented R3 had fallen when he attempted to stand or transfer from the wheelchair. The report documented as a "recommendation" for R3 "resident will not be left unattended in the bathroom". The nurses notes dated [DATE] at 11:40 AM documented "res (resident) got self off stool and fell hitting crown of head on sink. abrasion to left forehead from res hat". The next note at 13:05 PM documented "res in severe pain from crown of head all the way down back of neck". The physician was notified and ordered R3 sent to the hospital. The communication nurses note dated [DATE] at 13:31 PM documented "res did not use call light asking for assistance before getting up Background: res has hx (history) of doing this". At 17:06 PM the nurses notes documented "Res transferred to (large hospital) for "burst fracture of C1 vertebrae". E5, Certified Nurse Aide (CNA), stated in an interview on [DATE] at 10:20 AM that she had put R3 on the toilet and left to go to the linen cart. E5 stated on the way back there were 2 call lights on that she answered on the way back to help R3. E5 stated when she got back to R3's room he had tried to get up and was on the floor. E5 stated she had never left R3 in the bathroom for any period of time before and R3 was a one person assist for transfers. E5 stated R3 had fallen before and he did not have any alarms on his bed or wheelchair. E6, CNA, stated in an interview on [DATE] at 11:05 AM that R3's balance was "sometimes not all that great". E6 stated R3 was known to stand up on his own and the policy is if anyone needs assistance they are suppose to stay with them. E6 stated R3 had fallen before. E4, Licensed Practical Nurse, stated in an interview on [DATE] at 10:40 AM that R3 should be supervised if he was a high fall risk and because he needed assistance she would think he was a high fall risk. E2, Director of Nursing, stated in an interview on [DATE] at 10:50 AM that R3 had fallen before and was a 1 assist for toileting. E2 stated when asked if R3 should have been left alone on the toilet "no, well for short periods". E2 stated R3 did not have any alarms on his bed or wheelchair. The "Resident Fall Risk Assessment" dated [DATE] and [DATE] documented R3 was a "36" or a "High Risk" for falls. The assessment documented R3 had indicators of "unaware of physical limitations", "CVA (cerebral vascular accident)", "falls in past 90 days", "reduced vision", "impaired standing or sitting balance" were identified. The Minimum Data Set ((MDS) dated [DATE] documented R3 diagnoses, in part, as history of falls, senile dementia, and muscle weakness. The MDS assessed R3 as "Moderately Impaired" for cognition. R3 was assessed as "extensive assistance" with "Two+persons physical assist" for "transfer" and "toilet use". R3's "balance during transitions and walking" was assessed as "not steady, only able to stabilize with staff assistance" for "moving on and off toilet" and "moving from seated to standing position". The Care Plan dated [DATE] documented R3 "is high risk for falls r/t (related to) Unaware of safety needs". The Care Plan documented "The resident uses...electronic alarm. Ensure the device is in place as needed" and with the call light "The resident needs prompt response to all requests for assistance". The Hospital "History-Physical" dated [DATE] documented R3 had fallen and hit his head on the sink. The "Diagnosis/Treatment" was "C-spine Fracture and Head contusion/abrasion from ground level fall, neurologically intact". R3 was admitted to the hospital. On [DATE] a "Video swallow study" was conducted due to "Dysphasia following C1 fracture". "Honey" and "nectar" consistencies caused "frank aspiration without cough". The report documented, "Fruit, thin liquids and crackers were not administered secondary to aspiration noted with the administered materials." According to the facility nurses notes dated [DATE] documented R3 was readmitted to the facility with a cervical collar. On [DATE] at 1:53 AM the nurses notes documented R3 was having difficulty swallowing saliva and his lungs had "expiratory rubs". The nurses notes on [DATE] at 14:50 PM documented R3 was admitted to hospice care with respiratory distress. The note documented R3's oxygen level was 85% with 5 liters of oxygen with a mask due to mouth breathing. The note documented R3 lungs were very congested and R3 was "shaky and very anxious at this time". The nurses notes documented R3 was unable to swallow his medication. R3 expired on [DATE] at 4:10 AM.

Based on record review and interview the facility failed to ensure staff use a gait belt when ambulating residents to prevent falls and injuries for 1 of 7 residents ( R9 ) reviewed for falls/injuries in a sample of 21. This failure resulted in R9 obtaining a fractured patella. The findings include: 1. Documentation of R9's current [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R9 required extensive assistance with transfers, was unable to maintain balance without assistance, and was incontinent of bowel and bladder frequently. R9's Plan of Care documents that he is at high risk for falls, with the intervention listed; "transfers with assist of staff gait belt and walker/wheelchair." Nurses Notes dated 1/29/11, 11:30 AM document, "Resident confused per usual. CNA (certified Nurses Aid) reports that resident was incontinent of BM (bowel movement) so she assisted him into room (another resident's room) d/t (due to) the floor in his room was wet and resident was up ambulating with his walker." The facility's Disciplinary Action Form dated 1/29/11, documents that E15 CNA, "did not have a gait belt on resident on 1/29/11 and the resident fell ." An x-ray of the knee dated 1/29/11 documents, "nondisplaced fracture right patella." The facility policy, revised 3/1/01 and titled; Ambulation Belt (Transfer of Gait Belt) documents, "Use ambulation belt during ambulation, transfer or movement of residents." On 9/22/11 at 12 noon E2 Director of Nurses, (DON), stated, I wrote that CNA up the same day for safety violations, she did not have a gait belt on the resident. There was a second incident after that and E15 was terminated.

