Every finding on record at Integrity HC of Anna

Based on observation, interview, and record review, the facility failed to ensure meals were served at regularly scheduled times in accordance with resident needs/preferences. This has the potential to affect all 64 residents residing in the facility. On 7/23/2026 at 8:50AM, R9 was asked how her meals are and R9 stated well they are late sometimes and supper is usually always late. R9 said it has been as late at 8:00PM when she has gotten a supper tray. On 7/23/2026 at 8:56AM, R10 stated she usually eats her meals in the dining room. R10 stated if she eats on the halls then the meals are always late. On 7/24/2026 at 5:40PM, the supper meal was observed, and the first tray was served out at 5:45PM. On 7/24/2026 at 5:45PM, the mealtimes were observed posted in the Dining Room and documented that Breakfast is at 7:30AM, Lunch is at 12:00PM and Dinner is at 5:30PM. On 7/24/2026 at 7:00PM, R3 and R4 were in their shared room and received their supper trays. R3 and R4 received their trays which included bologna sandwiches and soup. R4 took a bite of the soup and said, I don't like this. R4 was asked if he wanted something else to eat and R4 stated no I will just eat it because it is already too late to eat supper and I am hungry. R3 was asked if he was satisfied with his meal and R3 stated I am going to eat it because I want something to eat now. On 7/24/2026 at 7:10PM, R10 received her supper tray. R10 refused her tray and stated, I am not hungry now, so I don't want it. R10 told staff to take the tray back out of her room so staff did as R10 requested. R10's was the last tray to be served for this meal. On 7/24/2026 at 7:15PM, V1 (Administrator) was asked if she could explain why the supper meal was so late as it had been 1 hour and 40 minutes since they were supposed to receive the meal. V1 stated it has been an ongoing issue, she knows it is not acceptable, but they need to get people replaced in the kitchen to solve the problem. On 7/28/2026 at 8:15AM, this surveyor entered the facility and observedbreakfast being served. On 7/28/2026 at 8:55AM, R2 was in her room sitting on the side of her bed beginning to eat breakfast. R2 stated I just got my food and I am hungry. R2 was asked if she normally eats breakfast about this time of morning and R2 stated it is always late, but I am sure glad to get it because I am hungry in the mornings. On 7/28/2026 at 9:00AM, R3 and R4 received their breakfast trays in their shared room. R3 stated our meals are always late. R3 stated we eat it when we get it but sometimes it is just too late at night to eat. On 7/28/2026 at 9:05 AM, V14 (Licensed Practical Nurse/LPN) stated meals are late on certain days, it just depends on the day. On 7/28/2026 at 9:10AM, the last breakfast tray was observed being served to R9. On 7/28/2028 at 9:20AM, R9 stated I just got my breakfast a few minutes ago, but this is normal and it is not unusual for supper to be late, and I mean getting supper at 8:00PM at night. On 7/28/2026 at 11:13 AM, V16 (Cook) stated the reason breakfast was so late this morning is because the night shift from yesterday did not clean up and do dishes so we had to do that before we could start cooking. V16 stated supper is late very often and that is due to staffing. V16 stated she is working over today, and supper will be on time for sure tonight. On 7/28/2026 at 11:20AM, V17 (Dietary Aide/Cook) stated meals are late, especially at supper. V17 stated we are working on getting staff, we are short on cooks, aides, and a manager. V17 stated I have worked here for many years, and this is the worse I have ever seen this kitchen. On 7/28/2026 at 11:30AM, V1 (Administrator) stated I just hired a part time person for the kitchen and I have recently hired a few other kitchen staff, so we are trying to get good staff to get all of this straightened out. On 7/28/2026 at 11:33AM, V11 (CNA) stated the meals are not always late but it has become more often lately. V11 stated she thinks breakfast was late this morning due to meal cards not being ready on time. V11 stated the residents do complain when the meals are late and they are on their call lights asking where their trays are. On 7/28/2026 at 11:36AM, V9 (CNA) stated late meals are kind of a pattern and depend on who is working in the kitchen. The residents do complain about their meals being served late. The Facility's Midnight Census Report dated 7/22/26 documents 64 residents residing in the facility.

Based on interview and record review, the facility failed to provide the resident and resident representative written notification of transfer and Bed-Hold Policy information at the time of transfer or as soon as practicable for 1 (R1) out of 3 residents reviewed for discharge process in the sample of 13. Findings Include:R1's admission Record documented an admission date of [DATE], a discharge date of [DATE], and included diagnoses of generalized anxiety disorder, hypothyroidism, hyperlipidemia, depression, lack of coordination, muscle weakness, and schizophrenia. R1's admission Record documents R1 as Responsible Party but also lists V4 (Office of State Guardian/OSG Representative) as R1's Guardian. R1's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R1's cognition is intact. R1's Progress Note dated [DATE] at 4:19 PM documents R1 became agitated over not calling her OSG rep. (V4) from OSG does not want resident to call more than two times per day and R1 had already called several times and became extremely agitated, began calling staff racial slurs, telling staff she hoped that their baby died and continued to curse in hall, Sheriff's department was notified and arrived at building at approximately 1640 (4:40 PM) and took resident to ER (emergency room) for psych eval. R1's Progress Note dated [DATE] at 4:43 PM documents V4 (OSG Representative) attempted to be notified of R1 going to ER for eval related to behaviors. No answer received and message left. R1's Progress Note dated [DATE] at 12:46 AM documents RN (Registered Nurse) from the local hospital ER notified the facility that R1 would be transferring to an in-state behavioral health/psychiatric hospital (located approximately 5 hours away) on this date and is awaiting transport at this time and will notify facility when transport arrives. R1's Progress Note dated [DATE] at 7:00 AM documents R1 was being transferred to the in-state psychiatric hospital (approximately 5 hours away) and that Admin (Administrator/V1), DON (Director of Nursing/V2) and PCP (Primary Care Physician) were notified. R1's Progress Note dated [DATE] at 11:26 AM authored by V5 (Social Services Director/SSD) documented V5 spoke to V4 to see how R1 was doing and if she was coming back to the facility. V4 stated that R1 has nowhere else to go, so she will be coming back here until she can find R1 housing. V4 will call back if anything changes. R1's Progress Notes from [DATE] - [DATE] all document R1 being out of the facility at the psychiatric hospital. R1's Progresss Note dated [DATE] at 11:31 AM documented V5 called the psychiatric hospital to make sure they received the bedhold policy. CM (Case Manager) said that she will call back if they haven't received it. R1's Progress Notes nor her medical record show any evidence of R1 or V4 being provided with a written notice of transfer specifying the reason for transfer, the effective date of transfer, the location to which R1 was transferred, a statement of the resident's appeal rights, the name, address and telephone number of the Office of the State Long-Term Care Ombudsman nor the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act as required. R1's Progress Notes nor medical record show any evidence that written information was provided to R1 or V4 before transfer to the hospital which included information regarding the facility's bed hold policy. On [DATE] at 12:16PM, V4 (OSG Representative) stated she is the court ordered guardian for R1. V4 stated she received a voicemail the evening that R1 was sent out to the local emergency room on [DATE]. V4 stated she also received a call from the emergency room that R1 was being transferred to an outside behavioral/psychiatric hospital. V4 stated she had not received any other calls from anyone regarding R1 until she received a call from the case manager at the psychiatric hospital on [DATE], informing her that R1 was ready for discharge but when the case manager called this facility, he was told they would not take R1back and R1's bed hold was expired. V4 stated she called the facility on [DATE] and V1 (Administrator) and V3 (Business Office Manager/BOM) were not available so V4 had to leave a message for someone to call her back. V4 stated on [DATE], V1 called her back and stated that R1's bed hold was up and the facility had taken another admission so there were no beds available for R1, and she could be put on a waiting list. V4 stated she was not aware of the 10-day behold and she never received an explanation of anything. V4 stated she did not receive a call from the facility informing her that R1's time was getting close to losing her bed or anything. V4 stated she hadn't received a copy of the Bed Hold Policy until it was emailed to her by V5 on [DATE]. This was 11 days after R1's transfer so the bed hold was already expired and there was no way to appeal or to even have the opportunity to talk with the hospital to get R1 back to the facility before the 10 days were up. V4 stated R1 is still in the psychiatric hospital with no place to discharge to. V4 verified she received no written information from the facility until [DATE]. On [DATE] at 4:00PM, V2 (Director of Nursing/DON) stated she was at work the evening of [DATE] when R1 was taken to the hospital by police. V2 stated she was unsure if R1 was given the bed hold policy. V2 stated she believed it was sent with the other papers that were given to the police like her orders, POLST (Practitioner Orders for Life-Sustaining Treatment) form, and things like that. V2 said there were so many people trying to gather papers that she is not sure what all was sent with the police. V2 stated the reason the police were involved was because R1 was agitated and making threatening statements to others. V5 stated they could not get R1 calmed down so they called the police and the police took R1 to the hospital. On [DATE] at 4:20PM, V20 (Licensed Practical Nurse/LPN) stated she remembers the night R1 was taken out by the police, but she does not remember who prepared the paperwork that was sent with the police. V20 was asked when she sends someone out to the hospital, does she explain and give the bed hold policy to the resident or the resident representative and V20 stated no, she just puts the policy in the packet with everything else and gives it all to the people taking the resident out so they can give it all to the hospital. V20 stated that she doesn't ever remember receiving training on the bed hold policy. V20 was asked if she calls the POA or resident representative to notify them of transfer, does she at that time inform them of the bed hold policy and V20 stated no I don't tell them about the bed hold policy. On [DATE] at 9:15AM, V14 (Licensed Practical Nurse/LPN) was asked if she sends the Bed Hold Policy with residents and explain the policy when she sends residents out to the emergency room and V14 stated I just put it with all of the other papers and give it all to the ambulance crew. V14 was asked if she explains the bed hold to resident representatives when she calls to notify them of a resident transfer and V14 stated no I do not talk about the bed hold. On [DATE] at 2:00PM, V8 (Registered Nurse/RN) was asked what she sends with residents when they are transferred out to the hospital and V8 stated she sends face sheets, POLST forms, Physician Orders and the bed hold policy. V8 was asked if she explained the bed hold policy when providing it and V8 stated no, she just puts it in the yellow envelope with all the other papers. V8 was asked if she ever called the Power of Attorney or OSG representative to explain the bed hold policy when a resident goes out to the hospital and V8 stated usually not. An email from V5 (SSD) to V4 (OSG Representative) dated [DATE] at 11:52 AM with a subject line of BED HOLD POLICY documents Good morning, I'm sending the bed hold policy to you. Not sure it wasn't sent when (R1) went to the hospital. Was just making sure you receive a copy. The facility policy titled Bed Hold Policy Notification with review date of [DATE] documents This Bed Hold Policy will be given to you at the time of admission, and a copy will be given to you each time you are transferred from the facility. Under normal circumstances, if you leave the facility for a hospitalization, you will be readmitted to the first available bed in a semi-private room. Under certain conditions, we can hold your existing bed for you at your request, so when you return to the facility, you will have the same bed and room as before. Neither Medicare nor Medicaid will pay to hold your same bed if you are hospitalized . If you are a private pay, Medicare or Medicaid resident, we will hold your same bed and room for you as long as you wish, at a charge to you of 100% of the normal daily rate. If your care is being paid for by the Veteran's Administration, we will hold your bed for the 48 hours unless prior approval for a longer period has been received form the VA that initiated your contract. The Nursing Home Care Act required a nursing facility to hold a bed for a maximum of 10 days when you are hospitalized . The facility must hold a bed (not necessarily your specific bed) for up to 10 days during a hospitalization. On the 11th day there is no requirement to hold a bed, but you are still a resident and will receive the next available bed when you are ready to return, even if there is a waiting list. There is no requirement under the Nursing Home Care Act to hold a bed for 10 days during a therapeutic home visit. However, you are still considered a resident and will be given the next available bed when you are ready to return, even if there is a waiting list. The facility Bed Hold Policy does not document who is responsible for providing written notifications to residents' responsible parties, Power of Attorneys, or Guardian representatives, nor does it include a time frame for when the written notices should be provided to them.

Based on observation, interview, and record review, the facility failed to ensure care and services were provided to ensure a resident's highest level of practicable functioning for 1 (R4) of 3 residents reviewed for quality of care in a sample of 20. This failure resulted in R4 not receiving timely follow-up and treatment of known suspicious masses which have since metastasized. This failure resulted in Immediate Jeopardy, which was identified to have begun on 1/30/26 when the facility failed to follow through with referrals to an outside provider. V1 (Administrator), V3 (Senior Regional Administrator), and V7 (Regional Director of Clinical Services) were notified of the immediate jeopardy on 4/9/26 at 11:25 AM. The immediacy was removed on 4/9/26, but non-compliance remained at a Level Two because time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: R4's admission Record documented an admission date of 8/12/25 and included diagnoses of chronic obstructive pulmonary disease, type 2 diabetes, abnormal findings on diagnostic imaging of lung, muscle weakness, unsteadiness on feet, other fatigue, and bilateral hearing loss. R4's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. R4's Care Plan documents R4 is at risk for falls related to deconditioning, gait/balance problems, and vision/hearing problems. On 3/19/26 at 9:29 AM, R4 stated he has constant pain in his back, chest, and left arm/shoulder. R4 stated he was told he had cancer that was spreading and that is why he is having pain. R4 stated he keeps being told they are trying to get him an appointment for his cancer, but he still hasn't been to the doctor. R4 stated he isn't sure if they are even doing anything to help him. R4 stated he wants to get treatment for his cancer. R4's Progress Note dated 1/12/26 at 12:33 PM created by V6 (Assistant Director of Nursing/ADON) documented (V28, Nurse Practitioner) in facility to see res (resident). Res has c/o (complaints of) abd (abdominal) discomfort this AM that has somewhat subsided, last bm (bowel movement) yesterday that was large et (and) not hard per res. n.o. (new order) rec'd (received) for gas-x/simethicone tabs q4 prn (every 4 hours, as needed) for gas/bloating. R4's Progress Note dated 1/15/26 at 12:52 AM created by V6 documented Rec'd n.o. per (V28) to obtain cbc (complete blood count), cmp (comprehensive metabolic panel), lipase, thyroid panel, vit (vitamin) d, b12, lipid panel. CT (Computed Tomography, diagnostic imaging procedure) of abd/ pelvis with contrast. R4's Progress Note dated 1/22/26 at 11:04 AM created by V6 documented CT of abd scheduled for 1/28 at 0715 (7:15 AM). res to be npo (nothing by mouth) 4 hrs (hours) prior. to appt. res notified R4's CT Abdomen Pelvis results from local hospital dated 1/28/26 documented under Impression: nodular opacity in the right lower lobe with involvement and expansion of the right seventh rib. Findings suspicious for primary lung neoplasm with invasion. Tissue sampling and pulmonary consultation advised. Left hepatic lesions suspicious for metastatic disease. Enlarging bilateral adrenal nodules measuring up to 3.6 cm (centimeters) on the right and 4.1 cm on the left. Findings are suspicious for metastatic disease. Mild height loss of T11 vertebral body, new from prior with possible lucent lesion. Acute fracture is not excluded. R4's Progress Note dated 1/29/26 at 2:20 PM created by V4 (License Practical Nurse/LPN) documented Resident started complaining of left shoulder pain and states he doesn't know when it started but he can't lift his left arm up without pain being resulted. Resident states it doesn't hurt when you touch it, only when he goes to lift his arm up. (V19/Physician) notified and asked to obtain x-ray. R4's Progress Note dated 1/30/26 at 1:14 PM created by V4 documented X-ray results received and sent to (V19, Physician). (V19) orders oncology referral. Oncology referral faxed to (oncology facility) d/t (due to) abnormal CT of the abdomen and x-ray of left shoulder. (phone number). R4's Radiology Results Report dated 1/30/26 documents under Procedure: Left Shoulder, complete, 2+ views, under Clinical Information: new onset pain and limited range of motion, and under Impressions: 1. Lytic humeral mass (area of destroyed bone tissue) 2. No acute fracture or dislocation. R4's Order Summary Report documents an order dated 1/30/26 for an oncology referral due to an abnormal CT of the abdomen and an abnormal x-ray of left shoulder. R4's Progress Note dated 1/30/26 at 1:58 PM created by V4 documented Referral, face-sheet, med orders, x-ray report, and CT report all faxed. R4's Progress Note dated 2/3/26 at 11:21 PM created by V21 (Registered Nurse/RN) documented Resident alert & Oriented x (times) 4. Able to make needs known. Resident Deaf, but communicates reading lips. Speech clear. Meds (medications) taken whole. Up ad lib (freely). Steady gate, but experiencing weakness r/t (related to) to dx (diagnosis) of Cancer. set up assist with meals and showers. feeds self. Independent with ADLS (activities of daily living). Cont (continent) to B&B (bowel and bladder). room air. NCS (no concentrated sweets diet), regular texture, thin liquid diet. Blood sugar and insulin provided per orders. Continues on OT (Occupational Therapy). HOB (head of bed) elevated r/t COPD (Chronic Obstructive Pulmonary Disease). Afebrile 97.6. VS (vital signs) wnl (within normal limits). C/o (complaints of) pain to Abd and BUE (bilateral upper extremities), PRN (as needed) Tylenol provided per orders. Resident referred to Oncology. Resident continues on Mucinex 400mg TID (three times a day) x 1 week, Duonebs Q6h (every 6 hours) x 1week, and Prednisone 40mg daily x 5Days. Tolerated all well. No ADR (adverse drug reaction). Afebrile. Resp even and unlabored. Fluids offered and encouraged. Resident does not seem to grasp the severity that he has Cancer that has spread that is making him feel not good. Resident states what are you guys even doing for me what are you doing for my cough and shoulder Resident was started on the meds listed above and also given Tylenol to help manage pain. Resident has a care plan meeting 2/4 to discuss care. Resident reminded that he has been referred to Oncology in relation to his Cancer spreading. Call light within reach. plan of care to continue. R4's Progress Note dated 2/4/26 at 3:18 PM created by V31 (Former Director of Nursing) documented Spoke with (Oncology clinic) for an update on referral sent last week. They stated that they did not receive a referral. I did obtain a direct fax number for their referral dept. (department) (phone number). Face sheet, CT results, and x-ray results were faxed to medical oncology as well as radiation oncology. (V27, Family Member/Power of Attorney/POA) still in facility from earlier care plan meeting and aware of referral faxed. R4's Progress Note dated 2/5/26 at 8:46 AM, created by V8 (Social Services) documented (R4) stated to me while I was doing his MDS, that he feels down because he's not feeling good and that his health is failing. He also don't have the energy like he did before when he got here. He still wants to do activity and move around. The facility's fall incidents report documents R4 had three falls on 2/19/26, 2/21/26 and 2/22/26. R4's Progress Note dated 2/19/26 at 3:37 AM, created by V32 (LPN) documented immediate full body assessment rom (range of motion) as before moves both legs no rotation or shortening. is very weak in left arm cannot grip or raise arm. explained to resident that if he wants to get up from bed or chair to use his call light if he feels he can not get up on own aknowledged [sic] his understanding and took the call light. v/s (vital signs) 97.7-86-18-145/77-02 sat (saturation) 97% on room air room was free of clutter floor was dry bed was in low position. Dr. (doctor) notified of above at 7am DON (Director of Nursing) notified of above POA (V27) notified of above 710am. R4's Progress Note dated 2/21/26 at 2:51 PM created by V1 (Administrator) documented resident noted on floor in room by housekeeping staff, nurse alerted and assessment completed, VS 97.3, 69, 22, 162/68, 92%, resident already has c/o pain in L (left) arm, monitored by nurses for pain r/t (related to) dx (diagnosis) RCA (root cause analysis)- lost balance when self transferring. Immediate intervention- educate resident to use call light and ask for assist R4's Progress Note dated 2/22/26 at 1:50 PM created by V4 documented This nurse was responded to a resident yelling ah help! to resident's room. Upon immediate observation, resident was observed laying on his back in-front of his room mate's dresser. Resident questioned on what happened and how he fell and resident stated I don't know, I just got weak. Baseline is alert and orientated x4 and aware of placement at facility. Resident stood back up off the floor via 1x assist. Neurological exam performed and within normal limits. V/S: 98.1, 70 pulse, 20 respiration, 126/71. Resident denies any new pain. Head to toe assessment completed with no new injuries. ROM x4 without new pain. Resident unable to move resident's left arm d/t last x ray obtained. No deformity or shortening to extremities. (V19/Physician) to be notified. R4's Progress Note dated 2/23/26 at 9:45 AM created by V4 documented (V28/Nurse Practitioner) in facility and this nurse requested her to see resident d/t fast decline and increased weakness. (V28) ordered a CBC, CMP, a repeat x-ray to left shoulder and bicep, and to wear a sling to left arm at all times d/t resident no longer wanting to move that arm. (V27/Power of Attorney/Family Member) notified via phone call. R4's Radiology Results Report with examination date of 2/23/26 documents under Procedure: Left humerus 2+ views, under Clinical Information: Pain, and under Impressions: Large focal lucency of the proximal left humerus suspicious for metastatic disease, now with pathologic fracture of the humeral diaphysis proximally. Under Procedure: Left Shoulder complete 2+ views and under Impression: Known pathologic proximal humeral fracture associated with prominent mass is not identified on this extremely limited examination, pathologic fracture of the left 6th rib with focal lucency. On 3/19/26 at 9:40 AM, V18 (Director of Rehab) stated they have been working with R4 with pain management, positioning, and strengthening. V18 stated R4 is in a lot of pain due to his cancer diagnosis. V18 stated she isn't aware of R4 having any falls or having a fracture in his arm. R4's Progress Note dated 2/23/26 at 10:53 AM created by V4 documented Contacted (Oncology facility) and spoke to (name of oncology facility staff) and voiced they didn't receive referral until yesterday evening despite several confirmations on our end. (name) states she did receive the one that this nurse faxed over yesterday evening and will work on them in the order they received them. No ETA (estimated time of arrival) able to be given. (V27) notified and thankful to this nurse. R4's Progress Note dated 2/25/26 at 11:48 AM created by V6 documented (Orthopedic clinic) called et (and) spoke c (with) (name of Orthopedic clinic staff) to make appt (appointment) r/t humerus. (Name of orthopedic clinic staff) asked to have (x-ray company) send images over and to fax x-ray results. stated she will have to call on call dr (doctor) to decide on appt date. call back name et number given at this time. R4's Progress Note dated 2/25/26 at 12:22 PM created by V6 documented spoke c (oncology clinic). stated they didn't see res referral that was faxed et confirmation paper rec'd (received). referral refaxed to (phone number). R4's Progress Note dated 2/27/26 at 1:20 PM created by V6 documented (oncology clinic) was called et spoke c (name of oncology clinic staff) in referral dept r/t res referral faxed. stated they had not rec'd it yet. rec'd another fax number of (number) to fax to. referral faxed again at this time R4's Progress Note dated 2/27/26 at 1:23 PM created by V6 documented R4 has an orthopedic appointment on 3/2/26 at 1:30 PM. R4's Order Summary Report documents an order dated 3/6/26 for an urgent referral to pulmonology related to abnormal CT results and oncology. R4's Progress Note dated 3/6/26 at 12:28 PM created by V6 documented referral faxed to pulmonology at this time. onocology [sic] stated needed biopsy before tx. R4's Progress Note dated 3/11/26 at 3:03 PM created by V6 documented V19's (Physician) office called and gave an order for a stat interventional radiology guided pulmonology biopsy. R4's Order Summary Report documents an order dated 3/11/26 for a stat interventional radiology guided pulmonology biopsy. R4's Progress Note dated 3/11/26 at 3:12 PM created by V6 documented a referral was faxed to interventional radiology. R4's Progress Note dated 3/14/26 at 8:53 PM created by V30 (Registered Nurse/RN) documented late entry for 3:15 pm. resident in room with family for visit, is voicing c/o ongoing pain to arms, back, shoulders, and generally all over and voices the pain medication is not helping to stop his pain. after resident was assessed by this nurse for newiinjury [sic], with no new visible changes to areas of concern. (V19/Physician) notified with orders to repeat pain medication x 1 and continue to monitor. medication given per orders and continue to monitor. daughter in facility and updated and voices content with the update. resident again instructed to call with any new issues or change instatus [sic], at this time he has voiced agreement. call light within reach and resident back to bed and voices is comfortable. R4's Progress Note dated 3/18/26 at 2:41 PM, created by V6 documented interventional radiology called related to biopsy order and stated it was denied related to interventional radiology imaging protocol and gave number for her to call to see what is needed. R4's Progress Note dated 3/18/26 at 2:52 PM created by V6 documented (interventional radiology facility) called et spoke c (name). stated she was unsure of information that this writer gave et requested to have orders et imaging faxed to her et she would review et give this writer call back et try to remedy issue. call back name et number given. information faxed (number). R4's Progress Note dated 3/24/26 at 9:10 AM created by V1 (Administrator) documented spoke with (interventional radiology facility) this AM regarding IR (interventional radiology) lung biopsy, staff at (interventional radiology facility) he needed more imaging, called physician regarding imaging, he stated to attempt to schedule arm biopsy, if (interventional radiology facility) continues to ask for imaging, schedule CT with and without contrast, DON working on scheduling now R4's Progress Note dated 3/24/26 at 2:18 PM created by V2 (Director of Nursing/DON) documented spoke w/ (interventional radiology facility), states referral process would need to be restarted for new biopsy site. notified MD, MD gave order for CT w/ et w/o (without) contrast of chest. order faxed to (local hospital) central scheduling. CT scheduled for 3/26/26 at 9am. resident to have lab draw at (local hospital) prior to imaging on day of. resident to be NPO starting 4 hours prior to imaging. transport made aware, resident made aware. R4's Progress Note dated 3/25/26 at 10:34 PM created by V33 (LPN) documented This nurse called and spoke w/ (V19) at this time regarding residents current pain. This nurse explained to (V19) that even with PRN [NAME] (Tylenol), and medication increased to q6hr (every 6 hours) instead of q8hr (every 8 hours), resident was still experiencing breakthrough pain. Scheduled norco givin [sic] at 11AM. Will cont (continue) to monitor. R4's CT chest results from local hospital dated 3/26/26 document under Impression: Larger right lower lobe subpleural mass consistent with primary bronchogenic malignancy destroying right ribs 7 and 8. New hepatic metastases. New bilateral adrenal metastases. Additional metastatic lytic lesion with associated pathologic fracture of right rib 7. Metastatic soft tissue mass destroying left humeral head. Acute to subacute new burst fractures of T5 and T11 with lytic lesion associated with the 11 suspicious for pathologic fracture. On 3/26/26 at 2:49 PM, V27 (Family Member) stated she was told by V1 that R4 has cancer that has spread, and his arm is deteriorating due to the cancer, and he has a broken arm. V27 stated she doesn't know why they don't take him to the doctor for his cancer or his broken arm. V27 stated she was told by his pulmonologist back in September 2025 that R4 had a spot on his lung, but it was shrinking so they could wait to do a biopsy because they didn't have the money to pay for the biopsy at that time. V27 stated now that he has cancer that has spread, she nor R4 have told the facility they don't want treatment for R4, she stated they want him to get treatment for his cancer. V27 said back in August or September 2025 they canceled an appointment due to not having the finances to pay for it but now that he has known cancer that has spread R4 wants treatment, and she agrees with him. R4's Progress Note dated 3/29/26 at 2:00 PM created by V4 documented Resident stating he can't breathe. Oxygen saturation checked and was 90%. (V27) in room at this time requesting resident to have oxygen placed. Resident agrees to wear it right now. 2L (liters) via NC (nasal cannula) placed and oxygen rose to 95%. On 3/30/26 at 2:29 PM, V6 (ADON) stated R4 was admitted with a lesion on his lung. V6 stated in September 2025, V27 canceled an appointment for R4 and V6 was told by someone at the facility it was due to (R4) not having the money to pay for the doctor's visit. V6 stated in January 2026, R4 began complaining of abdominal pain and he had an x-ray that showed bowel gas; then on 1/29/26, R4 had a CT of the abdomen, and it showed some lesions so V19 ordered a referral to oncology on 1/30/26 and it was faxed on that day. V6 stated the previous director of nursing called and checked on the referral on 2/4/26 and re-faxed it then. V6 stated no one called to check on the referral until 2/23/26 when V4 (LPN) called and re-faxed the referral. V6 stated on 3/6/26 she received a call from oncology stating R4 needed to see pulmonology and needed a biopsy before they could see R4, so V6 faxed an order per V19 to pulmonology for a referral. V6 stated she received a phone call on 3/11/26 from V19's office stating V19 wanted a referral sent to interventional radiology for R4 to get a biopsy, so V6 faxed an order to them. V6 stated on 3/18/26 she called interventional radiology to see if they received the referral and they told V6 they couldn't do the biopsy because they didn't have the correct imaging and told V6 to call (outside radiology company) to see what else V6 needed to send. V6 stated she called and spoke with V29 (Interventional Radiology Clinical Coordinator), and V6 was told to send the records, and V29 would look at it and let V6 know what they needed. V6 stated at that time the facility was short staffed, and V6 was working the floor everyday so she passed the referral information for oncology and interventional radiology off to V1 and V2 but V6 forgot about the referral to pulmonology so that was never followed up on. V6 stated she forgot to follow up with V29 as well to see what they needed. V6 stated R4 had an appointment scheduled for 3/2/26 to see an orthopedic doctor for the fracture in his left arm but he did not go to it because they were short staffed and there wasn't anyone to take him. V6 stated they didn't call and reschedule the appointment, they no showed to the appointment, and it hasn't been rescheduled yet that V6 knows of. V6 stated she hasn't done anything else at this point with the referrals and as far as she knows, as of today R4 does not have an appointment with oncology, pulmonology, orthopedics, or had a biopsy. V6 stated since the new findings on the CT from 1/30/26, neither R4 nor V27 have refused treatment. V6 was under the impression that due to the new findings R4 wanted treatment even though he didn't have Medicaid yet. R4's Progress Note dated 4/2/26 at 9:22 AM created by V4 documented CT results sent to (V19). R4's Progress Notes dated 4/2/26 at 9:55 AM, 10:20 AM, and 11:42 AM created by V4 documented interventional radiology was called and no answers. R4's Progress Note dated 4/3/26 at 10:03 AM created by V4 documented Contacted (local hospital) Referral team and faxed results to (number). Spoke to (name) who states once they receive the results, they will call facility and schedule an appointment for biopsy. (V27) contacted and notified. R4's Progress Note dated 4/7/26 at 2:29 PM created by V1 (Administrator) documented received note from ortho (orthopedic) visit this morning at approximately 1104 (11:04 AM), after 6 attempts at calling, I was able to speak with (provider at orthopedic clinic) who saw (R4) at his visit, he does feel like after reviewing the CT, (R4's) dx of mets (metastases) and the fall being low impact that it is a pathological fx (fracture). R4's Progress Note dated 4/9/26 at 2:43 PM created by V1 documented 1415 (2:15 PM)- (local hospital) called to obtain CD of images 1420 (2:20 PM) called (interventional radiology) regarding appointment- (name of representative at interventional radiology) stated it was not approved and directed me to call (interventional radiology sister facility), they stated it was denied r/t not having images, so she emailed them, 1454 (2:54 PM)-they then called back, said it was approved and that (V19's) office would have to call and schedule it. (V19's) office notified, no nurse available but receptionist would give message, I asked they call me back after scheduled with date and time (local clinic name) oncology called, stated they have to have biopsy before they can schedule, but (name of representative at oncology clinic) advised to send to radiation oncology for quicker appt due to not needing biopsy, referral faxed to (number)- stated it was STAT as directed by (name of representative at oncology clinic) 1440 (2:40 PM)- (local clinic name) pulmonology called, spoke with (name of representative at pulmonology clinic), referral and CT results sent to (number) R4's Progress Note dated 4/9/26 at 4:17 PM created by V1 documented (V19) sent mediprocity (secure messaging system) message at 1538 (3:38 PM) regarding IR appointment r/t order must come physician's office (local clinic name) pulmonology called again at 1548 (3:48 PM) to see if referral was received- per (name), it can take up to 24 hours for that to come through, try back tomorrow around 1500 (3:00 PM), this admin (administrator) did receive confirmation email/ fax stating it went through 1615 (4:15 PM) (local clinic name) radiation oncology called to verify they received fax- reached a voicemail for (name) in radiation oncology, left message, confirmation was received by this admin that fax/email went through R4's Progress Note dated 4/10/26 at 8:25 AM created by V1 documented spoke with (name) at (V19's) office, resident is scheduled for (local hospital name) IR appt on 4/20/26, they will possibly move this appt up to 4/16/26 if it is confirmed they have an opening. per (name) we need to put his aspirin on hold an (local hospital name) IR will call Monday 4/13/26 with time and preop orders R4's Progress Note dated 4/10/26 at 10:13 AM created by V1 documented calls made to the following this AM: radiation oncology- per (name) they received the fax/referral and a nurse would look at it and call us with an appt. pulmonology- spoke with (name), she initially stated they received it but it has not been transcribed, then put me on hold and when she returned to call stated it had not been received and asked me to refax it, referral immediately sent again R4's Progress Note dated 4/10/26 at 11:17 AM created by V1 documented (name) from radiation oncology called, needed (V27's) phone number, states she is in need of information from before resident admitted to our facility. She states she can see orders for these tests but unable to see results, so she is unsure if POA (V27) took him to appts. R4's Progress Note dated 4/13/26 at 12:14 PM created by V1 documented R4 is scheduled for interventional radiology biopsy on 4/20/26 at 11:00 AM. R4's Progress Note dated 4/13/26 at 12:26 PM created by V1 documented pulmonology at (local clinic name) called for f/u (follow-up), receptionist stated they received referral and it has been sent to office for review, double checked that they had our call back number, will notify POA message left for radiation oncology R4's Progress Note dated 4/13/26 at 1:19 PM created by V1 documented spoke with (name) at radiation oncology, resident scheduled 4/14 at 1000 am, needs to arrive 15 minutes early scheduled 4/20/26 at 1100, orders in place (V27) notified of appt on 4/14 and 4/20 voices she is unsure if she can make appt. On 3/30/26 at 1:12 PM, V19 (Physician) stated R4 was admitted to the facility with a known lung lesion from the hospital, but the facility reported to him that the family refused treatment for the lesion at that time. V19 stated in his professional opinion, R4's fracture of his left upper arm is thought to be from the mass but most certainly a fall onto that area could have caused a fracture. V19 stated he ordered a referral to oncology and for R4 to see his pulmonologist on 1/30/26. V19 stated oncology wouldn't see him without a biopsy first, so they referred him to IR for a biopsy of the lesion that was found on his lung, then V6 (ADON) told him R4 needed further testing before they can do a biopsy, so he ordered another CT scan. V19 stated he ordered for R4 to be sent to orthopedics after his x-ray on 2/23/26 due to the results stating he had a fracture in his arm, but he hasn't received any notes from ortho yet, so he isn't sure why he hasn't seen him yet. On 4/2/26 at 3:14 PM, V1 (Adminisrator) stated R4 went to his orthopedic (appointment) 3/27/26 but she doesn't know what they said because he didn't bring any papers back with him. On 4/2/26 at 11:35 AM, V27 (Family Member) stated she just received a call from V4 (LPN) stating R4's cancer had spread to his spine, ribs, shoulder, arm, adrenal glands, and liver. V27 stated R4 saw a pulmonologist in (neighboring state) and they wanted $700 for the bronchoscopy and to biopsy the lesion on his lung but they did not have that money at the time and the pulmonologist told them the lesion has shrunk so it would be okay to just recheck it in April 2026. V27 stated when she was told R4 had cancer in his lungs, liver, stomach, and bones in February 2026 she told the facility to get him wherever he needed to go, and she didn't tell them not to schedule any appointments due to finances because R4 wanted treatment. V27 stated she was never told that R4 had an orthopedic appointment scheduled for 3/2/26 and she didn't know he missed it either. On 4/6/26 at 2:24 PM, V6 (ADON) stated she found the fax confirmation paper from the pulmonology referral she sent on 3/6/26 and it says there was an error, and it didn't go through when she faxed it. V6 stated nothing else has been done with that pulmonology referral because she forgot about it. On 4/8/26 at 2:09 PM, V34 (Interventional Radiology Radiologist Assistant) stated R4's biopsy was denied due to not having the images from the CT, they only had the report. V34 stated she denied it, and the charge nurse would have called the provider to let them know why. V34 stated the CT scan they had from January 2026 was sufficient, but they needed the images. On 4/9/26 at 12:56 PM, V35 (Interventional Radiology Registered Nurse) stated they received a fax on 3/11/26 that just had R4's name on it and IR/pulmonary biopsy on it with no diagnosis so it is not a valid order. V35 stated they then received an order on 3/17/26 that was put into their electronic charting system by V19. V35 stated after they received that order on 3/17/26, she sent a message to V19 stating they needed the images from R4's CT scan before they could do the biopsy. V35 stated they haven't had any further communication regarding R4, but she does see in their system that R4 had another CT, but they were only sent the report again and not the actual images. V35 stated R4 still has an active order so as soon as they get the images to them, they can do the biopsy. On 4/9/26 at 7:28 AM, V19 stated he ordered a CT scan on 1/12/26 due to abdominal bloating and that CT recommended tissue sampling and pulmonary consultation. V19 stated at that time he ordered R4 to have a referral to oncology and to see the pulmonologist R4 was already established with. V19 stated if R4 couldn't see his current pulmonologist due to it being too expensive, he should have been referred to a pulmonologist at the local healthcare system that is non-profit. V19 stated he was under the impression R4 was seeing the pulmonologist. V19 stated that on 3/3/26, his office stepped in to help with referrals because he noticed some of the referrals he ordered weren't getting done in a timely manner. V19 stated he isn't sure what the outcome would have been if R4 had been sent to his pulmonologist on 1/30/26 like he ordered, but they might have been able to get it biopsied faster and sent to oncology quicker as well. V19 stated R4 should have been referred to the pulmonologist when he ordered it and taken to his orthopedic appointment when it was scheduled. A document provided by the local oncology facility titled Referral documents on 3/3/26 Call made to (V6) at (facility name) regarding referral. Noted in CT scan results, recommendation was made for Pulmonary biopsy/workup for likely primary lung neoplasm. Requesting referral be placed urgently to Pulmonology at this time. (V6) verbalized she would pass this on to (V19). In the same document on 3/10/26, it notes Called (V19's) office and spoke with (name) regarding requested referral to Pulmonology. (name) states she will send urgent message for nursing to address. On 3/18/26 it documents Noted in chart that V19 placed an order on 3/17/26 for an IR CT needle biopsy lung. Will continue to monitor for biopsy to be performed and resulted. On 3/30/26 at 8:15 AM it documents At this time patient does not have a biopsy proven malignancy. PCP (Primary Care Provider) has not placed order to seen [sic] Pulmonology for lung biopsy/work-up as requested. This referral will be closed and a new referral will be placed if diagnosed with malignancy. On 4/13/26 at 2:05 PM, V7 (Regional Director of Clinical Services) stated they do not have a policy related to following physician's orders. The Immediate Jeopardy that began on 1/30/26 was removed on 4/9/26 when the facility took the following actions to remove the immediacy: 4/9/26 2:15 p.m. Administrator called Hospital Medical Records Department to obtain CD of images.4/9/26 2:40 p.m. Administrator called Pulmonology Facility and spoke with Pulmonology Facility Representative, updated referral and CT results sent to (phone number) as directed.4/9/26 2:42 p.m. Administrator called Oncology Facility to schedule an appointment. Oncology Facility Representative stated they must have a biopsy before they can schedule. CT does not suffice. Oncology Facility Representative advised facility to send the referral to Radiation Oncology for a quicker appointment because they do not require a biopsy. Referral faxed to (phone number) stating it was STAT as directed by Oncology Facility Representative.4/9/26 2:45 p.m. Administrator has called Interventional Radiology Facility regarding appointment. Interventional Radiology Facility Representative stated it was not approved and directed facility to call another Radiology Facility at (phone number). The second Radiology Facility stated it was denied r/t not having images, so they emailed them.4/9/26 2:54 p.m. The second Radiology Facility called back and said it was approved and that Primary Care Physician's office would have to call and schedule it. Primary Care Physician's office immediately notified. Requested Primary Care Physician's office to call facility back after it is scheduled with a date and time.4/9/26 3:38 p.m. Interim DON contacted Primary Care Physician directly requesting that he expedite the scheduling of the biopsy.4/9/26 3:48 p.m. Administrator contacted Pulmonology Facility again to see if referral was received. Per

Based on observation, interview, and record review the facility failed to ensure cognitively impaired residents were adequately supervised and failed to implement interventions to prevent elopement for 2 (R1, R2) of 3 residents reviewed for accidents and supervision in the sample of 3. This failure resulted in R1 exiting the facility on 2 occasions, accompanied by R2 on one of those occasions, without staff knowledge. This failure resulted in Immediate Jeopardy, which was identified to have begun on 10/26/25 when the facility failed to prevent R1 from exiting the facility without staff knowledge and failed to put effective interventions in place to prevent a second occurrence on 3/6/26 when R1 and R2 exited the facility without staff knowledge. V3 (Senior Regional Administrator), V22 (Chief Executive Officer/CEO), and V7 (Regional Director of Clinical Services) were notified of the Immediate Jeopardy on 3/19/26 at 3:24 PM. The immediacy for both examples was removed on 3/20/26, but non-compliance remained at a Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include:1. R1's admission Record documented an admission date of 9/5/25 and included diagnoses of dementia, osteoarthritis of knee, and hypertension. R1's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 07, indicating R1's cognition is severely impaired. Section E of this same MDS assessment, titled Wandering-Presence and Frequency documents this behavior occurred daily. R1's Care Plan documents a focus area of R1 is at risk for elopement related to dementia. R1 has a wander guard on but can remove it. It has been found on the bottom of her purse a couple of times (created 10/27/25). Interventions for this focus area include in part, 15-30 minute checks as needed (initiated 10/26/25 and revised 10/27/25), elopement on 10/26/25; 2nd wander guard attached to outside of her purse due to the fact she always carries her purse everywhere she goes, initiated 10/27/25 and revised on 11/3/25, R1 moved room closer to dining room for better observation, initiated on 10/28/25, revised 11/3/25, and resolved on 3/18/26, and elopement 2/6-staff educated that resident is at even higher risk for elopement when wearing makeup initiated 3/6/26. R1's Elopement/Wandering Risk Assessments dated 9/5/25 at 3:00 PM, 10/26/25 at 5:00 PM, 10/27/25 at 8:50 AM, and 1/25/26 at 9:39 AM all document R1 is at risk for elopement and wandering at this time. R1's document titled Risk Management dated 10/26/25 at 4:25 PM documents under nursing description This nurse was notified by another staff member that resident was brought back to facility with a police officer and that resident had eloped and was found wondering (sic) in town. Per administrator (V1), family stated resident was on (name of road which facility is located). Police officer left before speaking to this nurse. In the same document under Resident Description it documents Resident questioned and stated 'I just walked out the front door, I was going for a walk.' Resident was last seen two hours ago. and under Description of Action Taken it documents Bracelet in resident's pocket. Resident said she took her bracelet off when coming back into the building. Elopement bracelet immediately placed back on. Alarms to building and bracelet working effectively. Emergency contact, (V5/Family Member), aware of situation and spoke to resident. Head to toe assessment completed. No areas of concern. Resident denies any pain. 15 minute checks initiated. DON (Director of Nurses, V2) and administrator (V1) made aware. (V19, Physician) notified as well. Re-direct intervention: Have resident call emergency contact, (V5) for comfort. Interventions when exit seeking-offer snack, discuss knitting, offer to call family, sit with resident and let her talk/vent concerns and worries. Resident moved to room closer to dining room for better observation. R1's document titled Risk Management dated 3/6/26 at 11:30 AM documents under Nursing Description resident noted to be up the street pushing her friend to go look at cemetery, no s/s (signs/symptoms) of injury noted, resident brought back to facility in company van. Under Resident Description, it documents I was just going to show her my Mom and Dad's grave and under Description of Action Taken it documents resident noted to be up the street pushing her friend to go look at cemetery, no s/s of injury noted, resident brought back to facility in company van, assessed and brought back to facility per (name) another resident, they followed the smokers out and went the opposite direction. RCA (Root Cause Analysis)-confusion, thinks she is in community. Immediate intervention-staff educated that if resident is noted to be wearing makeup they should monitor for increased elopement risk. R1's Progress Note dated 10/26/25 at 4:25 PM, created by V4 (License Practical Nurse/LPN) documents This nurse was notified by another staff member that resident (R1) was brought back to facility with a police officer and that resident had eloped and was found wondering (sic) in town. Per administrator (V1), family stated resident was on (name of road where facility is located). Police officer left before speaking to this nurse. Resident questioned and stated I just walked out the front door, I was going for a walk. Resident was last seen two hours ago. Bracelet in resident's pocket. Resident said she took her bracelet off when coming back into the building. Elopement bracelet immediately placed back on. Alarms to building and bracelet working effectively. Emergency contact, (V5, Family Member) aware of situation and spoke to resident. Head to toe assessment completed. No areas of concern. Resident denies any pain. 15 minute checks initiated. DON (V2) and administrator (V1) made aware. (V19/Physician) notified as well. R1's Progress Note dated 10/26/25 at 5:00 PM, created by V1 documents This admin spoke with (V5), (V5) stated that they received a call regarding resident, she stated that resident was on (name of road where facility is located) when observed by police officer, let family know that resident had been placed on 15 minute checks and appeared to have no s/s of injury or emotional distress. Resident frequently worries about her money and sister stated when she visited earlier today that (R1) asked her to take her to the credit union. She reminded resident that she lived at (facility name) and that her family helps with her money. I asked sister for ideas for better redirection, she stated- offer snack, discuss what she is knitting, call sister or sister in law. Family coming to facility at 2 pm on 10/27/25 for careplan. R1's Progress Note dated 10/26/25 at 5:05 PM, created by V20 (Former Director of Nursing) documents Head to toe assessment complete. Skin intact with no issues noted. Resident voices no complaints of pain. Vitals 148/88, 97.9, 80, 20, O2 (oxygen) sats (saturation) 95% on room air. Resident states she is tired and just worn out from her walk today and just wants to lay down. Wander guard in place on right wrist and functioning properly. Resident lying in bed at this time no s/s of distress at this time. 15 min checks continue at this time. R1's Progress Note dated 10/27/26 at 3:50 PM, created by V1 documents spoke with dispatch regarding incident on 10/26/25, he stated that according to the officer the resident was on (name of road where facility is located) at approximately 1602 (4:02PM), taken to police station, family called, and resident was brought back to facility at 1620 (4:20PM). No distress was noted when they spoke with resident, she just wanted to call her sister in law. Per officer, resident was noted at church on (name of road where facility is located) and a pastor took her to police station when she couldn't remember the name of where she lived. R1's Progress Note dated 10/28/25 at 11:44 PM, created by V21 (Registered Nurse/RN) Resident continues on 15min (minute) checks. Resident in bed resting at this time. Resp (respirations) even and unlabored. no attempts to go out the door at this time. wandergaurd in place and working. Resident was moved to a room closer to the nurses station on day shift today. resident tolerating room change w/o (without) any issues at this time According to https://www.timeanddate.com/weather/@4237312/historic, on 10/26/25 the temperature in the city that the facility is located was 53 degrees Fahrenheit at 2:52 pm with a wind speed of 9 miles per hour and there was light rain with fog, and it was 54 degrees Fahrenheit at 3:52 pm with a wind speed of 10 miles per hour and there was light rain with an overcast. R1's Progress Note created by V1 (Administrator) on 3/18/26 at 11:32 AM with effective date of 3/6/26 at 11:32 AM documents Late Entry: Note Text: resident noted to be up the street pushing her friend to go look at cemetery, no s/s of injury noted, resident brought back to facility in company van, assessed and brought back to facility RCA (root cause analysis) - confusion, thinks she is in community Immediate intervention- staff educated that if resident is noted to be wearing makeup they should monitor for increased elopement risk According to https://www.timeanddate.com/weather/@4237312/historic, on 3/6/26 the temperature in the city that the facility is located was 75 degrees Fahrenheit at 10:52 AM with wind speed of 16 miles per hour and it was 74 degrees Fahrenheit at 11:52 AM with wind speed of 21 miles per hour. According to https://google.com/maps, R1 traveled 0.5 miles from the facility to the location she was found by R1's family member on 3/6/26. Also, according to the website, the journey would take a minimum of 12 minutes on foot. 2. R2's admission Record documents an admission date of 9/11/25 and included diagnoses of anxiety disorder, chronic obstructive pulmonary disease, muscle weakness, cerebral atherosclerosis, primary hypertension, history of falling, metabolic encephalopathy, and osteoarthritis. R2's MDS assessment dated [DATE] documents a BIMS score of 04, indicating R2's cognition is severely impaired. R2's Care Plan documents R2 is at risk for elopement related to recent event with peer on 3/6/26 initiated on 3/6/26 and revised on 3/18/26. Corresponding interventions included in part elopement 3/6/26-educate staff R2 is at higher risk for elopement when wandering with R1. R2's Elopement/Wandering Risk Assessments dated 9/11/26 and 12/11/26 document R2 is not at risk for elopement or wandering at this time. R2's Elopement/Wandering Risk assessment dated [DATE] documents R2 is at risk for elopement or wandering at this time. R2's document titled Risk Management dated 3/6/26 at 11:30 AM documents under Nursing Description resident went with roommate on a 'walk,' no s/s of injuries noted. Under Resident Description, it documents I told her we should head on back and under Description of Action Taken it documents resident went with roommate on a 'walk' no s/s/ of injury noted. Per (name) another resident, they followed the smokers out and went the opposite direction. RCA-went for a walk with friend. Immediate intervention-resident educated to let staff know if roommate talks about going for a walk. R2's Progress Note created on 3/18/26 at 11:39 PM and effective 3/6/26 at 11:38 AM documents Late Entry: Note Text: resident went with roommate on a walk, no s/s of injuries noted RCA- went for a walk with friend. Immediate intervention- resident educated to let staff know if roommate talks about going for a walk According to https://www.timeanddate.com/weather/@4237312/historic, on 3/6/26 the temperature in the city that the facility is located was 75 degrees Fahrenheit at 10:52 AM with wind speed of 16 miles per hour, and it was 74 degrees Fahrenheit at 11:52 AM with wind speed of 21 miles per hour. According to https://google.com/maps, R2 traveled 0.5 miles from the facility to the location she was found by R1's family member on 3/6/26. Also, according to the website, the journey would take a minimum of 12 minutes on foot. On 3/18/26 at 10:11 AM, V5 (Family Member) said she was very upset over R1's elopement, stating something could have happened to her. V5 stated in October 2025, R1 left the facility without anyone knowing and no one knows how long she was gone. V5 stated R1 was found by a pastor and taken to the police station. V5 stated R1 didn't know where she lived but remembered her brothers phone number, so the police called him, and he told the police where she was living. V5 stated the police officer took R1 back to the facility and when she arrived back, they didn't even know R1 had been gone or how long she had been gone. Regarding the second incident, V5 stated that on 3/6/26 she was driving to the facility to see R1 and V5 saw her walking down the road pushing R2 in her wheelchair. V5 stated she thinks it was around 11:30 AM. V5 stated it was very windy that day. V5 stated they were on (name of street and business name approximately 0.5 miles away from the facility). V5 stated R1 was limping and told her that her foot and knee were hurting, and V5 stated R1 was exhausted looking and could hardly walk. V5 said she called V1 at the facility and V1 told her they didn't know R1 and R2 were gone. On 3/19/26 at 3:50 PM, the surveyor drove from the facility in the direction of the church/cemetery and local business where R1 and R2 were found on 3/6/26. The street is a striped, busy street that runs uphill for approximately 0.4 miles with no shoulder and no sidewalk observed until approximately the last 250 feet of the route. The next road, where R1 and R2 would have turned right to walk another 0.1 miles before being found by V5 is also a busy street with no shoulder and very little sidewalk. On 3/18/26 at 11:46 AM, R1 stated she left the facility a while back to go to the graveyard. R1 stated she didn't mean to make everyone mad when she left, she just wanted to go see her mom and dad's [NAME]. R1 started crying during the interview so this surveyor changed the subject. R1 was alert to person only. On 3/18/26 at 2:46 PM, V1 stated R1 just walked out of the building in October, and she doesn't know why the wander guard didn't alarm. V1 stated she thinks R1 walked outside with the smokers on 3/6/26 because there was an alert and an oriented resident sitting in the hallway and she told V1 that R1 walked by her in the hallway pushing R2 towards the line of smokers waiting to go outside. V1 stated she doesn't know if the wander guard went off when she walked out of the door. V1 said when R1 returned to the facility, her wander guard bracelet was in her pocket. V1 stated R1 reported she took it off on the way back to the facility. V1 stated if the wander guard was in her left pocket instead of the right wrist it would not have alarmed because the scanner is only on the right side of the door. On 3/18/26 at 3:17 PM, R7 stated she was sitting in the hallway by her room door and R1 walked by pushing R2 on 3/6/26. R7 stated R2 asked her if she could go out with the smokers and R7 told R2 she would have to ask the staff member to take them out. She doesn't remember what time of day it was, but the smokers were lined up at the door around the corner. R7 stated she couldn't see the door from where she was sitting but she could see the end of the line of residents waiting to go outside on their smoke break. R7 stated R1 pushed R2 around the corner with the smokers, and she couldn't see where they went after they rounded the corner. R7 stated she never heard an alarm during that time, and she didn't see them walk out the door. On 3/19/26 at 2:13 PM, V14 (Power of Attorney/Family Member) stated he was not notified when R2 eloped from the building on 3/6/26. V14 stated he was told on 3/18/26 when he came to the facility for a care plan meeting. On 3/19/26 at 1:42 PM, V4 (Licensed Practical Nurse/LPN) stated she was working when R1 eloped on 10/26/25 and she did not know R1 was gone until the police brought her back. V4 stated she didn't know where R1 was found but the police said she was found uptown. V4 stated when R1 was brought back to the facility, she had her wander guard in her pocket, and the door should have alarmed when she left. V4 stated in October there was not a door alarm on the front door so if R1 went out that door it wouldn't have alarmed unless the wander guard was working properly. V4 stated there was a door alarm installed on the front door in December 2025. V4 stated when the police brought R1 back to the facility she was upset and hysterically crying. V4 stated it was raining that evening so R1's hair and clothes were wet from walking in the rain. V4 stated R1 didn't understand why the police had her, she thought she was in trouble. V4 stated R1 just didn't understand what was going on. V4 stated she called R1's sister to talk to her to try and help calm R1 down, then R1's sister ended up coming to the facility to see her to calm her down. V4 stated when R1 returned they did a head-to-toe assessment to make sure she didn't have any injuries, and no injuries were observed. V4 stated the CNA's (Certified Nurse Aides) said they saw R1 shortly after lunch when picking up her tray, then V4 said she saw R1 walk by her medication cart while she was passing medication in the hallway around 1:00 PM. V4 stated R1 was brought back around 4:25 PM on 10/26/25. V4 stated R1 was in a room near the nurses station when she eloped in October and then they moved her to a room further away from the nurses station and further away from the dining area, which is a common area, right before the elopement happed on 3/6/26. V4 stated she was working on 3/6/26 when R1 and R2 eloped. V4 stated no one knew they were gone until R1's sister called the facility and V1 called a code yellow. On 3/18/26 at 12:39 PM, V17 (Registered Nurse/RN) stated she was the nurse working R1 and R2's hall when they eloped on 3/6/26. V17 stated she doesn't know how they got out or how long they had been gone. V17 stated she did not notify the physician. On 3/18/26 at 12:30 PM, V1 stated the physician was not notified when R1 and R2 eloped on 3/6/26. On 3/18/26 at 12:19 PM, V19 (Physician) stated he was not notified of the incident on 3/6/26 involving R1 and R2. V19 stated he should have been notified. On 3/18/26 at 12:55 PM, V1 stated R1 was not moved closer to the dining room when they moved her just prior to her 3/6/26 elopement because they instead decided to put her in the room with R2 since they are good friends. V1 stated the intervention to move R1 closer to the dining room was left in the care plan until today, it was removed today. V1 stated an intervention in R1's care plan was added today for the elopement 3/6, stating staff was educated that resident (R1) is at even higher risk for elopement when wearing makeup. On 3/18/26 at 12:58 PM, this surveyor requested the care plans for R1 and R2 after reviewing them in the electronic medical record. When reviewing R1's care plan in the electronic medical record, there was an intervention documenting R1 was moved to a room closer to the dining room for better observation, initiated on 10/28/25. When reviewing R2's care plan in the electronic medical record there was no documentation pertaining to elopement. V2 (Director of Nursing/DON) provided the care plans for R1 and R2 and this surveyor noticed R1's intervention documenting R1 being moved to a room closer to the dining room for better observation was no longer in the care plan. This surveyor questioned V2 about the intervention and she stated she deleted that intervention prior to printing out the care plan for this surveyor because R1 was never moved to a closer room. V2 stated she was going to go back into R1's care plan and put the intervention back in and resolve it the correct way then reprint it. After reviewing R2's printed care plan provided by V2 this surveyor noted a care area documenting R2 is at risk for elopement related to a recent event with peer on 3/6/26 that documented it was initiated on 3/6/26 and revised on 3/18/26. Corresponding interventions included in part elopement 3/6/26-educate staff R2 is at higher risk for elopement when wandering with R1. This surveyor asked V2 when those interventions were added and V2 stated she just put them in after the surveyor requested the care plan and back dated it to 3/6/26. On 3/19/26 at 10:28 AM, V24 (Activities Aide) stated she took the smokers out on 3/6/26 around 11:30 AM and she never saw R1 or R2 standing in the line or go out the door with them. V24 stated she stands at the door and holds it open for all the residents that come out for the smoke break and R1 and R2 did not come out with the rest of the residents. V24 stated when she started working at the facility on 2/18/26, she was told about the elopement book but not who was an elopement risk, and she has never looked at the book. V24 stated she still hasn't looked at the elopement book, but she will look at it today. On 3/19/26 at 10:38 AM, V25 (Maintenance Director) stated he has never done any maintenance or checking of the wander guard system, adding he doesn't know anything about it. V25 stated every outside door has an alarm on it. At this time, V25 was observed checking each exit door. There were 6 doors leading outside. The dining room door was alarmed with a pull alarm that was tied around the top hinge of the door and it pulled apart when the door opened. V25 did not know how to shut the alarm off. There was a resident sitting in the dining room that was yelling to V25 telling him how to shut the alarm off. V6 (Assistant Director of Nursing/ADON) then came and showed V25 how to shut it off by reconnecting the pull tab. The door down the hallway next to the kitchen was alarmed with a keypad. The door on hall A had an alarm that required a key to shut it off, but it shuts off automatically after 30 seconds if the key isn't used, V25 stated only the nurse for this hallway and V26 (BOM) have a key for this door. The door near the therapy department was alarmed with a push button to shut it off. The door at the end of hall B had an alarm that required a key to shut it off, or it automatically stops alarming after 30 seconds if the key is not used. V25 stated only the nurse for this hallway and V26 have a key to this door. V25 stated he checks the alarms monthly. On 3/19/26 at 10:38 AM, this surveyor asked V25 for the log documenting the monthly door alarm maintenance. V25 stated he doesn't know of one as he has only done it once this month because he just started working at the facility. On 3/19/26 at 10:57 AM, V1 had a wander guard in her hand, opened the front door and the door alarm sounded when she opened it. R1 walked out the door with the wander guard in her hand then walked back in the door. The door alarm continued the whole time but there was never an additional alarm when V1 walked out the door with the wander guard. V1 then put the door code in and walked back out the door with the wander guard, then walked back in the door and no alarm sounded. V1 stated she isn't sure why they use the wander guard as an elopement intervention because a door alarm was installed on the front door in December of 2025. Now the door alarms when it is opened if the code is not entered. V1 stated she requested today to stop using the wander guard system since it doesn't work properly. On 3/19/26 at 11:06 AM, V1 stated the wander guard system is only on 1 of the 6 exterior doors, the front door. V1 stated there isn't any maintenance or checking of the wander guard system that is on the front door. V1 stated the company they get the wander guards from will call them when the wander guard band that is on the resident is starting to go bad and tell them it needs changed. V1 stated they have a small portable box the nurses use to check the wander guard bands on the residents who wear them, and this is supposed to be done daily. V1 stated as far as she knows it gets done daily. V1 stated the front door previously did not have a door alarm and when they put one on it in December 2025, it was hard wired in with the wander guard system so when the door alarm is shut off, it also disables the wander guard system. V1 stated she doesn't know if there is a log for the maintenance checks on the door alarms because the former maintenance director is no longer working at the facility and he oversaw checking door alarms. On 3/30/26 at 8:40 AM, V1 provided this surveyor with documents titled (Corporate Name) Door Alarm Checks dated November 2025, December 2025, January 2026, February 2026, and March 2026. The documents have Yes checked for each day of the month with V1's initials. V1 stated she did the door checks because she wasn't sure if the former maintenance director was doing them. This surveyor asked her if she was the one doing the door checks and she stated yes. After being asked to clarify if V1 came into the facility every day including weekends to complete the door alarm checks, V1 stated the manager on duty was actually doing them and she just signed them off. This surveyor asked V1 why on 3/19/26 at 11:06 AM she stated she didn't know if they were being done and V1 stated she must have just forgotten. On 3/19/26 at 11:10 AM, the surveyor asked V2 (DON) to check each residents wander guard band with the alarm system on the door. V2 walked each of the residents through the doors that were agreeable to do it and none of the wander guards alarmed. The door alarmed when opened and the alarm shut off when the door code was entered, but when walking the residents with the wander guard bands on out the door, it did not alarm. The following residents wander guards were checked: R8 (wander guard on left wrist), R9 (wander guard on right wrist), R1 (wander guard on right wrist), R10 (wander guard on right wrist), R11 (wander guard on right wrist), R12 (wander guard on right wrist), R13 (wander guard on right wrist), and R14 (wander guard on right wrist). On 3/19/26 at 11:33 AM, R1 emptied her purse with V1, and this surveyor present to look for the wander guard that was supposed to be put in her purse as a elopement intervention. R1 emptied her entire purse onto a table with this surveyor and V1 observing and V1 stated the wander guard was not in the purse. This surveyor did not observe the wander guard in the purse or in the belongings on the table. V1 asked V10 (Activities Director) to get bags to help organize R1's purse. V10 came back and bent down in front of the belongings out of R1's purse. V1 bent down beside her and whispered to V10 then stood up with a wander guard band in her hand and stated she found the wander guard in the pile of belongings. On 3/18/26 at 12:48 PM, V13 (CNA) stated she was just now educated today to watch for R1 wearing makeup as an intervention for her elopement risk. V13 stated she hasn't been educated on anything regarding R2 being an elopement risk. On 3/18/26 at 11:54 AM, V15 (CNA) stated she was not educated to watch for R1 to be wearing makeup or anything regarding her purse. On 3/18/26 at 11:59 AM, V16 (CNA) stated she started working at this facility about 2 months ago. V16 stated she was working when R1 and R2 eloped on 3/6/26 and she didn't know they were gone until they came back. V16 stated she wasn't educated on anything directly related to R1 or R2 after their elopement. On 3/18/26 at 12:27 PM, V6 (ADON) stated she knows R1 and R2 eloped, but she doesn't remember if she was working on 3/6/26 and she remembers being educated on something regarding the incident, but she doesn't remember what the education was. A facility policy titled Elopements dated 2026 documents under Policy Interpretation and Implementation, 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: b. Notify the Attending Physician, c. Notify the residents legal representative (sponsor) of the incident, d. Document the notifications and exam in the resident's medical record. A facility policy titled Safety and Supervision of Residents dated 3/2026 documents under Individualized, Resident-Centered Approach to Safety, 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff, c. providing training, as necessary, d. ensuring that interventions are implemented and e. Documenting interventions. In the same documents under Systems Approach to Safety, 4. As part of the facility elopement prevention, when taking residents outside for their supervised smoking times the following three head counts will be conducted, a. Head count upon exit from the building, b. Head count upon arrival at designated smoking area, and c. Head count upon re-entry to the facility. The Immediate Jeopardy that began 10/26/25 was removed on 3/20/26 when the facility took the following actions to remove the immediacy: R1 is safe and on 15-minute visual checks. R1 will remain on these checks indefinitely.R2 is safe and on 15-minute visual checks. R2 will remain on these checks until IDT determines the checks are no longer warranted through ongoing assessment, monitoring, and care plan review.Facility has reviewed the following policies for education and implementation, Elopement Policy and Safety/Supervision of Residents to include head counts for supervised smoking as a systems approach to safety.V1 immediately checked all exit doors for alarm function. All alarms are functioning and require a key and/or code to shut them off.V1 immediately did a resident head count to assure all residents accounted for. All residents were accounted for.V1 contacted R1's responsible party about sending referrals to locked dementia/Alzheimer units within the state as this would be the safest environment for R1.Facility has placed Stop Sign door guards at each exit door with the exception of the front lobby door where visitors and staff enter and exit many times a day. Staff are being educated to not remove the door guards. No one will work without receiving the education first.V3 (Regional Senior Administrator) placed a sign at the front lobby exit door asking all visitors to please make sure no one exits the facility with them and that the door closes completely behind them.Wander guards will not be used as an elopement prevention intervention on care plans going forward. The system was only applicable to the front door. The facility switched to a door alarm that sounds every time the door opens without a code being entered and stays sounding until a code is entered on 12/9/2025. The wander guard system on this door used the same audible alarm sound that the constant door alarm now does. All exit doors in the facility are alarmed every time a door opens regardless of who is going in or out since 12/9/2025. This is much safer than having the front lobby door only equipped with a wander guard system. The wander guard was proven to be ineffective for elopement prevention because of individual resident placement and/or removal. Care plans are being updated to reflect the change. Physician and responsible parties are being notified of same.The facility will increase the frequency of the Elopement/Alarm Drill Protocol from monthly to weekly for the next four weeks. The Elopement/Alarm Drill Protocol includes instruction and teaching on how the staff respond to alarms and the steps to follow when responding to an alarm. Director of Nursing, Maintenance Director, MDS Coordinator, Social Service Director, Regional Senior Administrator, Regional Director of Clinical Services, and Activity Director will be educated by the Administrator on the following policies and procedures, Elopement Policy and Safety Supervision Residents policy.Prior to working next scheduled shift until all employees are educated. Train the trainer has been completed so this training will be conducted by either the Administrator or an IDT (interdisciplinary) team member who has been trained by the Administrator to conduct such training.All department new hires will be educated prior to starting any shifts by a member of the IDT that has been trained to provide the training.Resident elopement risk assessments on all residents are being reviewed for accuracy.All resident elopement risk care plan audit initiated to assure all interventions are in place and implemented according to plan of care.Clinical staff will be educated upon hire on the following policies and content; Elopement Policy and