Based on interviews, observations and record review, the facility failed to ensure that 1 (R2) of 3 sampled residents received adequate, consistent monitoring and treatment for [REDACTED]. This failure resulted in R2's abscess worsening and developing [MEDICAL CONDITION] requiring hospitalization and intravenous antibiotics via a central line. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] identifies R2 as an [AGE] year old male who had no memory or cognitive impairment but requires extensive assist of 1-2 staff for most activities of daily living. The MDS identified pain which limited his day to day activities. R2 described the pain as a "3" or severe with frequency cited as the past 3-4 days. R2 is able to verbalize pain. According to the physician's orders [REDACTED].> 101. The Medication Administration Record (MAR) also reflected a directive to "assess and observe for signs and symptoms of pain at least every shift" with initials present for shifts 6-2, 2-10 and 10-6 from December 1st through December 11th, 2010. The nurses notes written on 12/6/10 at 1900 (7pm) state "Called to shower room per CNA (Certified Nurses Aide) - Noted 3 x 3 cm (centimeter) in diameter hard raised red area to Rt (right) chest just under Rt breast area has tiny scab ? to center - area very tender to touch - called Dr..." The on-call physician told the nurses to call Z3's office in the morning and gave no orders at the time. The nurses notes reflected no further documentation regarding the abscess or pain medication given for the tenderness until 12/7/10 at 1120am. The note then stated "abscess on stomach very red, tender." At 1345 (1:45pm), Z3 called back with an order for [REDACTED]. The Bactrim was started at 5pm on 12/7/10 according to the MAR for December 2010. Nurses notes written at 6pm state "area to Rt upper quad (quadrant) conts (continues) red swollen - firm/hard to touch very tender to to touch - no drainage - po (by mouth) ABT (antibiotic) started." Vitals were 168/80, temperature 97.5, pulse 60 and respirations 22. The MAR shows no pain medication given and the assessment section for all three shifts have only initials present. On 12/8/10 at 9am, the nurse documented "ABT cont for abscess to R chest area remain red, firm and tender to touch" with no reaction to the antibiotics but doesn't include any reference to R2's response to the Bactrim and the wound. At 6pm on 12/8/10, the nurses wrote "abscess cont. no drainage noted." On 12/9/10 at 3:30am, the nurses notes state "ABT for abscess R chest continue" and "area very tender." At 9pm on 12/9/10, the nurses notes state "area remains red et (and) tender." but again includes no information that would suggest they were monitoring R2's wound for positive response to the Bactrim. On 12/10/10 at 11:45am, the nurses notes state "Area remains red swollen an tender to touch will continue to monitor." There is no indication that the nurses identified if the area was improving with the antibiotic or not. Four and a half hours later at 4pm, the nurses notes state "RUQ (right upper quadrant) worse - hardness extends in diameter @ 6 x 6 cm - redness extend to side + mid abd - have called MD to report change - awaiting return call - warm cloth laid on area to promote drainage c no results - area very tender." R2's daughter was informed. At 9pm, the nurses notes indicate R2's physician, Z3, had not returned a call and he was put on a call list for the morning. On 12/11/10 at 5am, the nurses notes state warm compresses were applied thought the night but that the area around the abscess remains hard and that the center is "to a head." At 9am, the physician was called again with a report that the area was not improving. Orders were received to send to the hospital with the nurses notes noting that R2 requested to go to the hospital.. Review of the MAR shows no pain medication was given from 12/6/10 through to discharge to the emergency roiagnom on [DATE] for pain and discomfort from the abscess. The Hospital history and physical examination [REDACTED]. The [DIAGNOSES REDACTED]." Measurements taken in the emergency room describe the surrounding red area as approximately 14 centimeters in length with a red raised bump in the middle that was open and draining yellow exudate on small to moderate amount. R2 had a central line placed and IV [MEDICATION NAME] was given. The facility policy entitled "Wound Assessment" state each wound will be assessed weekly or with any significant change noted. The wound must be evaluated including the following factors - size - specifying length, width, depth, tunneling/undermining, drainage indicating amount, color and consistency, pain or tenderness which may be indicators of underlying tissue destruction, peri wound condition and odor. The facility pain policy indicates a 1-10 pain scale will be used or non-verbal communications of pain will be identified. The nurses used neither of these tools and although documented tenderness at the site, failed to identify it as pain and treat it. On 12/21/10 at 2:30pm, E2, Director of Nursing stated she had reviewed the nurses notes and found no reference to pain management or that the nurses identified the wound as not responding to the Bactrim. E2 acknowledged that no pain medication was given according to the MAR and agreed the nurses should use the pain scale when assessing for pain. E2 had no further documentation to provide in refutation to these concerns. Upon returning from the hospital on [DATE], R2 was care planned for pain with interventions indicating staff were to monitor medication effects, administer routine pain meds and PRN as is routine is not maintaining comfort, anticipate and treat pain before treatments, determine intensity, character, location, duration and precipitating and relieving factors of his pain among others. This was not evident according to the MAR for pain assessment that simply had initials in the slot of 6-2 shift on 12/21/10. On 12/21/10 at 11:37am, R2 was taken to his room. He was still connected to the intravenous fluid and had a central line noted in the right side of his neck. He remained in his wheelchair at bedside and complained on his legs hurting. The nurse, E3, Registered Nurse, did not ask about the severity of the pain although R2 stated it was leg pain. E3 passed the complaint on to his floor nurse. At 11:55am, R2 was given two Tylenol tabs but no scale was utilized at the time according to the MAR or nurses notes. At 12:45pm, E4 and E5, CNAs, transferred R2 to bed via a mechanical lift. Both CNA's stated leg pain is not usual for R2 but did state that he complained of a lot of pain with his side before he went to the hospital.