Based on observation, interview and record review, the facility failed to provide a sufficient amount of staff to meet the needs of the residents in a timely manner. These failures have the potential to affect all 67 residents living in the facility. Findings include:1. R4's admission Record documented an admission date of 8/12/25 and included diagnoses of chronic obstructive pulmonary disease, type 2 diabetes, muscle weakness, primary hypertension, atherosclerotic heart disease of native coronary artery, other fatigue, abnormal findings on diagnostic imaging of lung, and bilateral hearing loss. R4's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. R4's Order Summary Report documents a referral to oncology due to abnormal results from CT (Computed Tomography, diagnostic imaging procedure) of the abdomen and abnormal results of x-ray of left shoulder with an order date of 1/30/26, stat referral to interventional radiology for guided pulmonology biopsy with an order date of 3/11/26, and an urgent referral to pulmonology related to CT results and oncology request with an order date of 3/6/26. On 3/19/26 at 9:29 AM, R4 stated he has constant pain in his back, chest, and left arm/shoulder. R4 stated he was told he had cancer that was spreading and that is why he is having pain. R4 stated he keeps being told they are trying to get him an appointment for his cancer, but he still hasn't been to the doctor. R4 stated he isn't sure if they are even doing anything to help him. R4 stated he wants to get treatment for his cancer. On 3/30/26 at 2:29 PM, V6 (Assistant Director of Nursing) stated R4 was admitted with a lesion on his lung. V6 stated in January 2026, R4 began complaining of abdominal pain and he had an x-ray that showed bowel gas; then on 1/29/26, R4 had a CT of the abdomen, and it showed some lesions so V19 ordered a referral to oncology on 1/30/26 and it was faxed on that day. V6 stated the previous director of nursing called and checked on the referral on 2/4/26 and re-faxed it then. V6 stated no one called to check on the referral until 2/23/26 when V4 (Licensed Practical Nurse/LPN) called and re-faxed the referral. V6 stated on 3/6/26 she received a call from oncology stating R4 needed to see pulmonology and needed a biopsy before they could see R4, so V6 faxed an order per V19 (Physician) to pulmonology for a referral. V6 stated she received a phone call on 3/11/26 from V19's office stating V19 wanted a referral sent to interventional radiology for R4 to get a biopsy, so V6 faxed an order to them. V6 stated on 3/18/26 she called interventional radiology to see if they received the referral and they told V6 they couldn't do the biopsy because they didn't have the correct imaging and told V6 to call (outside radiology company) to see what else V6 needed to send. V6 stated she called and spoke with V29 (Interventional Radiology Clinical Coordinator), and V6 was told to send the records, and V29 would look at it and let V6 know what they needed. V6 stated at that time the facility was short staffed, and V6 was working on the floor everyday as a CNA (Certified Nurse's Aide) so she passed the referral information for oncology and interventional radiology off to V1 (Administrator) and V2 (Director of Nursing) but V6 forgot about the referral to pulmonology so that was never followed up on. V6 stated she forgot to follow up with V29 as well to see what they needed. V6 stated R4 had an appointment scheduled for 3/2/26 to see an orthopedic doctor for the fracture in his left arm but he did not go to it because they were short staffed and there wasn't anyone to take him. V6 stated they didn't call and reschedule the appointment, they no showed to the appointment, and it hasn't been rescheduled yet that V6 knows of. V6 stated she hasn't done anything else at this point with the referrals and as far as she knows, as of today R4 does not have an appointment with oncology, pulmonology, orthopedics, or had a biopsy. 2. On 4/16/26 at 11:01 AM, V4 (LPN) observed R4's toenails with this surveyor present. R4's toenails were long and wrapping around the end of his toes, extending to underneath of his toes. V4 stated R4's toenails needed trimmed, and she doesn't know why they haven't been trimmed. V4 stated they used to have a podiatrist come to the facility, but they don't have one that comes to the facility anymore. R25's admission Record documented an admission date of 9/8/22 and included diagnoses of type 2 diabetes, Alzheimer's disease, muscle weakness, and need for assistance with personal care. R25's MDS assessment dated [DATE] documented a BIMS score of 07, indicating severe cognitive impairment. R25's Care Plan documents R25 has an ADL (Activities of Daily Living) self-care performance deficit related to weakness and requiring assistance with ADL's. On 4/16/26 at 11:15 AM, V4 observed R25's toenails with this surveyor present. R25's toenails were thick and needed trimmed. V4 stated she wouldn't feel comfortable trimming R25's toenails due to the thick growth of the nails and stated R25 needs a podiatry referral. R11's admission Record documented an admission date of 12/27/22 and included diagnoses of type 2 diabetes, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side, borderline intellectual functioning, and muscle weakness. R11's MDS assessment dated [DATE] documented a BIMS score of 13, indicating intact cognition. On 4/16/26 at 11:08 AM, V4 observed R11's toenails with this surveyor present. R11's toenails were long and V4 stated they needed trimmed. R11 stated her toes are painful and her toenails need trimmed. On 4/16/26 at 12:02 PM, V6 (ADON) stated the nurses oversee trimming toenails for diabetic residents but it always ends up being her because the nurses don't do it and she hasn't had time to trim toenails due to being short staffed. 3. On 3/19/29 at 9:29 AM, R4 did not have water in his room. R4 stated he doesn't get water very often and he likes to have water to drink because sometimes he gets thirsty. On 3/30/26 at 8:55 AM, R4 did not have water in his room. R4 stated sometimes someone brings him water but not every day. On 4/13/26 at 2:15 PM, R4 stated no one has filled his water cup up today. R4 stated there is a little bit of water left in his cup, but it is old and warm. On 4/2/26 at 11:35 AM, V27 (Family Member/Power of Attorney-POA) stated every time she would visit R4 he wouldn't have water in his room. Therefore, she brought a cup in for R4 so they could fill it with water and often when she visits, the cup still doesn't have water in it. R21's admission Record documented an admission date of 2/19/26 and included diagnoses of dehydration, muscle wasting and atrophy, urinary tract infection, and adult failure to thrive. R21's MDS assessment dated [DATE] documented a BIMS score of 12, indicating moderate cognitive impairment. R21's Care Plan documents R21 has potential/actual impairment to her skin integrity related to chronic disease processes (initiated 2/20/26) with a corresponding intervention to encourage good nutrition and hydration to promote healthier skin (initiated 2/20/26). On 4/13/26 at 1:52 PM, R21 stated she doesn't get water passed every day. R21 stated she was admitted to the hospital with dehydration prior to her admission to the facility, so it is important she drinks enough water every day. R21 stated when she was first admitted to the facility, she never got water passed to her, so her daughter had to start bringing her water, stating she comes by almost every day with a fresh cup of ice water. R21 stated the facility is so short staffed on CNA's (Certified Nurse Aides) that she hates having to ask for water because she knows they don't have enough CNA's to do everything. V36 (Family Member) was present during this interview and stated there was an issue with R21 not getting anything to drink during the day so V36 started bringing R21 water to the facility. R7's admission Record documented an admission date of 8/15/25 and included diagnoses of urinary tract infection, chronic obstructive pulmonary disease, emphysema, chronic kidney disease, and disorders of kidney and ureter. R7's MDS assessment dated [DATE] documented a BIMS score of 14, indicating intact cognition. R7's Care Plan documents R7 has impaired skin integrity related to age related changes, chronic disease processes, incontinence, and deconditioning (initiated 8/22/25) with a corresponding intervention to encourage good nutrition and hydration to promote healthier skin (initiated 8/22/25). On 3/25/26 at 9:59 AM, R7 stated she doesn't get water passed to her every day and she wishes they would. R7 stated she likes having water to drink during the day. R7 stated she asks for water sometimes and they do get it, but only when she asks. R7 stated they shouldn't have to ask for water, adding what happens to the residents that can't ask? On 4/6/26 at 9:25 AM, R7 stated they don't pass fresh water to her every day, stated the water she has now is from the night before when she asked someone to get her a drink. R7 stated the CNA's tell her they are short staffed often, so she thinks that is why they don't pass water every day. On 4/6/26 at 1:16 PM, R7 still did not have a cup of water in her room and stated she hasn't gotten any water passed to her today. R22's admission Record documented an admission date of 8/29/25 and included diagnoses of muscle wasting and atrophy, muscle weakness, and fatigue. R22's MDS assessment dated [DATE] documented a BIMS score of 15, indicating intact cognition. R22's Care Plan documents R22 has potential impairment to her skin integrity related to limited mobility (initiated 9/2/25) with a corresponding intervention to encourage good nutrition and hydration to promote healthier skin initiated 9/2/25. On 4/6/26 at 9:28 AM, R22 did not have a cup of water in her room. R22 stated occasionally someone will bring her water to her room, but not very often. R22 stated sometimes she gets thirsty and would like a cup of water. On 4/6/26 at 1:25 PM, R22 still did not have a cup of water in her room. R22 stated no one has brought her water all day. On 4/13/26 at 2:10 PM, R22 did not have a cup of water in her room. R22 stated no one has brought her any water to her room today. On 3/23/26 at 3:20 PM, V12 (Helping Hand) stated water is supposed to be passed once in the morning and once in the afternoon. V12 stated she is still in school, so she doesn't come in until 3:00 PM during the week and a lot of the time water hasn't been passed for the day yet because there aren't enough CNA's to properly care for the residents and pass water. V12 stated when she gets to the facility, V2 (Director of Nursing/DON) usually tells her she needs to pass water because the CNA's haven't had time to pass water yet. 4. R6's admission Record documented an admission date of 3/2/22 and included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, morbid obesity, cystitis, weakness, and polyarthritis. R6's MDS assessment dated [DATE] documented a BIMS score of 12, indicating moderately impaired cognition. On 3/19/26 at 9:41 AM, this surveyor observed R6's call light already activated. During continuous observation, this surveyor observed V10 (Activities Director) go into R6's room. V10 did not ask R6 if she needed anything, then left room and the call light remained on. R6 stated to this surveyor, she needed to be cleaned up, she was incontinent. At 9:57 AM, V38 (Medical Records) came into the room and asked R6 if she needed something and she said she needed cleaned up. V38 said she would go get someone to help R6. At 10:00 AM, V15 and V23 (both CNA's) came into R6's room to clean her up. V15 stated she is the only one on this hallway and she is training V23 because it is her first day. R24's admission Record documented an admission date of 7/16/25 and included diagnoses of anxiety disorder, chronic kidney disease, and essential tremors. R24's MDS assessment dated [DATE] documented a BIMS score of 11, indicating moderate cognitive impairment. R24's Care Plan documents R24 is a fall risk (initiated 8/22/25) with corresponding interventions to be sure R24's call light is within reach and encourage R24 to use it for assistance as needed. R24 needs prompt response to all requests for assistance (initiated 8/22/25). On 3/31/26 at 1:35 PM, R24's call light was observed to be already activated at 1:35 PM. R24 stated she was needing someone to bring her an (adult brief) because she had been incontinent. Continuous observation revealed the call light to be answered by V6 (ADON) at 1:56 PM. R24 stated she always has a long wait when she puts her call light on. R24 stated she usually has to wait at least 20 minutes. V6 stated she got to R24 as quickly as she could, but they had more CNA's (Certified Nursing Aides) call in today and she was working the floor to help. On 4/20/26 at 9:46 AM, V7 (Regional Director of Clinical Services) stated they do not have a policy related to call lights. On 4/21/26 at 1:23 PM, V1 (Administrator) confirmed they do not have a policy related to call lights that she is aware of. V1 stated anyone can answer call lights so she would hope that within 15 minutes max that someone has answered the call light. 5. R18's admission Record documented an admission date of 6/5/24 and included diagnoses of Parkinson's disease, dementia, muscle weakness, and other lack of coordination. R18's MDS assessment dated [DATE] documented a BIMS score of 05, indicating severely impaired cognition. R18's Care Plan documents an ADL self-care performance deficit related to dementia, Parkinson's, and impaired balance with generalized weakness initiated 6/7/24. On 3/25/26 at 2:43 PM, this surveyor observed facial hair on R18's face and asked R18 if the staff shave his face. R18 stated well, as you can see, they haven't and stated he doesn't like having facial hair. R19 (R18's roommate/family member) stated they only have one girl at the facility that can shave so (R18) has to wait until she has time. On 3/31/26 at 1:31 PM, V30 (Registered Nurse/RN) stated she doesn't think there are enough CNA's to properly care for the residents. V30 stated she gets complaints from residents that they have to wait to be cleaned up after being incontinent and she sees beds are not being stripped and clean linens put on due to not having enough CNA's. V30 stated water isn't passed to residents every day either due to not having enough CNA's to do it. On 4/16/26 at 11:58 PM, V39 (CNA) stated she thinks staffing is better now but there were a couple of times she worked with only 2 CNA's in the building. V39 stated a few weeks ago on a weekend there were only 2 CNA's for most of the day. On 4/16/26 at 12:00 PM, V1 (Administrator) stated they do not have a policy related to staffing. The facilities Daily Census report dated 3/18/26 documents 67 total residents living in the facility.

Based on interview and record review, the facility failed to ensure quarterly Quality Assurance meetings were held and failed to ensure the Medical Director attended the Quality Assurance meetings. This failure has the potential to affect all 67 residents residing in the facility. Findings include:The facility's Quality Assurance Meeting Sign-in List and Minutes dated 1/23/25, 3/13/25, 7/30/25, and 1/9/26 did not document a signature from the facility's medical director affirming the medical director's attendance. On 3/24/26 at 11:20 AM, V1 (Administrator) stated they did not have a QAPI (Quality Assurance and Performance Improvement) meeting for the 4th quarter in 2025. V1 stated they only had one in January 2025, March 2025, and July 2025 in 2025. V1 stated the medical director has never attended the QAPI meetings. On 4/13/26 at 3:00 PM, V1 stated they do not have a policy related to quarterly quality assurance meetings, but they are to be held quarterly, and the medical director should be in attendance. The facility Daily Census report dated 3/17/26 documented there were 67 residents residing in the facility.

Based on interview and record review, the facility failed to ensure staff were trained on effective communications. This has the potential to affect all 67 residents currently residing at the facility. Findings include:On 3/24/26 at 11:00 AM, staff training in-services provided to this surveyor by V1 (Administrator) were reviewed. Training subjects that were missing included communication, behavioral health, and nursing aide annual required training. On 3/24/26 at 12:50 PM, V7 (Regional Director of Clinical Services) stated he was only able to find staff training on QAPI (Quality Assurance and Performance Improvement), infection control, resident rights, and abuse. V7 stated he was unable to find any staff training on communication, compliance and ethics, behavioral health, and any nursing aide required training. On 3/24/26 at 1:00 PM, V1 (Administrator) stated the staff have not been trained on communication, behavioral health, and the nurses' aides have not received their required number of annual training hours. V1 stated she wasn't aware those were required. On 4/13/26 at 3:00 PM, V1 stated they do not have a policy related to staff training. The facility Daily Census report dated 3/17/26 documented there were 67 residents residing in the facility.

Based on observation, interview, and record review, the facility failed to provide dependent residents with timely ADL (Activities of Daily Living) assistance for diabetic toenail care and shaving for 5 of 5 residents (R4, R11, R17, R18, R25) reviewed for ADL assistance in a sample of 25. Findings include: 1. R4's admission Record documented an admission date of 8/12/25 and included diagnoses of type 2 diabetes, muscle weakness, unsteadiness on feet, other fatigue, and bilateral hearing loss. R4's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Under Functional Goals and Abilities, this MDS documents R4 needs supervision or touching assistance for personal hygiene. R4's Care Plan documents an ADL self-care performance deficit related to chronic disease process. R4's Order Summary Report documents may see podiatrist with an order date of 8/12/25. On 4/16/26 at 11:01 AM, V4 (License Practical Nurse/LPN) observed R4's toenails with this surveyor present. R4's toenails were long and wrapping around the end of his toes, extending to underneath of his toes. V4 stated R4's toenails needed trimmed, and she doesn't know why they haven't been trimmed. V4 stated they used to have a podiatrist come to the facility, but they don't have one that comes to the facility anymore. 2. R25's admission Record documented an admission date of 9/8/22 and included diagnoses of type 2 diabetes, Alzheimer's disease, muscle weakness, and need for assistance with personal care. R25's MDS assessment dated [DATE] documented a BIMS score of 07, indicating severe cognitive impairment. Under Functional Abilities and Goals, the MDS documented R27 is dependent with personal hygiene, meaning the helper does all the effort. R25's Care Plan documents R25 has an ADL self-care performance deficit related to weakness and requiring assistance with ADLs. R25's Order Summary Report documents may see podiatrist with an order date of 11/18/25. On 4/16/26 at 11:15 AM, V4 (LPN) observed R25's toenails with this surveyor present. R25's toenails were thick and needed trimmed. V4 stated she wouldn't feel comfortable trimming R25's toenails due to the thick growth of the nails and stated R25 needs a podiatry referral. 3. R11's admission Record documented an admission date of 12/27/22 and included diagnoses of type 2 diabetes, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side, borderline intellectual functioning, and muscle weakness. R11's MDS assessment dated [DATE] documented a BIMS score of 13, indicating intact cognition. Under Functional Abilities and Goals, the MDS documented R11 needs supervision or touching assistance with personal hygiene. R11's Care Plan documents R11 has a diagnosis of type 2 diabetes initiated 1/26/23 with included interventions refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails initiated 1/26/23. R11's Order Summary Report documents may see podiatrist with an order date of 7/22/24. On 4/16/26 at 11:08 AM, V4 observed R11's toenails with this surveyor present. R11's toenails were long and V4 stated they needed trimmed. R11 stated her toes are painful and her toenails need trimmed. 4. R18's admission Record documented an admission date of 6/5/24 and included diagnoses of Parkinson's disease, dementia, muscle weakness, and other lack of coordination. R18's MDS assessment dated [DATE] documented a BIMS score of 05, indicating severely impaired cognition. Under Functional Abilities and Goals, the MDS documented R18 is dependent with personal hygiene. R18's Care Plan documents an ADL self-care performance deficit related to dementia, Parkinson's, and impaired balance with generalized weakness initiated 6/7/24. On 3/25/26 at 2:43 PM, this surveyor observed facial hair on R18's face and asked R18 if the staff shave his face. R18 stated well, as you can see, they haven't and stated he doesn't like having facial hair. R19 (R18's roommate/family member) stated they only have one girl at the facility that can shave so (R18) has to wait until she has time. 5. R17's admission Record documented an admission date of 6/27/25 and included diagnoses of arthritis and glaucoma. R17's MDS assessment dated [DATE] documented a BIMS score of 11, indicating moderately impaired cognition. Under Functional Abilities and Goals, the MDS documented R17 is dependent with personal hygiene, meaning the helper does all the effort. R17's Care Plan documents ADL's: R17 has limited physical mobility related to COPD (Chronic Obstructive Pulmonary Disease) and being on oxygen. On 3/25/26 at 10:31 AM, this surveyor observed facial hair on R17's face. R17 stated they don't shave him very often, but he would like to be shaved. R17 stated he gets showers 2 times a week and they didn't shave him with his last shower. On 3/30/26 at 3:05 PM, R17 was observed with facial hair and stated he was told he is getting a shower tomorrow and they would shave him then. On 3/31/26 at 3:00 PM, R17 was again observed with facial hair and dirty appearing hair. R17 stated they didn't get him up for a shower yesterday, they gave him a bed bath and didn't wash his hair or shave him. R17 stated he doesn't know why they didn't get him up for a shower, shave him, or wash his hair and stated he didn't refuse any of it. R17 stated the CNA's are always in a hurry and act like they don't have time to do anything. R17 stated he is sick and tired of bed baths and wants a shower. On 3/31/26 at 3:48 PM, V37 (CNA) stated she gave R17 his bed bath and she didn't shave him or wash his hair. V37 stated R17 didn't want shaved. On 4/16/26 at 11:01 AM, V4 (LPN) stated the nurses are supposed to trim toenails for diabetic residents and she doesn't know if toenails are supposed to be trimmed on shower days or on skin check days, but the CNA's should let the nurses know if a diabetic resident needs their toenails trimmed. On 4/16/26 at 12:02 PM, V6 (Assistant Director of Nursing/ADON) stated the nurses oversee trimming toenails for diabetic residents but it always ends up being her because the nurses don't do it and she hasn't had time to trim toenails due to being short staffed. On 4/16/26 at 11:20 AM, V1 (Administrator) stated toenail care for diabetic residents should be done when the nails need trimmed. V1 stated there isn't a schedule or any one nurse in charge of diabetic toenail care, it should just be done when they see the toenails need trimmed. V1 stated they don't have a podiatrist that comes to the facility, they refer out for that. On 3/31/26 at 3:06 PM, V6 (ADON) stated residents are supposed to be shaved on shower days and in between as needed/requested by residents. On 4/20/26 at 10:57 AM, V7 (Regional Director of Clinical Services) stated they do not have a policy regarding shaving of residents' faces. A facility policy titled Care of Fingernails/Toenails dated 2022 documents under Purpose: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Under Steps in the Procedure: 5. RNs (Registered Nurses) to trim toenails of a diabetic mellitus resident.

Based on observation, interview, and record review, the facility failed to pass water to 4 of 4 residents (R4, R7, R21, R22) reviewed for hydration in a sample of 25. Findings include:1. R4's admission Record documented an admission date of 8/12/25 and included diagnoses of chronic obstructive pulmonary disease, type 2 diabetes, muscle weakness, primary hypertension, and atherosclerotic heart disease of native coronary artery. R4's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. R4's Order Summary Report documents Furosemide oral tablet 20 milligrams (mg), give one tablet by mouth in the morning related to primary hypertension. R4's Care Plan documents R4 has potential/actual impairment to skin integrity related to fragile skin (initiated 8/22/25) with a corresponding intervention to encourage good nutrition and hydration to promote healthier skin (initiated 8/22/25). On 3/19/29 at 9:29 AM, R4 did not have water in his room. R4 stated he doesn't get water very often and he likes to have water to drink because sometimes he gets thirsty. On 3/30/26 at 8:55 AM, R4 did not have water in his room. R4 stated sometimes someone brings him water but not every day. On 4/13/26 at 2:15 PM, R4 stated no one has filled his water cup up today. R4 stated there is a little bit of water left in his cup, but it is old and warm. On 4/2/26 at 11:35 AM, V27 (Family Member/Power of Attorney-POA)stated every time she would visit R4 he wouldn't have water in his room. Therefore, she brought a cup in for R4 so they could fill it with water and still a lot of the time she goes to see him, the cup still doesn't have water in it. 2. R21's admission Record documented an admission date of 2/19/26 and included diagnoses of dehydration, muscle wasting and atrophy, urinary tract infection, and adult failure to thrive. R21's MDS assessment dated [DATE] documented a BIMS score of 12, indicating moderate cognitive impairment. Dehydration is listed in the Active Diagnoses section of this MDS. Under Care Area Assessment Summary Dehydration/Fluid Maintenance is checked as a triggered care area. R21's Care Plan documents R21 has potential/actual impairment to her skin integrity related to chronic disease processes (initiated 2/20/26) with a corresponding intervention to encourage good nutrition and hydration to promote healthier skin (initiated 2/20/26). On 4/13/26 at 1:52 PM, R21 stated she doesn't get water passed every day. R21 stated she was admitted to the hospital with dehydration prior to her admission to the facility, so it is important she drinks enough water every day. R21 stated when she was first admitted to the facility, she never got water passed to her, so her daughter had to start bringing her water, stating she comes by almost every day with a fresh cup of ice water. R21 stated the facility is so short staffed on CNA's (Certified Nurse Aides) that she hates having to ask for water because she knows they don't have enough CNA's to do everything. V36 (Family Member) was present during this interview and stated there was an issue with R21 not getting anything to drink during the day so V36 started bringing R21 water to the facility. 3. R7's admission Record documented an admission date of 8/15/25 and included diagnoses of urinary tract infection, chronic obstructive pulmonary disease, emphysema, chronic kidney disease, and disorders of kidney and ureter. R7's MDS assessment dated [DATE] documented a BIMS score of 14, indicating intact cognition. R7's Care Plan documents R7 has impaired skin integrity related to age related changes, chronic disease processes, incontinence, and deconditioning (initiated 8/22/25) with a corresponding intervention to encourage good nutrition and hydration to promote healthier skin (initiated 8/22/25). R7's Order Summary Report documents R7 was referred to urology related to frequent urinary tract infections on 1/15/26. On 3/25/26 at 9:59 AM, R7 stated she doesn't get water passed to her every day and she wishes they would. R7 stated she likes having water to drink during the day. R7 stated she asks for water sometimes and they do get it, but only when she asks. R7 stated they shouldn't have to ask for water, adding what happens to the residents that can't ask? On 4/6/26 at 9:25 AM, R7 stated they don't pass fresh water to her every day, stated the water she has now is from the night before when she asked someone to get her a drink. R7 stated the CNA's tell her they are short staffed often, so she thinks that is why they don't pass water every day. On 4/6/26 at 1:16 PM, R7 still did not have a cup of water in her room and stated she hasn't gotten any water passed to her today. 4. R22's admission Record documented an admission date of 8/29/25 and included diagnoses of muscle wasting and atrophy, muscle weakness, and fatigue. R22's MDS assessment dated [DATE] documented a BIMS score of 15, indicating intact cognition. R22's Care Plan documents R22 has potential impairment to her skin integrity related to limited mobility (initiated 9/2/25) with a corresponding intervention to encourage good nutrition and hydration to promote healthier skin initiated 9/2/25. On 4/6/26 at 9:28 AM, R22 did not have a cup of water in her room. R22 stated occasionally someone will bring her water to her room, but not very often. R22 stated sometimes she gets thirsty and would like a cup of water. On 4/6/26 at 1:25 PM, R22 still did not have a cup of water in her room. R22 stated no one has brought her water all day. On 4/13/26 at 2:10 PM, R22 did not have a cup of water in her room. R22 stated no one has brought her any water to her room today. On 3/23/26 at 3:20 PM, V12 (Helping Hand) stated water is supposed to be passed once in the morning and once in the afternoon. V12 stated she is still in school, so she doesn't come in until 3:00 PM during the week and a lot of the time water hasn't been passed for the day yet because there aren't enough CNA's to properly care for the residents and pass water. V12 stated when she gets to the facility, V2 (Director of Nursing/DON) usually tells her she needs to pass water because the CNA's haven't had time to pass water yet. On 3/31/26 at 1:31 PM, V30 (Registered Nurse/RN) stated she sees water isn't passed to residents every day due to not having enough CNA's to do it. On 4/13/26 at 2:24 PM, V1 (Administrator) stated water should be passed in the morning around 7:00 AM to 10:00 AM, again in the afternoon, and again around 7:00 PM to 10:00 PM. V1 said then the night shift picks all the cups up around 4:00 AM to 5:00 AM and takes them to the kitchen for them to be washed so the day shift can get them again for that morning. On 4/16/26 at 12:00 PM, V1 stated the facility does not have a policy related to hydration and passing water to residents.

Based on observation, interview, and record review the facility failed to answer call lights in such a manner to promote resident dignity and provide timely assistance for 2 of 2 residents (R6 and R24) reviewed for resident rights in the sample of 25. Findings include:1. R24's admission Record documented an admission date of 7/16/25 and included diagnoses of anxiety disorder, chronic kidney disease, and essential tremors. R24's MDS (Minimum Data Set) assessment dated [DATE] documented a BIMS score of 11, indicating moderate cognitive impairment. R24's Care Plan documents R24 is a fall risk (initiated 8/22/25) and included corresponding interventions to be sure R24's call light is within reach and encourage R24 to use it for assistance as needed. R24 needs prompt response to all requests for assistance (initiated 8/22/25). On 3/31/26 at 1:35 PM, R24's call light was observed to be already activated at 1:35 PM. Continuous observation revealed the call light to be answered by V6 (Assistant Director of Nursing/ADON) at 1:56 PM. R24 stated she always has a long wait when she puts her call light on. R24 stated she usually has to wait at least 20 minutes. V6 stated she got to R24 as quickly as she could, but they had more CNA's (Certified Nursing Aides) call in today and she was working the floor to help. 2. R6's admission Record documented an admission date of 3/2/22 and included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, morbid obesity, cystitis, weakness, and polyarthritis. R6's MDS assessment dated [DATE] documented a BIMS score of 12, indicating moderately impaired cognition. Under Functional Abilities and Goals, the MDS documented R6 as dependent with toileting hygiene, meaning the helper does all the work. R6's Care Plan documents R6 has bowel/bladder incontinence and requires assistance with toileting (initiated 4/28/20). The same Care Plan documents R4 displays behavioral symptoms related to turning the call light on, staff will answer the call light, and as soon as staff walks out, call light is turned back on (initiated 6/27/25). Corresponding interventions document, once call light is turned on, staff will go see what R6 needs and once staff have completed care if R6 turns the light on after leaving the room, staff will go back into room to verify if she needs anything (initiated 6/27/25). On 3/19/26 at 9:41 AM, this surveyor observed R6's call light already activated. During continuous observation, this surveyor observed V10 (Activities Director) go into R6's room. V10 did not ask R6 if she needed anything, then left room and the call light remained on. R6 stated to this surveyor, she needs to be cleaned up, she was incontinent. At 9:57 AM, V38 (Medical Records) came into the room and asked R6 if she needed something and she said she needed cleaned up. V38 said she would get someone to help R6. At 10:00 AM, V15 and V23 (both CNA's) came into R6's room to clean her up. V15 stated she is the only one on this hallway and she is training V23 because it is her first day. On 4/20/26 at 9:46 AM, V7 (Regional Director of Clinical Services) stated they do not have a policy related to call lights. On 4/21/26 at 1:23 PM, V1 confirmed they do not have a policy related to call lights that she is aware of. V1 stated anyone can answer call lights so she would hope that within 15 minutes max that someone has answered the call light.

Based on interview and record review the facility failed to notify the physician and resident representative of an elopement event for 2 of 5 residents (R1 and R2) reviewed for notifications in a sample of 25. Findings include:1. R1's admission Record documented an admission date of 9/5/25 and included diagnoses of dementia, osteoarthritis of knee, and hypertension. R1's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 07, indicating R1's cognition is severely impaired. Section E of this same MDS assessment, titled Wandering-Presence and Frequency documents, this behavior occurred daily. R1's document titled Risk Management dated 3/6/26 at 11:30 AM documents under Nursing Description resident noted to be up the street pushing her friend to go look at cemetery, no s/s (signs/symptoms) of injury noted, resident brought back to facility in company van. Under Resident Description, it documents I was just going to show her my Mom and Dad's grave and under Description of Action Taken it documents resident noted to be up the street pushing her friend to go look at cemetery, no s/s of injury noted, resident brought back to facility in company van, assessed and brought back to facility per (name) another resident, they followed the smokers out and went the opposite direction. RCA (Root Cause Analysis)-confusion, thinks she is in community. Immediate intervention-staff educated that if resident is noted to be wearing makeup they should monitor for increased elopement risk. There is no documentation of physician notification in this document. R1's Progress Note created on 3/18/26 at 11:32 AM and effective on 3/6/26 at 11:32 AM created by V1 documents resident noted to be up the street pushing her friend to go look at cemetery, no injury noted, resident brought back to facility. RCA (Root Cause Analysis)-confusion, thinks she is in community. Immediate intervention-staff educated that if resident is noted to be wearing makeup they should monitor for increased elopement risk. 2. R2's admission Record documents an admission date of 9/11/25 and included diagnoses of anxiety disorder, chronic obstructive pulmonary disease, muscle weakness, cerebral atherosclerosis, primary hypertension, history of falling, metabolic encephalopathy, and osteoarthritis. R2's MDS assessment dated [DATE] documents a BIMS score of 04, indicating R2's cognition is severely impaired. R2's document titled Risk Management dated 3/6/26 at 11:30 AM documents under Nursing Description resident went with roommate on a 'walk,' no s/s of injuries noted. Under Resident Description, it documents I told her we should head on back and under Description of Action Taken it documents resident went with roommate on a 'walk' no s/s/ of injury noted. Per (name) another resident, they followed the smokers out and went the opposite direction. RCA-went for a walk with friend. Immediate intervention-resident educated to let staff know if roommate talks about going for a walk. There is no documentation of physician or family notification in this document. R2's Progress Note created on 3/18/26 at 11:39 PM and effective 3/6/26 at 11:38 AM documents Late Entry: Note Text: resident went with roommate on a walk, no s/s of injuries noted RCA- went for a walk with friend. Immediate intervention- resident educated to let staff know if roommate talks about going for a walk On 3/19/26 at 2:13 PM, V14 (Power of Attorney/Family Member) stated he was not notified when R2 eloped from the building on 3/6/26. V14 stated he was told on 3/18/26 when he came to the facility for a care plan meeting. On 3/18/26 at 12:39 PM, V17 (Registered Nurse/RN) stated she was the nurse working R1 and R2's hall when they eloped on 3/6/26. V17 stated she doesn't know how they got out or how long they had been gone. V17 stated she did not notify the physician. On 3/18/26 at 12:30 PM, V1 stated the physician was not notified when R1 and R2 eloped on 3/6/26. A facility policy titled Elopements dated 2026 documents under Policy Interpretation and Implementation, 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: b. Notify the Attending Physician, c. Notify the residents legal representative (sponsor) of the incident, d. Document the notifications and exam in the resident's medical record.

Based on observation, interview, and record review the facility failed to develop a comprehensive care plan that includes interventions to effectively communicate with a hearing-impaired resident for 1 of 3 residents (R4) reviewed for resident rights in a sample of 25.Findings include:R4's admission Record documents an admission date of 8/12/25 with included diagnoses of bilateral hearing loss.R4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 12, indicating R4 has moderate cognitive impairment. Section B documents R4's hearing is highly impaired, absence of useful hearing and under ability to understand others it documents R4 usually understands, misses some part/intent of message but comprehends most conversation.R4's Comprehensive MDS dated [DATE] documents in Section B that R4's hearing is highly impaired, absence of useful hearing and under ability to understand others it documents R4 usually understands, misses some part/intent of message but comprehends most conversation. Under Care Area Assessment Summary, it documents Communication-Care Area Triggered, Yes.R4's current Care Plan did not document a focus area of R4's hearing loss and did not document R4's communication needs. R4's Progress Note dated 8/22/26 at 3:28 AM authored by V40 (Licensed Practical Nurse/LPN) documents Resident resting calmly in bed at this time. No s/s (signs or symptoms) of acute distress noted at this time. No c/o (complaint of) pain or discomfort voiced this date. Up ad lib (freely), feeds self with setup. Alert and able to make needs known well. Deaf but can read lips very well. This nurse communicates with text to speech function on device. Resident able to read well. Breathing even and non labored, no cough noted this date.R4's Progress Note dated 2/3/26 at 11:21 PM authored by V21(Registered Nurse) documents Resident alert & Oriented x4. Able to make needs known. Resident Deaf, but communicates reading lips. Speech clear. Resident does not seem to grasp the severity that he has Cancer that has spread that is making him feel 'not good.' Resident states 'what are you guys even doing for me' 'what are you doing for my cough and shoulder' Resident was started on the meds listed above and also given Tylenol to help manage pain. Resident has a care plan meeting 2/4 to discuss care. Resident reminded that he has been referred to Oncology in relation to his Cancer spreading. Call light within reach. plan of care to continue.On 4/6/26 at 11:14 AM, V37 (Certified Nursing Aide) came into R4's room to pull him up in his chair and V37 walked to his bathroom and was talking to him while she was in the bathroom, with her face out of R4's sight. R4 stated to this surveyor that he didn't know what V37 was saying, he couldn't hear her. This surveyor asked V37 if she knew R4 was deaf, and V37 replied she was told that R4 could hear in one ear.On 4/21/26 at 1:28 PM, V9 (MDS Coordinator) stated if the MDS assessment triggers a care area it should be care planned in his care plan. V9 stated she doesn't know why communication isn't care planned for R4 because it should be. V9 stated she thinks she might have missed the care area trigger and didn't put it in his care plan. V9 stated since R4 is deaf and sometimes struggles to read lips that a dry erase board in his room would help with communication. V9 stated when she is talking to R4 he will start to look away and she has to wave her hand in front of him to get him to look back to her to communicate. V9 stated she doesn't know how R4's communication needs are communicated with the rest of the staff.

Based on interview and record review the facility failed to ensure the safety of 1 of 3 (R5) residents reviewed for accidents in the sample of 20. This failure resulted in R5 falling out of his wheelchair when the van made a sudden stop, resulting in R5 sustaining fractured ribs and clavicle.This past non-compliance occurred between 2/13/26 and 2/16/26.Findings Include:R5's admission Record with a print date of 2/26/26 documents R5 was admitted to the facility on [DATE] with diagnoses that include history of myocardial infarction, heart failure, hypertension, and atrial fibrillation.R5's Minimum Data Set, dated [DATE] documents R5 has a Brief Interview Mental Status Report score of 13, indicating R5 is cognitively intact.R5's current Care Plan documents a Focus area of, ADLs: (R5) has limited physical mobility r/t (related to) COPD (chronic obstructive pulmonary disease) and being on oxygen. Date Initiated: 01/14/2026. This same Focus area includes the Intervention of, Ambulation: (R5) requires a wheelchair to ambulate the facility. Date Initiated: 01/14/2026.R5's Fall report dated 2/13/26 documents, Received a call from transport driver stating that while on transport a deer ran in front of the van. The brakes were applied abruptly, and resident came out of wheelchair striking his head on the floor. Resident taken to (initials of local hospital) for evaluation. Upon return from hospital no injuries were noted.RCA (root cause analysis) malfunction of seatbelt per staff. Immediate Intervention: Resident taken to (initials of hospital) for eval (evaluation).van taken out of service, re-education of staff with return demonstration.Notes: R (right) clavicle fx (fracture), rib fx, initially cleared at (name of hospital) ER (emergency room), after return to building had increased pain, which was addressed, new xray indicated fxs on 2/16/26.R5's Progress Notes document the following,2/13/26 2:45 PM, Received call from staff stating that a deer ran in front of the facility van, brakes were applied and (R5) was noted in the floor of the van. I instructed the staff member to take resident to (name of hospital) for evaluation.2/13/26 6:15 PM, (R5) back in facility with a diagnosis of shoulder strain. No new orders received.2/15/26 2:50 PM, (R5) returned a call to (name of nurse) and ordered lidocaine patch and ice to the effected area. Lidocaine patch and ice applied.2/16/26 11:00, Resident continues on monitoring checks post fall on 2/13. WNL. (within normal limits). Current vital signs are WNL.Resident complaining of pain to right ribcage. (name of physician) ordered lidocaine patch yesterday per orders. This nurse reached out about obtaining x-ray, awaiting response.2/16/26 11:24 AM, (name of physician) agrees with order of 2 view x-ray to right ribcage.2/16/25 3:16 PM, Received results from Biotech via fax. Results show: acute non-displaced right lateral 10th rib fracture and acute distal clavicle fracture. DON (Director of Nurses and administrator aware.2/16/26 4:32 PM, .orders to send resident to ER (emergency room). 911 contacted.2/16/26 6:43 PM, Resident arrived back to facility with order for hydrocodone 5-325 mg (milligrams) Q (every) 6h (hours) PRN (as needed) for pain and to follow up with orthopedics. Sling in place to right arm.R5's hospital records dated 2/16/26 documents a discharge summary that indicates R5 was discharged with diagnoses of fractures, including a fractured clavicle.On 2/26/26 at 9:16 AM, R5 stated he was in the van going to an appointment and the driver made a quick stop. R5 stated he hit the dashboard, and the wheelchair landed on top of him. R5 stated he went to the emergency room, and they did x-rays and sent him home. R5 stated he didn't remember if he was buckled in or if the wheelchair was buckled but it must not have been for the wheelchair to have ended up on top of him.On 2/26/26 at 10:22 AM, V11 (CNA/Certified Nursing Assistant) stated she was driving the van on 2/13/26 when R5 fell. V11 stated there are four clamps that lock the wheelchair in place and then the seatbelt on the resident. V11 stated when the van stopped, R5 was sitting on the floor and as she was assisting him up the wheelchair fell over because R5 was too heavy for her to lift by herself. V11 stated she did eventually get him into his chair. V11 stated she had buckled R5 and the chair in prior to starting the trip.On 2/26/26 at 10:46 AM, V12 (CNA) stated she knew R5 wasn't buckled in properly on the day the incident occurred (2/13/26). V12 stated R5 went flying and ended up with a broken clavicle. When asked how she knew R5 wasn't buckled in, V12 stated, R5 told her he wasn't buckled in. V12 stated she didn't know when R5 told her that.On 2/25/26 at 9:20 AM, V1 (Administrator) stated on the day the incident occurred, the driver stopped suddenly to keep from hitting a deer. V1 stated R5 was in the wheelchair with a seat belt on but it came unlatched and R5 fell. V1 stated they took R5 to the emergency room and they said he had a shoulder strain. V1 stated R5 continued to complain of pain so they notified the physician and got a pain patch ordered. V1 stated R5 continued to complain of pain so they got new x-rays and found a fractured clavicle and ribs. V1 stated after the incident they took the van out of commission until it could be checked by mechanics. V1 stated the seat belt appeared to be functioning properly. V1 stated the driver no longer works at the facility. On 2/26/26 at 1:48 PM, V1 stated V12 does work for the facility but was suspended pending the outcome of the investigation.The Self-Identified Quality Assurance Plan of Correction dated 2/13/26 documents, .Problem Identified: Resident had a fall in facility transportation van. 1. Corrective Action(s).(R5) will be taken to ER (emergency room) for evaluation. 2. All residents transported by facility van have the potential to be affected by the alleged deficient practice. Facility immediately re-educated staff on proper securing of residents in seatbelt of transportation van. All van drivers' re-education initiated with return demonstration on proper seatbelt application in the van. Facility immediately initiated an incident investigation. Van removed from service for seatbelt safety check to be completed. Facility completed incident investigation and placed safety intervention with updated care plan. ADMIN (administrator/V1), DON (Director of Nurses/V2 and/or designees will do random observations of at least one staff member securing a wheelchair in transportation van a minimum of 5 times per week for 4 weeks. ADMIN, DON and/or designee will do random education checks to ensure staff is knowledgeable of proper wheelchair securement in transportation van minimum of 5 times per week for 4 weeks. Results of the observations will be discussed in the Quarterly QA (quality assurance) Meeting times 2 with education needs discussed as needed by the Facility Administrator/DON and/or designee. According the Survey Plan of Correction Tool training was completed on 2/16/26.The facility undated Drive Safe Program documents under 2. Transporting Residents and Employees, .Driver of vehicle is responsible to make sure all passengers are securely seated and use their seat belts. No employee is authorized to ride or work from the bed or rear of a vehicle while it is in motion .

Based on observation, interview, and record review the facility failed to ensure the facility was kept clean for 4 of 5 (R2, R3, R13, and R15) residents reviewed for safe and home like environment in the sample of 20. Findings Include: 1.R2's admission Record with a print date of 2/26/26 documents R2 was admitted to the facility on [DATE] with diagnoses that include heart disease, osteoarthritis, muscle weakness, and fatigue.R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 11, indicating a moderate cognitive deficit.R2's current Care Plan does not address R2's activities of daily living (ADL) status in a Focus area or intervention.On 2/25/26 at 9:45 AM, R2 stated the facility staff clean, ok. R2 stated later in the day the room does not get clean. R2 stated someone made a mess on the commode in the shared bathroom last night, he asked an unknown staff member to clean it and was told it wasn't their job.On 2/25/26 at 9:48 AM, R3 who was alert to person, place and time stated he was R2's roommate. R3 stated R2 tried to use the bathroom last night (2/24/26) and wasn't able to because the commode was too dirty. R3 stated they asked for it to be cleaned and was told by an unknown staff member it wasn't her job. R3 stated the housekeeper cleaned it for them the next morning (2/25/26).On 2/25/26 at 11:14 AM, V8 (Housekeeper) stated she was asked by R2 and R3 to clean their bathroom the morning of 2/25/26. V8 stated it was messy but not too bad. V8 stated there was a little bit of feces on the inside of the toilet where you open the lid. When asked if she would have been comfortable using the commode with the feces on it, V8 stated she would not.2. R13's admission Record with a print date of 2/26/26 documents R13 was admitted to the facility on [DATE] with diagnoses that include diabetes, morbid obesity, heart failure, and chronic kidney disease.R13's MDS dated [DATE] documents a BIMS score of 14, indicating she is cognitively intact.R13's current Care Plan documents a Focus area of, ADLs: (R13) has limited physical mobility r/t (related to) weight and need for ADL assistance to be safe. Date Initiated: 11/25/2024. This same Focus area includes the intervention of, Provide supportive care, assistance with mobility as needed. Document assistance as needed. Date Initiated: 11/25/2024.On 2/25/26 at 10:22 AM, R13 refused to answer this surveyor when asked if her room was kept clean by the facility staff. R13's bathroom was observed on this same date and time and noted feces stuck to the toilet riser.On 2/25/26 at 11:59 AM, feces remainwd on R13's commode riser.3. R15's admission Record with a print date of 2/26/26 documents R15 was admitted to the facility on [DATE] with diagnoses that include dementia, peripheral vascular disease, muscle weakness, and fatigue.R15's MDS dated [DATE] documents a BIMS score of 05, indicating a severe cognitive deficit.R15's current Care Plan documents a Focus area of ADLs: (R15) has an ADL Self Care Performance Deficit r/t chronic disease process. Date Initiated: 09/06/2025. This same Focus area includes the intervention of, Encourage the resident to participate to the fullest extent possible with each interaction. Date Initiated: 09/05/2025.On 2/26/26 at 7:08 AM, R15's commode had a red/brown substance that appeared dry around the commode fixtures and splattered down the wall.On 2/26/26 at 10:22 AM, V11 (CNA/Certified Nursing Assistant) stated there are times the resident bathrooms are horrible. V11 stated if you ask housekeeping to clean something specific, they do it, but they don't always take the initiative to clean the bathrooms without being told.On 2/26/26 at 10:46 AM, when asked about the cleanliness of the bathrooms, V12 (CNA) stated, They could do better. V12 stated she tries to clean the bathrooms when she works but you can only do so much. When asked what types of things she has seen, V12 stated, around the toilet bowl, they are just dirty.On 2/26/26 at 9:24 AM, V10 (Housekeeping Supervisor) stated he had not had any complaints/concerns brought to him related to cleaning. V10 stated if he did, he would reeducate staff on how to clean and would fix the problem.The facility Quality Control, Environmental Services policy dated 2021 documents, A quality control program shall be maintained by the housekeeping and laundry departments.1. To assist in maintaining a standard of excellence, our housekeeping and laundry departments have developed a quality control program that: a. Identifies specific deficiencies; b. Measures the level of the quality of services provided by our departments; and c. Continually furnishes information to the Quality Assessment and Assurance Committee that will aid in taking corrective action to assure that compliance with regulations can be maintained.

Based on observation, interview, and record review the facility failed to ensure resident preferences were honored for 5 of 5 (R3, R4, R12, R13, and R18) residents reviewed for preferences in the sample of 20.Findings Include: 1.R4's admission Record with a print date of 2/26/26 documents R4 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease, spondylolysis, repeated falls, chronic obstructive pulmonary disease, heart disease, adult failure to thrive, anxiety, and cognitive communication deficit.R4's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 09, indicating R4 has a moderate cognitive deficit.R4's Order Summary Report dated 2/26/26 includes the following physician order with a start date of 11/21/25, NCS (No Concentrated Sweets) diet Mechanical soft texture, Thins Liquids consistency, SC (super cereal) at breakfast, Health Shakes TID (three times daily) with meals. Fortified foods TID for diet.R4's current Care Plan Report documents a Focus area of Nutrition: (R4) has potential nutritional problem r/t (related to) He is on a NCS, mechanical soft texture, thin liquids diet. He receives super cereal at breakfast, fortified foods TID, health shakes TID. Diet restrictions: Date Initiated: 06/14/2024. This same Focus area includes the following interventions, .NCS (No Concentrated Sweets) diet, Regular texture, Thin Liquids consistency SC (super cereal) at breakfast, Health Shakes TID with Meals for diet. Date Initiated: 10/17/2024.Provide and serve supplements as ordered. Date Initiated: 05/14/2024.Provide, serve diet as ordered.On 2/26/26 at 7:56 AM, R4 was in his room with his breakfast tray sitting on the bedside table. R4 was served fruit loops, orange juice, milk, mighty shake, coffee, cookies, pears, and a bowl of milk.R4's meal card documents under Notes, Likes Cheerios.On 2/26/26 at 3:06 PM, V4 (Dietary Manager) stated residents who had a diagnosis of diabetes would be served a non-sugar cereal such as cheerios or rice krispies. When asked why R4 received fruit loops, V4 stated that was R4's preference. This surveyor reviewed R4's meal card documenting R4 liked cheerios and V4 stated R4 should have been served his preference cereal of cheerios.2. R3's admission Record with a print date of 2/26/26 documents R3 was admitted to the facility on [DATE] with diagnoses that include diabetes.R3's MDS dated [DATE] does not document a BIMS score.R3's current Care Plan does not document a nutrition Focus area.On 2/25/26 at 9:48 AM, R3 stated he had been served peanut butter and jelly sandwiches for the past few days because the kitchen had been down and he was getting tired of them.On 2/25/26 at 12:01 PM, the kitchen was noted to be empty of appliances, cabinets, flooring, and sinks. There were contractors working in the kitchen. There were tables set up in the dining room with kitchen staff serving lunch off them. On 2/26/26 at 9:51 AM, V4 (Dietary Manager) stated they started the remodel on 2/23/26 and it was expected to be completed within 9 business days. V4 stated they were using the emergency menu with shelf stable foods.The facility emergency menu documents the following breakfast menu, Day 1- juice, dry cereal, canned fruit, peanut butter cookies, pudding, reconstituted canned or dry milk, Day 2- juice dry cereal, canned fruit, peanut butter and jelly sandwich, reconstituted dry or canned milk, Day 3- juice, dry cereal, canned fruit, peanut butter cookies, pudding, reconstituted dry or canned milk, Day 4- juice, dry cereal, canned fruit, peanut butter and jelly sandwich, reconstituted canned or dry milk, Day 5- juice, dry cereal, canned fruit, peanut butter cookies, pudding, reconstituted dry or canned milk, Day 6- juice, dry cereal, peanut butter and jelly sandwich, reconstituted dry or canned milk, Day 7- juice, dry cereal, canned fruit, peanut butter cookies, pudding, reconstituted dry or canned milk.3. The facility Resident Council Memorandum dated 2/12/26 documents 13 residents were present. Under Issue the Memorandum documents, Renovation to the kitchen on the 23rd and last 7 to 9 days and changing of the menu, signed by V13 (Social Services Director). Under Response the Memorandum documents, no to corned beef. Under Follow up in Resident Council the Memorandum documents, Resident agreed to the change due to renovation agreed to menu changes and change in routine, signed by V1 (Administrator).The facility Emergency Menu documents corned beef was to be served on day 2 and day 5.On 2/26/26 the facility kitchen staff served corned beef hash, green beans, cookies, and beverages to the residents.On 2/26/26 at 12:29 PM, R18 was served the noon meal of corned beef hash, green beans, and cookies and stated, Take it away. R18 was offered a corn dog or sandwich by facility staff.On 2/26/26 at 12:40 PM, R12 who was alert to person, place and time, stated lunch was awful and stated she ate a ham sandwich instead of the corned beef hash she was served.On 2/26/26 at 12:43 PM, R13 was in her room making a deli sandwich from her personal food supply. R13 who was alert to person, place and time, stated lunch is awful, terrible.On 2/26/26 at 1:19 PM, V13 (Social Services Director) stated she did the Resident Council Meeting to discuss the kitchen renovations and menu change. V13 stated there were four residents in the meeting who stated they didn't want corned beef, and they discussed substitutions they could get on the day it was served.On 2/26/26 at 3:06 PM, V4 (Dietary Manager) stated he was aware a few of the residents had said they didn't want corned beef hash in the Resident Council Meeting, but they had a plan in place for the residents who didn't want it. V4 stated they didn't ask all the residents if they wanted corned beef hash.The facility Resident Food Preferences dated 2020 documents, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent.

Based on observation, interview, and record review the facility failed to ensure the food was served at a safe temperature. This has the potential to affect all 63 residents currently residing at the facility.Findings Include: The facility Daily Census dated 2/24/26 documents 63 residents currently reside at the facility.R13's admission Record with a print date of 2/26/26 documents R13 was admitted to the facility on with diagnoses that include diabetes, morbid obesity, heart failure, and chronic kidney disease.R13's MDS dated [DATE] documents a BIMS score of 14, indicating she is cognitively intact.R13's current Care Plan documents a Focus area of, Nutritional: She is on a NAS (no added salt), regular texture, thin liquids, two liter fluid restriction. She also is given protein supplement BID (twice daily). Date Initiated: 08/12/2025. This Focus area includes the intervention of, Prepare/serve the resident's nutritional diet as ordered. Date Initiated: 08/12/2025.On 2/26/26 at 12:43 PM, R13 stated the food (corned beef hash) was served cold today.On 2/26/26 at 12:46 PM, this surveyor entered the dining room where the dietary staff was serving the noon meal out of roasting pans due to the kitchen being remodeled. This surveyor asked them to check the temperature of the food and V14 (Cook) checked the temperature of the food in the roasting pans with the facility thermometer she stated was calibrated and accurate. The thermometer read 110.0 degrees Fahrenheit when placed in the corned beef hash and 130 degrees Fahrenheit when placed in the green beans. V4 (Dietary Manager) stated the corned beef hash temperature should be 155-165 degrees Fahrenheit and the green beans should be 145 degrees Fahrenheit and they would plug the roasting ovens back in to heat them up.On 2/26/26 at 1:26 PM, V14 (Cook) rechecked the temperature of the corned beef hash and green beans located in the roasting pans using the facility calibrated thermometer. The temperature of the green beans was 168.0 Fahrenheit, and the temperature of the corned beef hash was 129.0 Fahrenheit. V4 (Dietary Manager) stated they were not going to serve the corned beef hash and would serve cold cut sandwiches as a substitute. The facility was not able to provide this surveyor with a policy related to food temperatures. According to the 2022 FDA (Food and Drug Administration) Food Code, Section 3-501.16(A)(1) hot holding temperatures for time/temperature control for safety (TCS) food must be maintained at 135 degrees Fahrenheit or greater. (https://www.fda.gov/food/fda-food-code/food-code-2022.)

Based on observation, interview, and record review the facility failed to ensure they maintained linens to fit specialty mattresses for 1 of 3 (R1) residents reviewed for accommodation of needs in the sample of 20.Findings Include: R1's admission Record with a print date of 2/26/26 documents R1 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease and morbid obesity.R1's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 15, indicating she is cognitively intact.R1's current Care Plan does not address R1's linens/mattress in a Focus area or Intervention.On 2/25/26 at 9:40 AM, R1 was sitting in her wheelchair near her bed. Her bed had a flat sheet on the mattress that was partially tucked in under the mattress. There was no fitted sheet on the mattress, and the flat sheet was only partially covering it. R1 stated, They don't have sheets for my bed. R1 stated they have two sets that fit her mattress, and they can't always find one. R1 stated when they put the wrong size sheet on the mattress, the corners don't stay in place and if they put a half sheet on it comes off the mattress.On 2/26/26 at 7:00 AM, R1's mattress had a fitted sheet on it with the upper left-hand corner pulled off the mattress.On 2/26/26 at 8:04 AM, R1 stated the facility staff got her a sheet but she had to beg them for it. R1 stated her bed is a bariatric bed and normal sheets don't fit it.On 2/26/26 at 10:22 AM, V11 (Certified Nursing Assistant/CNA) stated they don't have enough sheets for the bariatric beds. On 2/26/26 at 10:46 AM, V12 (CNA) stated they had supplies including sheets. When asked if they had enough sheets for bariatric size beds, V12 stated, Oh, not really, no. We need some of those. V12 stated R1 always asks her to get the sheets with the orange stitching because those are the ones that fit her bed. V12 stated if they use the green stretchy ones sometimes, they will work but not really.On 2/26/26 at 9:24 AM, V10 (Housekeeping/Laundry Supervisor) stated he found three sheets that fit R1's bed. V10 stated he bought new ones, but they weren't the right size, and he was going to order more after the first of March when he got his budget. V10 stated he wasn't sure how many bariatric beds they had in the facility and would have to count sheets to see if they had enough to fit the beds.On 2/26/26 at 3:52 PM, V1 (Administrator) stated she didn't know why R1 didn't have sheets that fit her bed.The facility was unable to provide this surveyor with a policy related to supplies.

Based on observation, interview, and record review the facility failed to ensure supplements were served as ordered by the physician for 1 of 3 (R4) residents reviewed for nutritional supplements in the sample of 20. Findings Include:R4's admission Record with a print date of 2/26/26 documents R4 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease, spondylolysis, repeated falls, chronic obstructive pulmonary disease, heart disease, adult failure to thrive, anxiety, and cognitive communication deficit.R4's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 09, indicating R4 has a moderate cognitive deficit.R4's Order Summary Report dated 2/26/26 includes the following physician order with a start date of 11/21/25, NCS (No Concentrated Sweets) diet Mechanical soft texture, Thins Liquids consistency, SC (super cereal) at breakfast, Health Shakes TID (three times daily) with meals. Fortified foods TID for diet.R4's current Care Plan Report documents a Focus area of Nutrition: (R4) has potential nutritional problem r/t (related to) He is on a NCS, mechanical soft texture, thin liquids diet. He receives super cereal at breakfast, fortified foods TID, health shakes TID. Diet restrictions: Date Initiated: 06/14/2024. This same Focus area includes the following interventions, .NCS (No Concentrated Sweets) diet, Regular texture, Thin Liquids consistency SC (super cereal) at breakfast, Health Shakes TID with Meals for diet. Date Initiated: 10/17/2024.Provide and serve supplements as ordered. Date Initiated: 05/14/2024.Provide, serve diet as ordered.R4's Weights and Vitals Summary documents the following weights, 9/4/25 184.5 pounds (lbs), 10/10/25 188.5 lbs, 11/11/25 186 lbs, 12/11/25 186.2 lbs, 1/14/26 182.5 lbs, and 2/12/26 188.5 lbs. This indicates no significant weight loss in 6 months. On 2/26/26 at 7:56 AM, R4 was in his room with his breakfast tray sitting on the bedside table. R4 was served fruit loops, orange juice, milk, mighty shake, coffee, cookies, pears, and a bowl of milk. No other food was seen on R4's meal tray.R4's meal card documents under Breakfast Supplements . Fortified Super Cereal- 1 serving.On 2/26/26 at 3:06 PM, when asked what the super cereal was V4 (Dietary Manager) stated, oatmeal. This surveyor reviewed with V4, R4 was not served oatmeal with breakfast. V4 stated R4 should have been served oatmeal as a super cereal with his breakfast.The facility Therapeutic Diets Policy dated 2022 documents, Therapeutic diets shall be prescribed by the Attending Physician. The facility will strive for the fewest possibly dietary restrictions. 1. Mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets. Examples of therapeutic diets include a. Diabetic/calorie-controlled diet; b. Low sodium diet; and c. altered consistency diet.6. Routine menus are planned by the Food Services Manager and approved by a Registered Dietitian for nutritional adequacy. The Food Services Manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered.

Based on observation, interview, and record review the facility failed to ensure diets were served in the consistency ordered by the physician for 1 of 3 (R4) residents reviewed for nutrition in the sample of 20.Findings Include: R4's admission Record with a print date of 2/26/26 documents R4 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease, spondylolysis, repeated falls, chronic obstructive pulmonary disease, heart disease, adult failure to thrive, anxiety, and cognitive communication deficit.R4's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 09, indicating R4 has a moderate cognitive deficit.R4's Order Summary Report dated 2/26/26 includes the following physician order with a start date of 11/21/25, NCS (No Concentrated Sweets) diet Mechanical soft texture, Thins Liquids consistency, SC (super cereal) at breakfast, Health Shakes TID (three times daily) with meals. Fortified foods TID for diet.R4's current Care Plan Report documents a Focus area of Nutrition: (R4) has potential nutritional problem r/t (related to) He is on a NCS, mechanical soft texture, thin liquids diet. He receives super cereal at breakfast, fortified foods TID, health shakes TID. Diet restrictions: Date Initiated: 06/14/2024. This same Focus area includes the following interventions, .NCS (No Concentrated Sweets) diet, Regular texture, Thin Liquids consistency SC (super cereal) at breakfast, Health Shakes TID with Meals for diet. Date Initiated: 10/17/2024.Provide and serve supplements as ordered. Date Initiated: 05/14/2024.Provide, serve diet as ordered.On 2/26/26 at 7:56 AM, R4 was in his room with his breakfast tray sitting on the bedside table. R4 was served fruit loops, orange juice, milk, mighty shake, coffee, cookies, pears, and a bowl of milk. R4 stated facility staff told him to dunk his cookie in the bowl of milk. R4 picked up a cookie and dunked it in the milk and attempted to take a bite of the cookie. R4 stated, I only got one set of teeth, they aren't soft enough to eat with one set of teeth.R4's meal card documents under Texture: Dental Soft (Mech/mechanical Soft).On 2/26/26 at 9:37 AM, V3 (Dietitian) stated the peanut butter cookies for any resident on a mechanical soft diet should have been softened prior to being served.On 2/26/26 at 3:06 PM, V4 (Dietary Manager) stated the peanut butter cookies were supposed to be softened in milk prior to serving but a cognitive resident could do it themselves.The facility Therapeutic Diets Policy dated 2022 documents, Therapeutic diets shall be prescribed by the Attending Physician. The facility will strive for the fewest possibly dietary restrictions. 1. Mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets. Examples of therapeutic diets include a. Diabetic/calorie-controlled diet; b. Low sodium diet; and c. altered consistency diet.6. Routine menus are planned by the Food Services Manager and approved by a Registered Dietitian for nutritional adequacy. The Food Services Manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered.

Based on interviews, observations and record reviews, the facility failed to implement interventions for preventing deterioration of a pressure ulcer for 1 of 3 (R2) residents reviewed for wounds in a sample of 7. This failure resulted in worsening of R2's Stage IV pressure ulcer to the buttocks. The findings include:R2's admission Record documents an admission date of 8/10/2020 and includes diagnoses of Unspecified Sequelae of Cerebral Infarction, Pressure Ulcer of Right Buttocks (7/2/2025), Anemia, Hypertension, Schizoaffective Disorder, Psychosis, Vitamin D Deficiency, Hyperlipidemia, Vascular Dementia, Muscle Weakness, and Cognition Communication Deficit.R2's Minimum Data Set (MDS) dated [DATE] documents in section C, Cognitive Patterns, that R2 is rarely/never understood. There was no Brief Interview for Mental Status completed for R2. R2's cognitive skills for daily decision making is documented as severely impaired. Section GG, Functional Abilities, documents R2 is totally dependent on staff for all Activities of Daily Living (ADL's). Section H, Bladder and Bowel, documents R2 is always incontinent of bowel and bladder. Section M, Skin Conditions, documents R2 is at risk for developing pressure ulcers and R2 has 1 unhealed pressure ulcer that is a stage IV.R2's Care Plan documents Wound Prevention R2 has potential for pressure ulcer development/skin impairments related to incontinence, increased moisture potential, brief use, weakness and requires weight- bearing assistance with ADL's. Peri care provided by staff. End-stage skin failure of the right medial buttocks. Documented interventions include: 12/9/2024 monitoring any potential factors that could lead to skin alterations and prevent, if possible, follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor/document/report to MD as needed changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (Length xWidth xDepth), stage. Wound physician to evaluate and treat as indicated.R2's Braden Scale assessment for risk of skin breakdown dated 1/1/2025 documents a total score of 12, indicating a high risk for skin breakdown for a score of 12 or less.The facility policy titled Preventative Skin Care with a review date of June 2025, documents under #6) Special mattress and or chair cushions will be used on any resident identified as high risk for skin breakdown. On 2/10/2026 at 3:55PM, V2 (Director of Nursing /DON) presented a wound log dated February 2026, that included R2's wound with acquired date of 7/2/2025, site of wound right medial buttocks, type of condition documented as end stage skin failure, and measurements of 0.9 Centimeters (cm) length (L) x 1cm width (W) x 2.5cm depth (D) with preventative equipment of air loss mattress.On 2/10/2026 at 3:59 PM, an observation was made of R2's bed and noted a standard mattress was on the bed. R2 was up in the dining room in her wheelchair at this time.On 2/13/2026 at 9:12AM, R2's bed was observed with a standard mattress still in place. R2 was up in her wheelchair with a noted pressure relieving cushion in place in the wheelchair.On 2/13/2026 at 9:20AM, V9 (Wound Physician) stated the first time he saw R2 she had a bad wound. It was deep, dark, and black, and a stage IV but I thought she was dying so I put the category of End of Life. V9 was asked how long he usually keeps end of life as a category for wounds, and V9 stated well I kept thinking she is going to die so I didn't change it so I will change it on my next rounds. V9 was asked what he would change the stage/category of this wound and V9 stated a stage IV Pressure Ulcer. V9 was asked if he thought R2 should be on an air loss mattress with a stage IV wound. V9 stated well that is their policy and protocol. V9 stated The air loss mattresses are great if they used appropriately and the staff are trained on setting those correctly. V9 stated he would make sure she has everything in place when he makes rounds.On 2/13/2026 at 10:15AM, V2 and V13 (Social Service Director/SSD) were observed placing an air loss mattress on R2's bed.On 2/13/2026 at 10:20AM, this surveyor spoke with V1 (Administrator) and V14 (Administrator from Sister Facility) and informed them of the concerns with R2 not being on an air loss mattress with a stage IV wound. V1 stated she was not aware that R2 was not on an air loss mattress and V14 stated she thought R2 had just been moved from another room, and the air mattress did not get moved with her and they were getting this fixed immediately.On 2/13/2026 at 10:32AM, V12 Regional Clinical Director (RCD) was asked if he expected a resident with a stage IV wound to be on an air loss mattress. V12 stated yes, I do expect the resident to be on an air loss mattress. V12 was asked if a resident that has a stage IV wound to the buttocks and was not on an air loss mattress could this contribute to the deterioration of the wound or prevention of healing appropriately and V12 stated yes it definitely could. R2's Wound Evaluation and Management Summary by V9 document for the following dates were reviewed and document measurement of R2's right medical buttock pressure wound: 12/24/2025: 0.7cm L x 1cm W x 1.8cm D.12/31/2025: 1cm L x 1.2cm W x 2 cm D.1/7/2026: 1cm L x 1.1cm W x 2cm D.1/14/2026: 0.5cm L x 0.5cm W x 2.5cm D.1/21/2026: 0.7cm L x 0.8cm W x 3 cm D.1/28/2026: 1cm L x 1.2 cm W x 2.7cm D.2/4/2026: 1cm L x 1.2cm W x 2.6cm D.2/11/2026: 0.9cm L x 1cm W x 2.5cm D.On 2/13/2026 at 10:50AM, the pressure ulcer treatment to R2's Right Medial Buttocks by V11 (Licensed Practical Nurse/LPN) was observed. V11 removed existing dressing and cleaned area with Wound Cleanser. R2's wound was measured by V11 and resulted in wound measurements of 1.2 Centimeters (cm) Length (L) x 1 cm Width (W) x 4cm Depth (D). V11 was asked if R2 was on an air loss mattress prior to today and V11 stated I really don't know I don't usually work this hall. V8 (Certified Nurse Assistant/CNA) was asked if she remembers R2 being on an air loss mattress in her other room before the room change to current room and V8 stated she just remembers R2 being in a different room, but she doesn't remember if she was on an air loss mattress in the other room. On 2/13/2026 at 11:07AM, R2's census sheet with the most recent room moves was requested from V15 (Business Office Manager). The document provided documented that R2's most recent room move was on 11/11/2025. V15 was asked to double check and make sure this was the last room move and V15 stated yes, this was the last room move for (R2). On 2/13/2026 at 12:08PM, V2 (DON) was asked if R2 had an air loss mattress before she changed rooms on 11/11/2025, V2 stated yes, she was. V2 was asked why the air loss mattress was not moved with her when she changed rooms on 11/11/2025 and V2 stated I just don't know. V2 was asked if he felt R2 still needed the air loss mattress at that time and V2 stated yes but I don't know how that happened and how we missed it all that time. On 2/13/2026 at 1:24PM, V16 (Medical Director/Primary Physician) stated, I expect the facility to follow policy and procedures they have in place, and I remember R2's wound was bad in July of 2025. V16 stated the air mattress would have helped and without air loss mattress it can cause the wound to deteriorate. V16 stated R2 should be on an air loss mattress.R2's Progress Notes dated 2/17/2026 at 1:24PM documents V9 informed of deeper measurement of wound. New orders received to obtain culture of wound.

Based on observation, interview, and record review the facility failed to prevent a fall during transport and failed to implement interventions to prevent future falls for 3 (R11, R18, R49) of 6 residents reviewed for falls in a sample of 52. This failure caused R18 to fall backwards in her wheelchair while being transported in a facility van requiring R18 to be taken to the emergency room, given pain mediciation, suffering a skin tear, a knot to the head, bruising, and pain to the back and shoulders. Findings Include: 1.R18's admission record documents an admission date of 09/25/24 with diagnoses including: acute on chronic combined systolic and diastolic heart failure, acute and chronic respiratory failure, type 2 diabetes mellitus, chronic kidney disease, peripheral vascular disease, gastrointestinal hemorrhage, unspecified fracture of unspecified lumbar vertebra subsequent encounter for fracture with routine healing, seizures, presence of cardiac pacemaker, and chronic pain syndrome. R18's Minimum Data Set, dated [DATE] documents a brief interview of mental status of 10 indicating moderate impairment. Section GG indicates a manual wheelchair is utilized. On 08/20/25 at 10:45 AM, R18 stated, her back and neck still hurt and she can still fell the bump on her head that still hurts. R18 stated, she was in the facility van being transported to a doctor's appointment when she was not strapped in correctly, they only strapped the bottom of her wheelchair in, and when the driver pushed on the gas after turning around she went flying backwards in her wheelchair. R18 stated, she hit her head and her back and it hurt. She was checked out at the hospital and nothing was fractured but it really hurt and no one ever even asked her about it. R18's nurse's note dated 08/13/25 documents: This nurse was notified that while in route to resident's appointment in facility transport vehicle, resident fell backwards in wheelchair. This nurse told CNA (Certified Nursing Assistant) that notified staff to transport resident straight to emergency room (ER). Resident arrived back to facility at 12:50 PM with discharge papers. CT (computed tomography) of the head and spine completed along with x-ray to the left shoulder and left elbow that all were resulted normal. This nurse questioned resident on what happened once arrived back to facility and resident states we turned into a driveway to turn around and when we took off, I went flying backwards. I was buckled around my ankles. Baseline is alert and orientated and aware of situation and placement at facility x4. Neurological exam performed and within normal limits. Vital signs obtained: 97.5, 62 pulse, 16 respiration, 109/49. ROM x3 without pain. Resident complaining of pain to LUE (Left Upper Extremity). Tylenol given at 10:25 am at ER and will be given scheduled Oxycodone at 2pm. No shortening or deformity of extremities. Head to toe skin assessment completed. Resident has a new skin tear to top of left forearm measuring 0.3cm x 0.1cm with steri strips applied. Resident also has a knot to the back of the head. Not open. No other injuries visible at this time. Monitoring checks to be continued. Resident acting per baseline at this time. Resident is her own responsible party at this time. Doctor to be notified. R18's Daily skilled noted dated 08/17/25 at 11:26 PM documents: complaints of pain in upper back, knot remains to back of head. PRN (as needed) pain medications given, skin warm and dry, color fair, scattered bruising over upper arm remains from fall a few days ago. R18 continues to state that she hurts all over her back and shoulders, routine pain medication given and tolerated well. R18's nurse's note dated 08/18/25 at 1:09 PM documents: late entry: knot still present to back of head. R18's daily skilled note dated 08/18/25 at 10:42 PM documents: complaints of pain to back, resident received her scheduled oxycodone for pain management. R18's Nurse's note dated 08/20/25 at 3:19 PM documents: knot still present to back of head. R18's care plan documents a focus area of falls indicating R18 is at risk for falls relating to deconditioning, gait, and balance problems with an interventions including: staff educated on proper buckling of wheelchair in the facility van. On 08/22/25 at 10:24 AM, V21 (Licensed Practical Nurse) stated, she was the nurse working when the incident happened with R18. V21 stated V18 (CNA) had phoned her to state R18 had fallen backwards in the wheelchair during transport. R18 was sent to the ER for evaluation. V21 stated R18 did complain of pain to her head, back, and shoulders after she returned to the facility. V21 stated R18 has complained of pain since the fall and receives pain medication to assist with the pain. On 08/20/25 at 2:10 PM, V1 (Administrator) stated the facility document titled, Risk Management with incident #1954 with R18's name on it, is the fall investigation they have for R18's fall during transport. V1 stated, that document is the only and whole investigation they have. R18's risk management document dated 08/13/25 at 9:50 AM contains a section titled Nursing Description that documents: This nurse (V21) was notified by CNA (V18) that while en route to resident's (R18) appointment in facility transport vehicle, resident fell backwards in wheelchair. This nurse told CNA that notified staff to transport resident straight to (local ER). Resident (R18) arrived back to facility at 12:50 PM with discharge paper. CT of the head and spine completed along with x-ray to the left shoulder and left elbow that all were resulted normal. A section titled, resident description documents: this nurse questioned resident (R18) on what happened once arrived back to facility and resident states we turned into a driveway to turn and when we took off, I went flying backwards. I was buckled around my ankles. Baseline is alert and orientated and aware of situation and placement at facility x 4. The section titled, Description of Action Taken documents: neurological exam performed and within normal limits. Vital signs obtained: 97.5, 62 pulse, 16 respiration, 109/49. ROM (range of motion) x 3 without pain. Resident complaining of pain to LUE (left upper extremity). Tylenol given at 10:25 AM at ER and will be given scheduled Oxycodone at 2:00 PM. No shortening or deformity of extremities. Head to toe skin assessment completed. Resident has a new skin tear to top of left forearm measuring 0.3 cm (centimeters) x 0.1 cm with steri strips applied. Resident (R18) also has a knot to the back of the head. Not open. No other injuries visible at this time. Monitoring checks to be continued. Resident (R18) acting per baseline at this time. Resident (R18) is her own responsible party at this time. (Physician) to be notified. RCA (root cause analysis): improper tightness of straps. Immediate intervention: staff informed of proper buckling with wheelchair, this CNA (V18) was removed from driving the van. On 08/22/25 at 10:29 AM V1 (Administrator) stated, R18 did fall backwards in her wheelchair during a transport. The CNA (V18) that did the transport has been removed from doing transports and has been reeducated on how to secure residents in wheelchairs for transports. 2.R11's admission Record documents an admission date of 11/6/24 with diagnoses including in part: end stage renal disease, dependence on renal dialysis, and diabetes. R11's MDS dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 08, indicating R11 has moderate cognitive impairment. R11's Fall Risk assessment dated [DATE] documents R11 is a high risk for potential falls. R11's recent care plan documents R11 is at risk for falls. Interventions on the same Care Plan include in part wedges to be utilized while in bed dated 11/25/24, immediate intervention placed is a pressure alarm while in bed and personal alarm while in wheelchair dated 5/9/25, place R11 in bed with wedge placed for added support and to help prevent any additional fall dated 8/16/25, and be sure R11's call light is within reach and encourage R11 to use it for assistance as needed, R11 needs prompt response to all requests for assistance undated. On 8/18/25 10:12 AM, R11 was lying in bed sideways with her legs hanging off bed and her head against the wall with her pants pulled down to her knees. There was one wedge at the top of the bed between the wall and the headboard and there was one wedge on the floor under the bed. R11's call light was lying in the floor by nightstand, out of reach. There was no pressure alarm under R11 in the bed. On 8/21/25 at 7:23AM, V1 stated interventions in the care plan should always be in place. 3.R49's admission record dated 08/21/25 documents an admission date of 07/31/25 and a discharge date of 08/19/25 with diagnoses of nontraumatic intracranial hemorrhage, anxiety disorder, pain, unspecified malignant neoplasm of skin, delirium, unspecified osteoarthritis, and syncope. R49's MDS (Minimum Data Set) dated 08/12/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 7 which indicates severe impaired cognition. Section GG documents toileting as dependent. Lying to sitting as substantial/maximal assistance. Section J documents Number of Falls since admission/entry One with no injury and one with injury. R49's Care Plan with a date initiated of 08/07/25 documents a focus area of: The resident is at risk for falls r/t (related to) gait/balance problems. Interventions for this focus area document: 08/11/25 intervention-resident assisted back to his w/c and PRN (as needed) Haldol administered per order to help with nausea and PRN (as needed) Ativan administered for residents' anxiety, educated staff to keep resident at nurses' station when up in wc (wheelchair). No other fall interventions listed. R49's Fall Risk assessment dated [DATE] documents a score of 14 with a Category of High Fall Risk. R49's Risk management assessment dated [DATE] documents Type/nature of incident: Fall. Nursing Description: This writer was called to res (resident) room. Res observed on all 4's perpendicular to bed with head rested against floor. Res questioned as to what he was doing res stated, I was trying to get up. Res assisted to sitting position by staff x 2. Res able to move all extremities with no c/o (Complaints of) pain at this time. No lengthening /shortening or rotation noted. Staff x 2 assisted res onto bed. Skin tear observed to RT (Right) inner arm. Res stated he hit head no injuries observed to head at this time. Abrasion noted to RT shoulder 0.5cm (centimeter) x1cm, no bleeding or discharge noted at this time. Description of Action taken: Immediate intervention: Pressure pad alarm applied. R49's Risk management assessment dated [DATE] type/nature of incident: Fall. Nursing Description: Writer was down hall speaking with another nurse when I heard this resident's alarm go off, turned around to see this resident standing up and before this nurse could get to this resident, resident turned sideways, lost balance and landed on his coccyx, then rolled to right side. Resident did not hit head. Resident Description: resident stated he felt like he was going to throw up. Description of Action Taken: head to toe assessment completed. Immediate intervention- resident assisted back to his w/c and PRN (as needed) Haldol administered per order to help with nausea and PRN Ativan administered for residents' anxiety. Staff educated on the need to keep resident up to nursing desk for increased supervision r/t this resident being anxious and feeling nauseated. Admin (Administration)/Physician and hospice notified. Resident is responsible for self. On 08/18/25 at 1:14PM observed R49 lying in his bed his pants off in floor. Call light at the end of the R49's bed out of reach of the resident. R49 yelling for help and attempting to get out of bed unassisted. R49 trying to scoot himself out of his bed that was at normal bed height. No alarm sounding. No pressure pad alarm noted in resident bed. Observed a personal tabs alarm to R49's wheelchair. Surveyor notified staff that resident was trying to get up unassisted and yelling for help. On 08/21/25 at 7:23AM, V1 (Administrator) stated that all residents should have their call lights within reach at all times when they are in their rooms. V1 said that R49 should have had his pressure pad alarm on him, and she doesn't know why he didn't on 08/18/25. V1 stated that the pressure pad alarm with other interventions should have been on the care plan. V1 stated that they have a full time MDS person who does Care Plans sometimes, and that V15 (Registered Nurse) helps out at times. V1 stated that the MDS person is still learning how to do the MDS's and Care Plan is one of the reason the Care Plan wasn't up to date. On 08/21/25 at 11:03 V11 (Certified Nurse Assistant) stated that R9 should have had a pressure pad alarm on when he was in bed. V11 doesn't know they R49 would not of had his pressure pad alarm on in his bed on 08/18/25. The Facility policy titled Fall Management with a review date of 2019 documents the policy: It is the policy of the facility to have a fall prevention program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate intervention to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Program will monitor the program to assure ongoing effectiveness. Standards #3. Safety interventions will be implemented for each resident identified at risk using a standard protocol. Standard Fall/Safety Precautions: All Residents #1. At the time of admission and in accordance with the plan of care the resident will be oriented to the use the nurse call device. The nurse call device will be placed within the resident's reach at all times. The location of the placement will be verbalized for those residents with visual deficits. #2. The bed will be maintained in a position appropriate for care the resident transfers.

Based on interview, observation, and record review the facility failed to provide supplements or provide supplements in an accessible manner for 2 (R8 and R16) of 6 residents reviewed for nutrition in a sample of 52. This failure further contributes to continued harm to R16, who has a documented history of severe weight loss.Findings include: 1.R16's admission record documents an admission date of 01/26/22 with diagnoses including: laceration without foreign body of right great toe without damage to nail, rhabdomyolysis, muscle weakness, flaccid neuropathic bladder, and anxiety disorder. R16's Minimum Data Set, dated [DATE] documents a brief interview of mental status of 04 indicating severely impaired. Section GG for eating documents setup or clean-up assistance. R16's order summary report documents a dietary order of: regular diet, mechanical soft texture, thin liquids consistency, health shake three times a day, nutritional ice cream two times a day and likes fruit with an order date of 07/22/24 with no end date listed. R16's care plan documents a focus concern of nutritional: R16 has a potential nutritional problem related to lack of natural teeth. R16 receives a regular, mechanically altered diet, and thin liquids. R16 eats meals in her room per her request. R16 has a good appetite. R16 has vanilla health shakes three times a day with meals, nutritional ice cream two times a day, a soft cookie between meals and she likes fruit dated 08/12/25. R16's interventions include: provide and serve supplements as ordered dated 02/03/22. R16's weight summary documents: 07/09/25 at 10:01 AM a weight of 137.0 pounds, -7.5% change, comparison weight - 04/17/25 - 190.0 pounds, -27.9% (weight loss), -53.0 pounds (loss). On 06/16/25 at 11:04 AM 141.0 pounds; -7.5% change, comparison weight on 03/25/25 at 191.3 pounds with -26.3% (weight loss) and -50.3 pounds (lost). On 05/18/2025 at 10:19 AM 147.5 pounds with -5.0% change, comparison weight 04/17/25 at 190.0 pounds and -22.4 % (weight loss) and -42.5 pounds. On 04/17/25 at 7:27 AM a weight of 190.0 pounds, on 03/25/25 at 7:10 AM a weight of 191.3 pounds, and 02/11/25 at 8:46 AM a weight of 189.5 pounds.R16's dietary note dated 07/09/25 at 3:49 PM documents: current body weight is 137 pounds, BMI (body mass index) 26.8 %, appropriate for age, usual body weight is approximately 190 pounds. R16 has lost approximately 50 pounds in 3 months, with the majority of weight loss taking place from April to May. Note weight loss coincides with buspirone ordered 04/09/25.R16's Dietary note dated 08/08/25 at 2:35 PM documents: awaiting monthly weight for August. R16 has been losing significant amounts of weight that coincide with buspar ordered on 04/09/25. R16 is noted to be refusing her buspar but her weight is not coming back up. R16's diet is regular diet, mechanical soft texture, thin liquids consistency, health shake three times a day, nutritional ice cream two times a day and R16 likes fruit. R16's intakes are varied, approximately 50% on average. R16 dislikes Med Pass, this was discontinued in July. Trialed health shakes, which R16 reports she is liking, she prefers vanilla. R16 is still happy with her weight loss, states she is intentionally eating less. Encouraged good intakes for weight maintenance. Appropriate to continue with current nutrition intervention. On 08/18/25 at 12:48 PM, R16 had her lunch tray in front of her in her room. The plastic wrap was still covering the plate, the health shake was not opened, the nutritional ice cream was not opened, and the lids were still on the drinks. At 1:18 PM the tray was picked up, the health shake was still unopened, the nutritional ice cream was still unopened, the plastic wrap was off three quarters of the plate and a couple bites were eaten.On 08/19/25 at 12:43 PM, R16 had her lunch tray in front of her in her room. The plastic wrap was still covering the plate, the health shake was not opened, the nutritional ice cream was not opened, and the lids were still on the drinks. At 12:49 PM, R16 stabbed the food through the plastic wrap with her fork and pulled the plastic wrap most of the way off the plate. R16 then sat and stared at the food for approximately two minutes. After she was asked to try a bite (by the surveyor) she ate about three bites. The surveyor asked R16 if she could open the health shake, R16 did not answer but picked up the health shake and turned it over in her hand and set it back down. At 1:31 PM, R16 picked up the unopened popsicle that was on her tray, turned it over a few times in her hands and put it back down. At 1:42 PM the tray was picked up, the health shake was still unopened, the nutritional ice cream was still unopened, and only about three bites of food were eaten. On 08/20/25 at 8:38 AM, R16's breakfast was sitting in front of her in her room. The health shake and the nutritional ice cream was unopened. The plastic wrap was still covering the plate and the lids were still on the drink. At 8:54 AM the tray was picked up with the health shake and nutritional ice cream still unopened. On 08/20/25 at 1:01 PM, R16 stated she had not had lunch yet. At 1:04 PM R16 received her lunch in her room with the health shake and nutritional ice cream unopened. The plate covered with plastic wrap and a plate cover and the drinks were still covered. At 1:33 PM her tray was picked up with no food eaten. Her health shake was left on her bedside table unopened. On 08/21/25 at 8:24 AM, R16 received her breakfast tray in her room, the health shake and nutritional ice cream were not opened. R16 stated, She don't feel good and she is not hungry. V16 (Helping Hands) went to pick the tray back up and then set it back down, leaving the health shake and nutritional ice cream unopened and the plate covered. R16 then picked up the orange juice and took a drink and stated ugh and made a grimacing face and set the orange juice back down. R16 was asked if she could open the health shake and R16 stated No. At approximately 8:55 AM R16's tray was picked up with the health shake and nutritional ice cream unopened. On 08/22/25 at 12:38 PM, V22 (Registered Dietician) stated, R16 has lost a lot of weight. V22 stated, she was relating the weight loss to the Buspar but she has refused the medication a while back but has not gained any of the weight back. V22 stated it is hard to get any information out of R16, you usually have to ask leading questions to get a yes or no answer. V22 stated every time she has seen R16 she has been sitting in her chair hunched over with her hands on her stomach. V22 stated, she has never been with R16 during a meal time but she would expect the health shakes and nutritional ice creams to be given to her in a form she can access them. V22 stated, she would expect all supplements and recommended items to be given to the residents and given in a form they can eat or drink them.On 08/21/25 at 3:35 PM, V1 (Administrator) stated, she does not think R16 could always open the health shakes or nutritional ice cream. She stated she would expect set up and clean up assistance to mean; uncovering items on the tray, opening items, buttering bread if needed, tasks similar to that. V1 stated, she did believe that R16 could use some encouragement lately. On 08/21/25 at 3:12 PM, V3 (Registered Nurse) stated, she does not believe R16 could open the health shake carton by herself. This week R16 has seemed like she has not been doing as well so she believes R16 would struggle with opening both the health shake and the nutritional ice cream. On 08/21/25 at 3:18 PM, V14 (Licensed Practical Nurse) stated, R16 has declined, she does not believe that she could open the health shake by herself and she might struggle with the nutritional ice cream. V14 stated, she believes especially lately having her tray set up for her and some encouragement could be helpful. 2.R8's admission record documents an admission date of 03/07/22 with diagnoses in part of unspecified sequelae of cerebral infraction, vascular dementia, cognitive communication deficit, muscle weakness, other lack of coordination, and dysphagia.R8's MDS dated [DATE] documents no BIMS should be conducted due to resident is rarely/never understood. Section GG documents eating as dependent. Section K documents under weight loss as yes not on prescribed weight-loss program. R8's Care Plan with a revision date of 07/23/25 documents a focus area of: Nutritional: R8 has nutritional problem or potential nutritional problem r/t (related to) dementia. R8 requires assistance with feeding and eating. R8 has her own teeth with likely cavities. Will consult with dentistry as needed. R8's appetite is fair. Assistive devices: Divided plate. Intervention for this focus area include: 10/28/22 SC (Super Cereal) at BF (Breakfast), 4oz (Ounces) of 2.0 BID (Two times a day) with med pass, magic cup at lunch, whole milk TID (Three time a day) with meals, HS (Nighttime) snack, resident to use sectional plate, dessert x 2 at lunch and dinner. R8's Physician orders dated 07/22/24 documents an order summary for Regular diet pureed texture, thin liquids consistency, for HELP at all meals with feeding. SC at breakfast, magic cup at lunch, resident to use sectional plate with all meals. Whole milk, protein powder at breakfast and lunch. Nosey cup with drinks. No End Date. On 08/18/25 at 12:45PM, R8 was served pureed pork, pureed Au Gratin potatoes, pureed zucchini and tomatoes, frosted cake, Nutritional ice cream (Magic Cup), chocolate milk and regular milk in a nosey cup.On 08/19/25 at 12:23PM, R8 was served pureed roast beef with gravy, pureed carrots with celery and potatoes, banana pudding with whipped topping, chocolate milk in a nosey cup and milk. No Nutritional ice cream (Magic Cup) observed. On 08/20/25 at 12:30PM, R8 was observed being served pureed beef and noodles, pureed vegetable, pureed bread, chocolate milk and regular milk in a nosey cup. A Nutritional health shake. On 08/21/25 at 7:23AM, V1 (Administrator/ADM) stated that she does not know why R8 didn't get nutritional ice cream or shake on 08/19/25. V1 stated that she didn't know if the kitchen was out of nutritional ice cream or what, but she was going to find out why R8 didn't get the nutritional ice cream or even a shake. On 08/21/25 at 9:26AM, V12 (Dietary Manager) stated that he doesn't know why R8 did not receive her nutritional ice cream at lunch on 08/19/25. V12 stated that R8 should have gotten it. V12 said that he was the dietary aide on 08/19/25 and 08/20/25 and he stated that he must have forgotten to put the nutritional ice cream on R8's tray on 08/19/25. V12 said that he doesn't know why he gave R8 a nutritional shake instead of her ice cream on 08/20/25 either unless he read the wrong dietary card. V12 stated that he did have nutritional ice cream in the kitchen. V12 stated that R8 needs her nutritional ice cream, because she had a weight loss. The facility policy titled Weight Assessment and Intervention with a revised date of 2024 documents the policy statement of: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Interventions include: 1.g The use of supplementation and/or feeding tubes.

Based on interview, observation, and record review the facility failed to ensure residents were treated with dignity by not providing incontinence products for 4 of 6 residents (R3, R5, R6 and R7) reviewed for resident rights in a sample of 16. This failure resulted in R3, R5, and R7 feeling embarrassed after incontinence episodes. The findings include: 1. R3's admission record dated 06/06/25, documents an admission date of 03/07/22 to the facility with diagnoses in part of pressure ulcer of sacral region stage 4, pressure ulcer of other site stage 3, type 2 diabetes mellitus with foot ulcer, and non-pressure chronic ulcer of buttock with unspecified severity. R3's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 10 which indicates moderately impaired cognition. Section GG documents that R3 is dependent for toileting. Section H documents R3 is occasionally incontinent of urine and always incontinent of bowel. R3's Care Plan documents a focus area of R3 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) multiple health issues including cerebral palsy, DM (Diabetes Mellitus), IBS (Irritable Bowel Syndrome) and vertigo. R3 utilizes a wheelchair for locomotion in which she can propel herself very short distance with a revision date of 08/02/21. On 06/03/25 at 9:20AM, R3 stated that they don't put incontinent briefs on her at nighttime anymore. R3 stated that she would prefer to wear an incontinent brief at night, because she doesn't like wetting herself on a bed pad. R3 stated that she feels embarrassed and yucky at nighttime when she doesn't have an incontinent brief on. R3 said that she has asked staff several times for them to put an incontinent brief on her at nighttime, but they refuse to put one on her. R3 said that she doesn't know if they don't have any incontinent briefs to put on her or if they just don't want her to wear one at night. 2. R5's admission record, dated 06/06/25, documents an admission date of 01/26/25 with diagnoses in part of chronic obstructive pulmonary disease, type 2 diabetes mellitus, obesity, non-pressure chronic ulcers of other part of right foot with fat layer exposed, lymphedema, and chronic kidney disease. R5's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R5 is cognitively intact. Section GG documents toileting as substantial/maximal assistance. Section H documents that R5 is frequently incontinent of bladder and bowel. R5's Care Plan (with a revision date of 5/7/25) documents focus areas of with a revision date of R5 is at risk for falls and R5 is at risk for pressure injury. On 06/04/25 at 3:27PM, R5 stated he does have a problem with running out of his size incontinence briefs. R5 said they also want him to go without incontinent briefs at nighttime. R5 said that the facility doesn't order enough briefs and sometimes he has had to use a smaller brief. R5 said that they run out of his size incontinence briefs often. R5 said that he has even went without a brief at times, because they didn't have any for him to wear. R5 said that he doesn't like his clothes getting wet or peeing on himself. R5 said that he also doesn't like not having one at nighttime. R5 said he wakes up soaking wet and his bed is sometimes wet as well. R5 said that it is embarrassing to have your clothes all wet in urine and your bed soaked. 3. R7's admission record dated 06/06/25, documents an admission date of 05/20/25 to the facility with diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, type 2 diabetes mellitus, presence if cardiac pacemaker, and old myocardial infarction. R7's MDS dated [DATE] documents in Section C a BIMS score of 13 which indicates R7 is cognitively intact. Section GG documents that R7 requires set-up and supervision with toileting. Section H documents R7 is occasionally incontinent of bladder and continent of bowel. R7's Care Plan (revision date of 5/20/25) documents a focus area of R7 has an ADL deficit related to needing assistance with ADL's related to dx (diagnosis) of hemiplegia and hemiparesis following CVA affecting the left non-dominant side. R7 is able to feed himself with set-up assistance only. R7 requires weight bearing assistance with most ADL's. R7 uses a wheelchair for locomotion and is able to propel himself. On 06/05/25 at 10:08AM, R7 stated that there are days he has had to go without an incontinent brief because the facility doesn't have any. R7 said that he does have a couple of staff members that will hide some of his size incontinent brief to make sure he has some for the daytime. R7 said that he has gone days without any incontinent briefs, and he didn't like it. R7 said that it embarrassed him to be wetting himself. R7 said that they also make him go all night without wearing an incontinent brief now. R7 said that he asked if he could wear one during the night, but that staff told him they don't use them at nighttime now. 4. R6's admission record dated 06/06/25, documents an admission date of 04/11/23 to the facility with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, transient cerebral ischemic attack, retention of urine, aphasia, and chronic kidney disease. R6's MDS dated [DATE] documents in Section C a BIMS score of 03 which indicates severe cognitive impairment. Section GG documents that R6 is dependent for toileting. Section H documents R6 is frequently incontinent of bladder and bowel. R6's Care Plan has a focus area of R6 has an ADL (Activities of Daily Living) self-care performance deficit r/t hemiparesis to the right side following CVA (Cerebral Vascular Accident). R6 has weakness to the RUE (Right Upper Extremities) and RLE (Right Lower Extremities) which is dominant. On 06/03/25 at 1:54PM, V19 (Family Member) stated that sometimes the facility runs out of incontinent briefs. V19 said that they stopped putting incontinent briefs on R6 at nighttime. V19 said that now R6 must sit and lay in urine or stool until someone cleans him up. V19 said when R6 use to wear the incontinent briefs at nighttime when he urinated the incontinent brief would pull the urine away from his skin, now he just lays in it. On 06/03/25 at 11:08AM, V8 (Certified Nurse Assistant/CNA) stated that the facility stopped using incontinent briefs at nighttime on residents. V8 said that the facility had ran out of incontinent briefs and that they have had to let the resident go without an incontinent brief during the day and at nighttime. V8 said that residents will wet themselves, and they will just clean up the resident and change them. On 06/03/25 at 12:51PM, V1 (Administrator) stated that the reason the facility runs out of incontinent briefs is because staff isn't putting stuff on the list for her to order. V1 said that they stopped putting incontinent briefs on residents at nighttime, so the residents have time to air out. On 06/03/25 at 1:15PM, V9 (CNA) stated that they ran out of incontinent briefs for the residents just last week. V9 said that they have went several days with some residents not having any incontinent briefs. V9 said that they just check and change the residents often and try to make sure they stay dry. On 06/03/25 at 12:06PM, V10 (CNA) stated that the facility has ran out of incontinent briefs at times and they had to put resident in clothes without an incontinent brief on. V10 said that they checked and changed the resident to make sure they did not have an accident and if they had an accident then they would clean the resident up and change their clothes. V10 said they ran out of the larger incontinent sizes the most. V10 said that V1 would have some supplies in her office and that they had to ask for the supplies for the residents. On 06/03/25 at 3:02PM, observed storage room on B hall which had 2 boxes of gloves and at least 24 x-large incontinent briefs and 22 medium incontinent briefs. There were no other sizes of briefs noted. On 06/03/25 at 3:10PM, observed storage room on A hall which had 6 boxes of gloves and 30 x-large incontinent briefs and 34 medium briefs. There were no other sizes of briefs noted. On 06/03/25 at 3:12PM, observed the shed outside which is used to store extra supplies. There were 2 boxes of Medium incontinent briefs and 1 x-large incontinent brief box. On 06/04/25 at 1:46PM, V13 (CNA) stated that they have run out of incontinent briefs at times and they had to call V1 to get them some incontinent briefs for residents. On 06/04/25 at 2:05PM, V1 stated that she provides incontinent briefs for all residents and all sizes. V1 said that she doesn't order many incontinent briefs. V1 stated that she did have an order in for some incontinent briefs but the order did not come in today so she had to get an order from the local store until her shipment comes in. On 06/04/25 at 3:00PM, V1 stated that her supplies from the local store arrived, but she still did not receive her supplies from the company she normally orders from. On 06/04/25 at 2:15PM, V14 (CNA) stated that she has been told by V1 not to put incontinent briefs on residents at nighttime unless they ask to have one on. On 06/05/25 at 7:19AM, V6 (CNA supervisor) stated they do have a problem with running out of incontinent briefs at times. V6 said that she will let V1 know when they run out of something and V1 will go get what she needs. V6 said that resident do not wear incontinent briefs at nighttime now unless they request to wear one then we put one on them. V6 said that they use to have a problem with running out of 2 x large incontinent briefs and larger. On 06/05/25 at 7:30AM, V1 stated that she does not like to use depends at nighttime because she feels like it increases skin breakdown on residents. V1 said that she feels like the residents need time to dry out. V1 said that a doctor did not give her an order to not put an incontinent brief on the residents at nighttime. V1 said that if a resident is alert and requests to wear an incontinent brief at nighttime they should be allowed to wear one. V1 stated she did not call and see what the families of the resident who are not alert would prefer if they would like their family member to wear a brief at nighttime or not. V1 said that she did find in the contract that it says the facility is to provide incontinent care and supplies. V1 said that she knows that it doesn't have to be a specific brand, but it does have to be the appropriate size. On 06/05/25 at 7:44AM, observed storage room on B hall which had 1 box of gloves and 15 x-large incontinent briefs and 10 small incontinent briefs. On 06/05/25 at 7:46AM, observed storage room on A hall which had 25 x-large incontinent briefs and 20 medium incontinent briefs. On 06/06/25 at 10:46AM, V17 (Business Office Manager) stated that the facility is to provide incontinent briefs to all resident regardless of their payor source. On 06/06/25 at 2:00PM, V1 stated that the facility did not have a policy on incontinent care or incontinent supplies. The facility document titled Resident Grievance/Concern Follow-up Form dated 04/02/25 and completed by the Resident Council documents under describe the nature of the grievance/concern documents get bigger size pull-ups (incontinent briefs). The sections documenting recommendations and efforts made by the facility to resolve the concern is left blank. Another Resident Grievance/Concern Follow-up Form dated 05/06/25 documents still running out of bigger size pull-ups. Under the section that describes what efforts were made by the facility to resolve the concern it documents see attached. The facility document titled Resident Council Memorandum dated 04/02/25 documents an issue of bigger sized pull-ups and a response of staff educated to use appropriate size and update order board when stock getting low signed by V1. Under Follow up in Resident Council with a date of 05/06/25 documents residents feel that they are still running out. The facility document titled Resident Council Memorandum dated 05/06/25 documents an issue of running out of pull-ups in bigger sizes and a response of CNA meeting in progress this wk (week) discussing pull-ups and depends (incontinent briefs) educated to use appropriate size and to not place on residents in bed signed by V1. The facility Resident admission Packet with a revision date of 12/24 documents under Statement of Resident Rights under section I. Services included in Medicare and Medicaid payment documents During the course of a covered Medicare or Medicaid stay, facilities must not charge a resident for the following categories of items and services. (E) routine personal hygiene items and services as required to meet the needs of residents, including, but not limited to, hair hygiene supplies, comb, brush, bath soap, disinfesting soap or specialized cleansing agents when indicated to treat special skin problems or to fight infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, cotton swabs, deodorant, incontinence care and supplies, sanitary napkins and related supplies, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing assistance, and basic personal laundry. The facility policy titled Dignity Policy with a revision date of 08/2009 documents the policy statement as Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.

Based on interview and record review the facility failed to implement interventions to prevent future falls for 1 of 3 (R2) residents reviewed for falls in a sample of 16. This failure resulted in R2 falling and sustaining a laceration on his face requiring sutures. Findings include: R2's admission Record documents an initial admission date of 12/10/20 and a discharge date of 5/23/25 with diagnoses including in part Alzheimer's disease, legal blindness, abnormalities of gait and mobility, and lack of coordination. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 0 indicating that R2 is rarely/never understood. R2's most recent Care Plan documents a focus area of Falls: R2 is at risk for falls related to severely impaired mobility and very poor safety awareness with an initiation date of 12/16/20. Interventions documented include R2 is to be promptly laid down after all meals to reduce sleeping in his wheelchair, thus reducing risk of fall dated 2/6/25, staff educated to recline back of high back wheelchair and to ensure it is pushed under the table and locked for safety dated 3/31/25, and wheelchair to be tilted back in reclining position for safety dated 6/21/21. R2's Fall Risk assessment dated [DATE] documents a score of 10 with a score of 10 or greater indicating that the resident is at a high risk for falls. R2's Fall Risk assessment dated [DATE] documents a score of 10 and the assessment dated [DATE] documents a score of 15. R2's Nurse's Note dated 2/6/25 at 9:30 AM documents this nurse was at med (medicine) cart, alerted by CNA (Certified Nursing Assistant) to look further down the hallway where (R2) was noted to be laying in the floor on R (Right) side beside wheelchair. Fall was not witnessed. Head to toe assessment completed. No evidence of pain/discomfort noted at this time. No skin injury or redness noted. No physical injury or deformities noted. Neuro (Neurological) at baseline for (R2) at this time, neuro checks initiated. vitals BP (Blood Pressure) 127/75, HR (Heart Rate) 79, RR (Respiratory Rate) 16, temp (Temperature) 97.8, O2 sat (Saturation) 92%. (R2) assisted back to w/c (Wheelchair) x3 staff. immediate intervention - CNA's educated to lay resident down promptly after all meals, verbalized understanding. RCA (Root Cause Analysis): (R2) post meal sleeping in w/c, fell forward onto floor. R2's Nurse's Note dated 3/31/2025 at 5:30 PM documents Nurse was notified that (R2) was laying in the floor in the dining room and had fallen out of his wheelchair. (R2) was observed laying on his right side. (R2) has a laceration to right eyebrow measuring approximately 2cm (centimeters) x 0.4cm and can't measure depth d/t (Due To) hair present. Laceration cleansed with NS (Normal Saline) and pressure applied to stop bleeding. (R2) assisted back into wheelchair with staff x2. (R2) unable to express how fall occurred. Neurological exam performed and within normal limits. Vital signs obtained: 97.4, 69 pulse, 18 respirations, 121/87. ROM (Range of Motion) x4 without s/s (signs/symptoms) of pain. No shortening or deformity of extremities. Environment was dry floor, adequate lighting, non-skid socks on. Physician and POA (Power of Attorney) notified. Resident sent to (Local Hospital) ER for eval (evaluation) & treat. R2's Nurse's Note dated 3/31/25 at 10:51 AM documents (R2) returned back to facility at 2132 (9:32 PM) via facility van. 5 stitches to the R (Right) eyebrow, remove in 10 days. Monitor for s/s (Signs/Symptoms) of infection. MD (Physician) notified. Attempted to call Resp (responsible) party but no answer. Left a voicemail for her to call us back. (R2) in bed at this time. Resp (respirations) even and unlabored. Bed in lowest position. Floor mat at bedside. VS (Vital Signs) wnl (within normal limits). No SOB (Shortness of Breath). MA (Moves All) extremities. PERL (Pupils Equal and Reactive to Light). Call light within reach. CT (Computed Tomography scan) of head and spine done with no findings. R2's Nurse's Note dated 5/22/25 at 4:34 PM documents CNA called for this nurse to entrance hallway. (R2) noted to be laying on R side in fetal position, DON (Director of Nursing) sitting at head, blood noted to be coming from head. Applied pressure w/ (With) guaze [SIC]. Previous laceration site reopened at R (Right) eyebrow, laceration noted tobridge [SIC] of nose, nose noted to be slightly deviated to the R. Pressure dressing about [SIC] to laceration at eyebrow. (R2) nonverbal and unable to vocalize what happened or if he was in pain. CNA states resident refused to extend legs and remained in fetal position when got out of bed for dinner, and en route to dining room, (R2) leaned forward and fell out of w/c (wheelchair). EMS (Emergency Medical Services) called for transport to (Local Hospital) ER for eval (Evaluation) and treatment. EMS place c-collar upon arrival. (R2) assisted to stretcher x4 staff. MD notified. attempted to notify POA (Power of Attorney), no answer at this time, voicemail left to return phone call to facility. RCA (Root Cause Analysis): (R2) in fetal position in w/c, leaned forward, and fell. Immediate intervention: resident sent to (Local Hospital) ER for eval and treatment, (R2) will use geri chair (reclining chair with wheels) upon return as he is unable to self-propel. R2's Nurse's Note dated 5/22/25 at 10:16 PM documents (R2) returned back to facility via Ambulance from (Local Hospital) at 2208 (10:08 PM). (R2) has 6 sutures to the R eyebrow and a laceration to the bridge of the nose. CT of the facial bones, head and spine all came back as no acute fx (fracture). (R2) vs wnl and stable at this time. Resp even and unlabored. POA notified. MD notified. Sutures to be removes [SIC] in 1 week on 5/29. Keep area clean and monitor for any s/s (signs and symptoms) of infection u/h (until healed). Bed in lowest position. Floor mat at bedside at this time. Call light within reach. R2's Nurse's Note dated 5/23/25 at 1:21 AM documents Alert with baseline confusion. PERL. Moves all extremities at this time. Hand grasp equal. Pain expressed when site to R eyebrow or nose is touched. R2's Nurse's Note dated 5/27/25 at 11:26 AM documents On 5/22/25 at approximately 1630 (4:30 PM) (R2) had a fall from wheelchair. (R2) was assessed for injury, ROM (Range of Motion) and pain. (R2) was noted to have a laceration to the R eyebrow. MD, and POA notified. MD order to send resident to ER. (R2) returned with 6 sutures to R eyebrow area and per CT possible anterior mandible fracture vs. variant anatomy, no findings of acute facial bone fracture. Investigation was immediately initiated. During the investigation it was found that while the resident was being assisted to dining room, he put his foot down and fell forward. Resident is not educatable related to BIM of 99, upon his return the immediate intervention is assist to geri recliner (reclining chair on wheels) as he keeps his positioning in knees up/fetal position and occassionally [SIC] puts feet down, he also leans forward frequently, he is unable to propel self so thichair [SIC] would not be a restraint. R2's hospital records dated 5/22/25 at 5:19 PM documents under Physical Exam, Skin: Laceration to right forehead, eyebrow, and bridge of nose. In the same document under Laceration Repair, it documents Face location: right eyebrow, Length: 2.3 centimeters, and Depth: 1 millimeter. Layers/structure repaired: Deep dermal/superficial fascia number of sutures: 2 and Skin repair number of sutures: 4. In the same document it documents under Medical Decision Making: laceration repaired with suture to face and adhesive skin over bridge of nose without complication. Final Impression: 1. Laceration of multiple sites of face, 2. Contusion of face due to delivery. On 6/5/25 at 10:45 AM, V21 (CNA) stated she was pushing R2 on 5/22/25 when he fell forward out of his wheelchair. V21 stated she was pushing him to dinner and all his weight shifted forward then he fell forward out of the wheelchair, and she doesn't remember if he had foot pedals on the wheelchair. V21 stated the back of the reclining wheelchair was straight up and not reclined when she was pushing him when the fall occurred. On 6/6/25 at 7:44 AM, V1 (Administrator) stated R2 did not have foot pedals on his wheelchair, and he did not propel himself around in his wheelchair. V1 stated he would keep his feet pulled up under his chair and she didn't think foot pedals would be appropriate. On 6/6/25 at 7:46 AM, V2 (Assistant Director of Nursing) stated R2 did not propel himself in his wheelchair and she didn't think foot pedals on his wheelchair would work because he pulls his feet under the chair. On 6/6/25 at 9:30 AM, V4 (Rehab Director/Physical Therapy Assistant) stated R2 had a high back wheelchair that reclined, and they added a neck support to it to help with posture. V4 stated when he was eating the chair should be sitting straight up and other times it should be reclined for comfort and safety. V4 stated he didn't have the body strength to sit straight up on his own, his hip tendons were getting tight so that made him lean forward. V4 stated he was also getting contractures in his hips and knees making him lean forward and making his feet go back under the chair. V4 stated the wheelchair should be reclined for safety and comfort unless eating. A facility policy titled Fall Management dated 2019 documents under Standards: 3. Safety interventions will be implemented for each resident identified at risk using a standard protocol, 4. The admitting nurse and assigned CNA and/or designees are responsible for initiating safety precautions at the time of admission. Facility staff are responsible for assuring ongoing precautions are put in place and consistently maintained.

Based on interview and record review, the facility failed identify, evaluate and intervene to prevent or improve a resident with significant weight loss's nutritional status in 1 (R42) of 5 residents reviewed for nutrition in the sample of 30. This failure resulted in R1 continuing to lose weight over the next 9 months. The findings include: R42's Admission record notes he was admitted to the facility on [DATE]. The same Admission record lists some of his diagnoses as mild protein- calorie malnutrition, Benign Prostatic Hyperplasia without lower urinary tract symptoms. R42's MDS (Minimum Data Set) dated 8/28/24 note that R42 has a BIMS (Brief Interview of Mental Status) of 08 which indicates R42 has moderate cognitive impairment. Section K of the same MDS note that R42 has not had a weight loss of 5% or more in the last month or greater that a 10% weight loss in 6 months. Section K also notes that R42 has had no nutritional approaches provided while a resident at the facility. R42's Care Plan has a focus area of potential for nutritional problems related to dental impairment with date initiated 6/21/23. R42 likely has cavities and broken natural teeth. R42 is able to feed himself with set up and supervision assistance. R42 likes to eat meals in his room mostly, but will eat in the dining room at times. R42 has a fair appetite. He enjoys eating snacks throughout the day and will also keep snacks at the bedside. Some of the interventions listed are: Provide and serve diet as ordered, RD (Registered Dietitian) to evaluate and make diet recommendations prn (as needed). Staff will assist with oral care, monitor/record/report to MD (Physician) prn s/s (signs or symptoms) of malnutrition, emaciation (cachexia), muscle wasting, significant weight loss of 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. All of interventions were initiated on 6/21/23. R42's Order Entry printed 9/26/24 documents, order date 8/21/23 under additional directions: Health Shakes TID (three times daily), double protein all meals. R42's Order Entry printed 9/26/24 documents, order date 5/21/24 under additional directions: health shake BID (may mix with ice cream). R42's Order Entry printed 9/26/24 documents, order date 7/22/24 under additional directions: health shake between meals. Whole milk with meals. snacks TID. R42's Order Summary Report printed 9/26/24 documents, Regular diet, Regular texture, Thin liquids consistency, health shake TID for Diet order date 7/22/24 and start date 7/22/24. The order also documented, regular diet, regular texture, thin liquids consistency, health shake BID (may mix with ice cream) for diet. Discontinued 5/21/24. On 9/26/24, R42's diet card listed shakes and whole milk at breakfast, lunch and dinner. Double protein all meals. Review of document labeled Document profile dated 6/7/23 note under likes and dislikes, there is no answer provided. There were no other Nutritional assessments provided by the facility. Document labeled Clinical Weights and vitals document R42's weight on 1/10/24 as 175.0 lbs (pounds). The same titled document note that on 2/19/24, R42's weight was 148.0 lbs. Facility document labeled Weights and Vital Exceptions note on 3/12/24, R42 weighed 150.0 lbs. Document labeled Facility Progress note *NEW* dated 9/26/24 notes that on 3/13/24, V5 (Registered Dietician) documented the following: High Risk RD note d/t (due to) weight loss 5% x 1 month. CBW (Current body weight) 150# (pounds), BMI (Body mass index) 20.9. Diet: Regular diet, regular texture, thin liquids consistency, Health shakes TID with meals, Double protein at all meals. Meds (medications) include atorvastatin, Vitamin D3, Ca (calcium) - Vit (vitamin) D w/min (with minerals) Remains at risk of weight loss d/t refusing meals at times. Is encouraged to eat in dining room and does refuse at times. Receiving health shakes with varied PO (by mouth) intake. Appropriate to consider appetite stimulant to support improved PO intake. Recommend- consider appetite stimulant. Unlabeled document provided by V1 as IDT/QA notes note for 3/3/24 to 3/9/24, there were no residents with weight losses over 3 pounds. Notes for 3/10/24-3/16/24 note R42's weight as 150 lbs, continue supplements. monitor, poor appetite, refuses supplements at times. There were no other IDT/QA meeting notes provided that mentioned R42's weight loss. Facility document labeled Weights and Vital Exceptions note that R42 was not weighted in April 2024. There was no dietary notes by V5 for the month of April 2024. R42's document labeled Weights and Vital Exceptions note on 5/21/24, R42 weighed 139.0 lbs which notes -10.0% change (comparison weight 12/5/23, 176.0 lbs , -21.0%, -37.0 lbs). There was no dietary note by V5 for the month of May 2024. There was no documentation of progress notes by the Registered Dietician (V5) for April and May 2024. R42's document labeled Weights and Vitals Exceptions document R42 weighed 137.0 lbs on 6/10/24 which notes a -7.5% change (comparison weight 3/12/24, 150.0 lbs, -8.7%, -13.0 lbs), -10.0% change (Comparison weight 1/10/24, 175.0 lbs, -21.7%, -38 lbs). R42's Dietary note dated 6/12/24 note high risk RD note d/t weight loss -5% in 1 month. The same document notes a CBW (current body weight) 150#, diet: Regular diet, regular texture, thin liquid consistency. Meal intake varied and improving after recent acute illness. Requesting health shakes. Will add and may mix with ice cream to improve acceptance. Recommend: add health shake BID, may mix with ice cream. R42's document labeled Weights and Vitals Exceptions note R42 weighed 134.5 lbs on 7/9/24 which is a -10.0% change (Comparison weight 3/12/24, 150.0 lbs, -10.3%, -15.5 lbs) Dietary note dated 7/24/24 note high risk RD note d/t weight loss >10% x 6 months. CBW: 134.5 Diet: Regular diet, regular texture, thin liquid consistency, health shakes BID. Meal intake varies at times. Typically eats breakfast well. Health shakes added 7/22/24. Appropriate to continue current interventions to support nutrition needs for weight maintenance. Monitor prn (as needed). R42's document labeled Weights and Vitals Exceptions documents no weight for the month of August 2024. There is no progress note by V5 for the month of August 2024. R42's document labeled Weights and Vitals Exceptions documents R42 weighed 131.0 lbs on 9/9/24 which is a -10.0% change (Comparison weight 3/12/24, 150.0 lbs, -12.7%, -19 lbs). Dietary note dated 9/18/24 notes high risk RD note d/t weight loss >10% x 6 months. CBW: 131#. Diet: Regular diet, Regular texture, thin liquid consistency, health shakes BID (twice daily) weight decline continues with recent interventions. Staff reports he typically eats well at lunch meal. Usually skips breakfast and eats light dinner meal. Likes to snack. Appropriate to add snacks between meals and add whole milk. On 9/26/24 at 2:35pm, V5 (Registered Dietician) said that she did not see R42 in April, May and August 2024 due to not being flagged for weight loss. V5 said there were no weights done for him to be flagged. V5 said that R42 tends to skip meals or skip breakfast and also has a tendency to refuse meals. V5 said the fact of him missing her recommendations versus the fact he often refuses meals or skips meals would not really make a difference. V5 said she sends her recommendations to the Administrator, the Director of Nursing and the Dietary manager and they are to speak with the doctor. V5 said she usually sees a resident with significant weight loss monthly. On 9/27/24, V6 (Dietary Manager) said that they do not document when supplements are given. V1 said he could not provide any documentation that they were given. V1 also said that R42 did not have any weekly weights documented from January 2024 to August 2024. R42 was placed on weekly weights on 9/27/24. On 10/3/24 at 12:10pm, V7 (friend/POA/Power of Attorney) said that R42 was not eating good prior to his admission to the facility. R42 said he just didn't really want to get up or eat. V7 said she was not made aware of R42's weight loss until 9/27/24 when the facility called to get her approval for starting an appetite stimulant. R42 said she has not been notified of R42 having any weight loss until then. On 10/3/24 at 11:51am, V5 said she did not know if R42 was being given supplements or not. V5 said she was told he refuses them a lot and in June they were requesting health shakes and said they could add with ice cream. V5 also said they tried other foods. V5 was asked how she knew his preferences since there was no documentation of those and replied she was told he likes snacks and cookies. V5 said that R42 was getting an appetite stimulant and was told he was eating better and was snacking well and since his appetites were improving, she didn't get more aggressive with her interventions. V5 was informed that R42 was not getting an appetite stimulant, however it was begun on 9/27/24. V5 said if she would have known R42 possibly wasn't getting health shakes and the appetite stimulant, her approach would have been more aggressive. On 9/26/24 at 2:00pm, V1 (Administrator) said the Dietician does not have to see a resident monthly. V1 said that R42 refused his weights for the month of August and April. V1 said she did not have any documentation for refusals by R42. V1 said that R42 was getting his health shakes with meals. V1 said that the team meets every morning and discusses weight loss/gains and wounds. V1 said she does receive the Dietary recommendations from V6 each month. V1 said that is a residents weight is off from the last weight, they weigh the resident again, but can not provide any documentation to that. On 9/27/24 at 1:00pm, V1 also said that the IDT (Interdisiplinary Team) meet weekly and discuss weight loss on all of the residents. V1 was asked should R42 have been put on weekly weights and she replied Yes, I guess he should have. V1 said they had a problem with scales and felt that was the problem with weights being off. V1 said she bought new scales in January of 2024. V1 was asked if they calibrated them and she replied yes. V1 said she don't know why the doctor didn't order the stimulant since they always agree with the dietary recommendations. V1 said the called the previous physician's office and they sent a copy to them that said she did not want to order the stimulant. V1 said that V6 asks residents about their likes and dislikes of food. V1 could not provide any documentation of where V6 asked about it. V1 said she would think with weight loss, you should ask about the resident's likes and dislikes. V1 said they do not notify the dietician in writing about a resident's weight loss, she stated they may by phone. On 10/2/24 at 2:35pm, V8 (CNA/Certified Nurse Assistant) said she works the hall R42 was on and she has not given him any health shakes until the other day and now they have a list of names and have to sign them off. V8 said they can not put their weekly weights in the computer and they do them on paper. V8 said she did re-weigh R42 but don't remember when, possibly in the past couple months. On 10/2/24 at 2:45pm, V9 (LPN/Licensed Practical Nurse) said to her knowledge, R42 has not been given any health shakes until last week. On 9/26/24 at 1:45pm, V6 (Dietary Manager) said that the dietician does see residents monthly if they have a significant weight loss. V6 said that R42 has been getting health shakes with his meals and when they are given with meals, they do not sign them off any where and can not provide any documentation that they were actually given. V6 said each month he gives the weights to the DON (Director of Nursing) the weights on each resident. V6 said he does receive the recommendations made by V6 each month. R42's DiningRD Request for Diet Change PCP Fax Report provided by the Facility on 9/26/24 dated 3/13/24 from V5 documents in part, Appropriate to consider appetite stimulant to support improved PO (by mouth) intake. Recommend: -consider appetite stimulant. This document did not have any comments from the physician or a signature. On 9/27/24 at 3:30pm V1 emailed another version of R42's DiningRD Request for Diet Change PCP Fax Report dated 3/13/24 from V5 that now had marked under comments, Do no Change current orders with an unrecognizable signature and a date of 3/15/24. On 9/27/24 at 2:30pm, V2 (DON/Director of Nurses) said that he faxed the unsigned March dietary recommendation for an appetite stimulant to the physician and he ordered Remeron 7.5 mg (milligrams) daily. Facility Document labeled Weight Assessment and Intervention (revised September 2017) note any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. The Dietician will review the unit Weight record by the 15th of the month to follow individual weight trends over time. The same document notes Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the dietician, the Consultant Pharmacist, and the resident or resident's legal surrogate. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss, b. Goals and benchmarks for improvement and c. time frames and parameters for monitoring and reassessment. Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choices and preferences c. Functional factors that may inhibit independent eating, d. Environmental factors that may inhibit appetite or desire to participate in meals .g. The use of supplementation and/or feeding tubes.

Based on interview and record review, the facility failed to identify, assess, and implement treatment and interventions for pressure ulcers for 2 (R1, R2) of 3 residents reviewed for pressure ulcers in a sample of 6. This failure resulted in R1 developing a stage III pressure ulcer area to her left buttock. The findings include: 1. R1's Face Sheet documents that R1 was admitted to the facility on [DATE] with diagnoses of Sepsis, Unspecified Organism, Urinary Tract Infection, Site not specified, Bipolar Disorder, Unspecified, Unspecified Intellectual Disabilities, Unspecified Glaucoma, Acute Embolism, and thrombosis of superior vena cava. R1's Face Sheet documents a discharge date from the facility on 3/25/24. R1's Minimum Data Set (MDS) dated [DATE] documents in Section C, a Brief Interview for Mental Status (BIMS) score of 13, indicating that R1 is cognitively intact. Section GG, Functional Abilities and Goals, of the same MDS documents that R1 is dependent with all activities of daily living. R1's hospital notes discharge summary dated 2/20/2024, under Physical Exam documents in part . There was a 2-centimeter (cm) stage III sore on the left heel; No other sores or rashes noted. R1's Physician's Orders dated 2/20/2024 documents weekly skin check every day shift, every Wednesday. R1's Admission Braden assessment dated [DATE] documents score of 10. A score of 12 or less indicates a High Risk for skin breakdown. R1's Initial Skin Alteration Record (Admission) dated 2/20/2024 documents in part . small, scabbed area to left buttock noted. There were no measurements or location of the wound on the left buttock noted on this initial admission skin assessment. On 3/28/2024, at 11:15 AM, V2 (Director of Nursing) stated that she completed R1's initial skin assessment on admission and noted a scabbed area to left buttock, the size of a small eraser. V2 stated that no measurements were taken of scabbed area to left buttock and no treatment was obtained for scabbed area to left buttock upon admission assessment. V2 stated that R1 developed another area to her inner buttock that was first identified on 3/03/2024, and an order for a dry dressing to her left buttock area was obtained and R1 saw V13 (primary physician) on 3/5/2024 and he referred R1 to the local wound clinic. V2 stated that it is her expectation of the nursing staff to complete weekly skin checks as ordered, initiate a skin alteration record for all new wound areas, and notify the physician to obtain any new treatments. R1's Treatment Administration Record (TAR) for February 2024 documents weekly skin check not being completed for 2/28/2024. There was no Braden assessment noted in R1's Electronic Health Record or provided for review upon request for the week of 2/28/2024. R1's TAR for February and March 2024 documents left heel wound, cleanse with normal saline and apply topical ointment with moist dressing and wrap with another dressing every day shift with a start date of 2/21/2024. R1's TAR for 2/25/2024 and 2/28/2024 does not document the treatment as being completed. R1's Skin Monitoring: Shower Sheets dated 2/23/2024 documents an area to left heel (nurse aware); 2/29/2024 documents an area to left heel; 3/01/2024 documents an area to left heel; 3/7/2024 documents an area to left buttock, left heel (nurse notified); 3/14/2024 documents an area to left buttock and left heel; 3/17/2024 documents self-inflicted scratches to chest area, an area to left buttock and left heel; 3/19/2024 documents self-inflicted scratches to chest, and area to left buttock and left heel. R1's TAR for March 2024 documents cleanse wound to left heel, apply foam dressing, wrap with dry dressing, every day shift with a start date of 3/07/2024 and a discontinued date of 3/19/2024. R1's Progress Notes dated 3/01/2024, at 10:39 AM by V12 (Licensed Practical Nurse/LPN) documents in part . Wound to left buttock dry dressing applied. R1's Progress Notes dated 3/03/2024 at 2:28 PM by V12 documents During personal care, 3.5 centimeters (cm) x 4.5 cm area with eschar found on left buttocks; V13 (primary physician) notified; orders to cover area with dry dressing and change daily. R1's TAR for March 2024 documents Place dry dressing on open area to left buttocks daily with a start date of 3/04/2024, 7:00 AM. On 3/26/2024, at 10:20 AM, V10 (CNA) stated that when R1 was admitted she noticed little sores all over her body. V10 stated that she remembers R1 having an open area to her buttock and reported to it to V12 (LPN). On 3/26/2024, at 10:45 AM, V12 (LPN) stated that she reported to V13 (primary physician) on 3/03/2024 that R1 had an area to her left buttock and he ordered a dry dressing and referred her to the wound clinic. V12 stated that R1 went out to the wound clinic on 3/12/2024 and saw V31 (wound physician) and came back with new orders. V12 stated that she updated V30 (guardian) about this area. R1's physician's notes dated 3/05/2024 at 5:30 PM by V13 documents in part . pressure sores to left buttock . left buttock acquired since admission .4 centimeter (cm) soft eschar left buttock . refer to wound clinic for left buttock. R1's Weekly Skin Alteration Record dated 3/06/2024 documents left gluteal fold, 4 cm x 3 cm, open area with eschar); Type of Wound: Pressure, wound margins/edges document irregular, erythema; Peri-Wound area intact; Healing process: new wound; Comments: R1 will see local wound physician at local wound clinic. R1's Braden assessment dated [DATE] documents a score of 11, indicating that R1 is a high risk for skin breakdown. R1's Wound notes dated 3/12/2024 by V31 (wound physician) documents in part .Pt (patient) presents for evaluation of left buttock pressure ulcer. The wound note documents a location of left buttock unstageable pressure ulcer and documents measurements of 3.7cm x 4.5cm. Post debridement measurements are documented as 3.7 cm x 4.5 cm x 5 mm (millimeters) full thickness to adipose tissue. Under the Assessment/ Plan it documents in part .eschar and nonviable tissue was debrided from the wound . Under the section Plan it documents wash wound daily with soap and water; pack with polymen silver; secure with 4 x 4 and medipore tape; will call with culture results; follow up in one week. R1's Weekly Skin Alteration Record dated 3/13/2024 documents in part . Weekly skin check completed . R1 has a red area to back of left foot with daily treatment . R1 has a discolored area to back of left foot . R1 has an unstageable area of 3.7cm x 4.5cm to left lower buttock . R1 is seeing local wound clinic for these wounds. No measurements noted for left heel for weekly skin alteration dated 3/13/2024. R1's Braden assessment dated [DATE] documents score of 11, indicating that R1 is a high risk for skin breakdown. R1's Wound notes dated 3/19/2024 by V31 (wound physician) documents Pt (patient) presents for follow up of stage III left buttock pressure injury and new left heel ulcer stage II. Wound #1 is documented as a left buttock unstageable pressure ulcer with measurements of 4.0 cm x 3.9 cm x 6 mm. Wound #2 is documented with a location of left heel with measurements of 2 cm x 2 cm x 1 mm. Under Assessment/Plan it documents in part .last visits cultures revealed proteus mirabilis in the wound. A topical compound was prescribed . Under the section Plan it documents the following: wash wound daily with soap and water, apply wet to dry dressing BID (twice a day) to both wounds until the compound topical antibiotic arrives, secure with 4 x4 and medipore tape, when topical compound arrives, stop wt to dry, apply topical compound antibiotic as prescribed, secure with telfa and medipore tape, turn q (every) 2 hours, do not apply direct pressure to wounds, increase protein intake, follow up in 1 week, watch for signs of infection, fever, chills, redness, excessive or foul drainage, increase in pain. There was no order documented in the Electronic Health Record of R1's protein intake being increased as recommended on the wound notes by V31. R1's Weekly Skin Alteration Record dated 3/20/2024 documents in part .Weekly skin completed .R1 has an area to the back of the left foot that has opened up .See TAR for new order from wound doctor .R1 has a discolored area to back of left heel .R1 has unstageable pressure area of 3.7cm x 4.5cm to left lower buttock .R1 is seeing wound clinic for these wounds .New treatment orders on TAR. R1's hospital notes dated 3/21/2024 under Assessment documents in part . R1 has dressing to top of left foot, dressing to left buttock, dressing to right upper arm, scab to the back of neck, rash like area to center of chest and what appears to be an old ligature/scabbed area to left forearm; All areas are old and scabbed. There was no documentation of a wound to the left heel. On 3/26/2024, at 2:17 PM, V13 (Primary Physician) stated that he has been involved in R1's care for years, he was her medical provider at her previous facility she lived at for many years. V13 states that R1 is severely, cognitively impaired and has had a severe physical decline over the past year and prognosis has not been great. V13 recalls being informed of open area to left buttock on 3/03/2024 and giving treatment orders for it. V13 stated that R1 was being followed by an outside wound clinic for area to left buttock. V13 commented that the staff know the importance of notifying V13 of any new and changing skin conditions. On 3/27/2024, at 8:45 AM, V29 (LPN) stated that he works for this facility and also the previous facility that R1 was at. V29 stated that back in January 2024, R1 lost mobility of her right side. V29 stated that R1 would not cooperate fully but it is possible she had a stroke. V29 stated that he remembers R1 having an open area to her left heel and left buttock. V29 stated that she had a treatment for both and those treatments were done on day shift. On 4/01/2024, at 9:35 AM, V31 (wound physician) stated that he saw R1 in the clinic on 3/19/2024 for a follow-up to her stage III left buttock pressure ulcer and for her stage II left heel pressure ulcer. V31 stated that R1 was not a mobile resident and would need to be turned and repositioned on a regular schedule at least every two hours. V31 stated that it does not take a long time to develop a pressure area, could be less than two hours if not consistently turned and repositioned. On 4/01/2024, at 1:45 PM, V31 (wound physician) stated that he was only made aware of R1's left buttock wound when she first came to the clinic on 3/12/2024. V31 stated that they did not do a whole-body assessment on R1 that day. V31 stated the skin assessment was a focused skin assessment on just the left buttock. V31 stated that he saw R1 again on 3/19/2024 and the left heel area had been added to that appointment. V31 stated that only those two areas were the ones assessed for the 3/19/2024 appointment. On 4/01/2024, at 1:50 PM, V13 (primary physician) stated that he was not made aware of a scabbed area to the left buttock when R1 was admitted on [DATE] and no treatment was ordered at that time. V13 stated that he came to see R1 on 3/05/2024 and assessed her left buttock that showed dry eschar, not particularly affecting her general health. V13 stated that he referred R1 to the wound clinic so it could be debrided. V13 stated that he did not refer R1 to the wound clinic for her left heel wound. V13 stated that her left heel had good, granulating tissue and did not feel she needed to be referred to the wound clinic at that time. R1's Baseline Care Plan, dated 2/22/24, documents no wounds or interventions to prevent skin breakdown. R1 was sent to the hospital on 3/21/2024 with no interventions for pressure ulcers or to prevent skin breakdown in place. R1's Comprehensive Care Plan was not initiated until 3/25/2024. 2. R2's Face sheet documents admitted to the facility on [DATE] with diagnoses of Encephalopathy, Urinary Tract Infection, Chronic Kidney Disease, Type 2 diabetes, unspecified, Type 2 Diabetes Mellitus without complications, essential (Primary) Hypertension, unspecified Atrial Fibrillation, Fibromyalgia, morbid (severe) obesity, Arthropathy, unspecified. R2's Minimum Data Set (MDS) dated [DATE] documents Section C, documents a Brief Interview for Mental Status (BIMS) score of 13, indicating that R2 is cognitively intact. Section GG, Functional Abilities and Goals, documents that R2 requires setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, dependent with toileting hygiene, showering, upper/lower body dressing, putting on/off footwear, personal hygiene, bed mobility and transfers. R2's Treatment Admission Record documents the following orders related to wound care: Silvadene External Cream 1 % (Silver Sulfadiazine)(SSD) Apply to left buttock topically every day shift for wound apply SSD, collagen powder, calcium alginate pad, and dry dressing daily and as needed. -Start Date 3/13/2024 0700 (7:00 AM); Weekly Skin Check on Friday 7A-7P every day shift every Fri for skin integrity. -Start Date 3/08/2024 0700 (7:00 AM); Weekly Skin Check on Mondays 7A-7P every day shift every Monday for skin integrity. Start Date 2/26/2024 0700 -D/C (discontinue) Date 3/06/2024. R2's Baseline Care Plan, dated 2/23/24, under Functional Abilities and Goals-Mobility Substantial/ maximal assistance is marked for roll left to right, sit to lying, lying to sitting in the side of the bed, sit to stand, chair/ bed-to-chair transfer, toilet transfer, and tub/shower transfer. Under Bowel and Bladder documents that R2 is frequently incontinent of bowel and bladder. Under Skin Risk the boxes for current skin integrity issues and history of skin integrity issues are not marked. R2's Braden assessment dated [DATE] documents score is 16, a score of 15-16 indicates a Low Risk. Under the section Moisture, Occasionally moist: Skin is occasionally moist, requiring and extra linen change once a day is marked. Under the section Friction & Shear, Potential Problem: Moves freely or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair most of the time but occasionally slides down is marked. R2's Initial Skin assessment dated [DATE] documents Skin pink, warm & dry. No redness noted to bony prominences. Multiple discolorations noted to BUE (bilateral upper extremities) r/t (related to) IV (intravenous) & blood draws in hospital. Redness/excoriation noted to bottom/peri-area with barrier cream applied. Dry scaly skin noted to bilateral ankles & feet. Bilateral heels intact. No open areas or areas of concern noted at this time. R2's Care Plan dated 3/13/2024 documents a Focus area of: R2 has potential/actual impairment to skin integrity related to pressure injury (stage 2) to left buttock. Goals: R2 has potential/actual impairment to skin integrity related to pressure injury (stage 2) to left buttock with a target date of 6/11/2024. Interventions: Follow facility protocols for treatment of injury. Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to primary physician. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface with a start date of 3/13/2024. On 4/2/2024, at 3:00 PM, V9 (Regional Clinical Reimbursement) stated that if a resident has a pressure relieving mattress or cushion, it should be listed as an intervention in their care plan. R2's Weekly Skin Alteration Record dated 3/13/2024 documents left buttock, small pea size open area with pink wound bed measuring 0.5cm x 0.5cm. On 3/25/2024, at 2:00 PM, R2 stated that they just don't turn you enough here. R2 states that staff are sweet and try their best here, but there just aren't enough people. R2 reports she got in her chair at around 8:00 AM or 9:00 AM and has been in her chair since then. R2 reports that they forgot to put her pressure relieving cushion in her chair. R2 was observed to not have cushion in her chair and the pressure relieving cushion was observed lying on her bed at this time. R2 was observed with the call light around her wrist, she states it is her preference because she needs it and always knows where it is. R2 stated that her bottom hurts at this time, but the incontinence brief she wears does make it worse. On 3/25/2024, at 2:45pm, R2 was observed sitting on edge of chair, restless with expressions of pain. R2 stated that her bottom and legs hurt, and she just wanted to lay down. On 3/25/2024, at 3:15pm R2 was laid down and wound treatment was observed. V5 (Licensed Practical Nurse) performed wound care with the assistance of V7 (Certified Nurse's Assistant). Left buttock wound has pink wound bed with no drainage noted or signs and symptoms of infection noted. V5 performed treatment as ordered with no concerns of infection control noted. R2 tolerated treatment with no complaints of pain or discomfort noted. The facility's Decubitus/Pressure Area policy dated January 2014 documents under Policy: To ensure a proper treatment has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified; Procedure: Upon identification of skin breakdown, the following will be completed: 1. Pressure area will be assessed and documented; 2. Complete all areas of a wound assessment following National Pressure Ulcer Advisory Panel (NPUAP) guidelines: i) Document size, stage, site, depth, drainage, color, odor, and treatment (upon obtaining from the physician); 4. Documentation of the pressure area must occur upon identification and at least once each week. The facility's Preventative Skin Care policy dated January 2014 documents under Policy: To provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well-groomed, and free from pressure ulcers; under Procedures: 1. All residents will be assessed using the Braden Pressure Ulcer Scale at the time of admission and weekly x 4, then will be reassessed at least quarterly and/or as needed; 3. After thorough cleaning of the skin, lotion may be applied and observation of any reddened areas will be reported to the Charge Nurse; 5. Any resident identified as being at high risk for potential skin breakdown shall be turned and repositioned at a minimum of every two (2) hours.

Based on interview and record review, the facility failed to implement interventions for self-injurious behaviors and obtain necessary behavioral health services for 1 (R1) of 1 resident reviewed for behavioral health in a sample of 6. This failure resulted in R1 developing cellulitis to a self-inflicted wound to the chest wall. The findings include: R1's Face Sheet documents R1 was admitted to the facility on [DATE] with a diagnosis including Bipolar Disorder, Unspecified, and Unspecified Intellectual Disabilities. R1's Face Sheet documents a discharge date from the facility of 3/25/24. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13, indicating R1 was cognitively intact. This same MDS documents R1's Functional Abilities and Goals as Dependent with all activities of daily living. R1's baseline care plan, dated 2/22/24, the section Active diagnoses contributing to admission is left blank. There is no documentation of R1's self-injurious behavioral concerns and the Social Services section is left blank. R1's Care Plan dated 3/25/2024 (date of R1's discharge from the facility per Face Sheet) does not document scratching or self-injurious behaviors. On 3/25/2024, at 8:50 AM, V30 (Guardian) stated that she did not visit R1 while she was at the facility. V30 stated that she visited R1 when she was at the emergency roiagnom on [DATE]. V30 stated that she did not disclose any self-injurious behavior to the facility when R1 got admitted to the facility. V30 stated that R1 wore mittens at her previous facility to help keep her from scratching herself. On 3/26/2024, at 10:20 AM, V10 (Certified Nurse Assistant/CNA) stated that when R1 was admitted she noticed little sores all over her body. V10 stated that R1 would have repetitive scratching to different areas on her body and had to be redirected multiple times. V10 denies being informed of R1's chronic self-injurious behaviors. On 3/26/2024, at 10:40 AM, V11 (CNA) stated that she remembers seeing multiple scratch areas to R1's chest like she had dug into her chest. V11 stated that the staff would put socks over her hands to help keep her from scratching. V11 denies being informed of R1's chronic self-injurious behaviors. On 3/27/2024, at 8:20 AM, V20 (CNA) stated that she recalled R1 scratching her upper arms first about a week after she got admitted and reported this to V12 (LPN). On 3/26/2024, at 2:05 PM, V12 (Licensed Practical Nurse/LPN) stated that it was reported to her on 3/17/2024, that R1 had scratched her chest area. V12 stated that when she assessed her, she noticed R1 had dug into her chest hard. V12 stated that she notified V13 (Primary Physician) about R1's scratches to her chest. V12 stated that V13 told her that this was a long-time behavior of R1 and that her previous facility used mittens to cover her hands to keep her from scratching herself. V12 stated that she told him that mittens are not available at the facility. V12 stated that after she told him that, V13 hung up on her. V12 stated that she found soft, no-show socks and placed them on R1's left hand. V12 stated that R1 would rub her hand against her to remove the sock and continue to scratch herself. On 3/26/2024, at 2:17 PM, V13 (Primary Physician) stated that he has been involved in R1's care for years and was her medical provider at the previous facility she lived at for many years. V13 confirmed that R1 did have a history of self-injurious behavior including, scratching, picking and occasionally biting. V13 states that R1 was severely cognitively impaired and has had a severe physical decline over the past year and prognosis has not been great. V13 recalls being notified about new area to chest from R1 scratching and that he had advised the facility to use mittens as they have used in the past with R1 at her previous residence. V13 denied being informed that the facility did not have mittens or that they were using socks instead. On 3/26/2024, at 2:50 PM, V9 (Regional Director Clinical Reimbursement) stated that it is not an expectation for the facility to call a resident's previous facility concerning a resident's history, if they were admitted from a hospital and not a facility of residence. Unless a problem would arise, V9 stated the same regarding residents with intellectual disabilities/developmental disabilities or psychiatric diagnosis. On 3/27/2024, at 8:45 AM, V29 (LPN) stated that he works for this facility as well as the previous facility where R1 resided. V29 stated that R1 has a chronic behavior of scratching herself. V29 stated that at her previous facility, they would put mittens over her hands to keep her from scratching. V29 stated that it would not be uncommon for R1 to rub a spot open in two hours, it would happen so quickly at times. V29 stated that he works mainly at night at this facility and while he worked R1 was usually in bed, calm and quiet. On 3/27/2024, at 2:15 PM, V8 (CNA) stated that R1 scratched herself hard one day in the upper chest area. V8 stated that soft, fuzzy socks were placed over her hands to help to keep her from scratching self. On 3/27/2024, at 3:35 PM, V7 (CNA) stated that two weeks after R1 got admitted , she noticed her scratching her stomach, chest, and arms. V7 stated that she reported it to V12 (LPN) and was told they were going to monitor her scratching. On 3/27/2024, at 3:45 PM, V16 (CNA) stated that R1 would scratch herself with her left hand and soft socks were placed over her hands to help keep her from scratching herself. V16 stated that she reported R1's scratching herself to V12 (LPN) and that V12 applied some cream to her scratches. On 4/2/2024, at 10:45 AM, V2 (Director of Nursing/DON) stated that she did not receive any information about R1's medical or psychosocial history from V30 (Guardian). V2 stated that she spoke with a staff from her previous facility when she came to visit R1 but did not ask about her previous history at that time. R1's progress notes dated 3/16/2024 at 9:55 PM and written by V32 (LPN) documents in part . R1 has been scratching self to chest, stomach, arms. R1's progress notes dated 3/17/2024 at 2:44 PM and written by V12 (LPN) documents (R1) noted scratching her chest. Area cleansed and cream added. R1 went right back to scratching the area. Called (V13 Primary Physician) and he said she wore mittens at her facility. No mittens available. (R1) was placed in non-latex gloves and could no longer scratch area. R1's progress notes dated 3/19/2024 at 1:35 PM and written by V12 (LPN) documents in part .(R1) has self-inflicted scratches to middle chest. R1's hospital notes dated 3/21/2024 documents in part . Presents to emergency department with complaints of low oxygen .(R1) also has several skin wounds and ulcerations from chronic staph infections .(R1) also has cellulitis and possible aspiration pneumonia . started on intravenous antibiotics . been accepted to another higher level of care hospital and being transferred . Diagnosis - Cellulitis of chest wall. On 4/3/2024, at 1:25 PM, V1 (Administrator) stated that she spoke with V35 (staff form R1's previous facility) about R1's medical history and V1 stated that V35 told her that R1 did not have any behaviors but that she might curse at you occasionally. V1 stated that she always tries to get the previous history on residents from hospitals or other facilities before they get admitted . V1 stated that it is very important to her to know about any resident's behaviors so a decision can be made if the facility can meet their needs or not. On 4/2/2024, at 3:00 PM, V9 (Regional Director Clinical Reimbursement), stated that he was unaware of the staff placing socks on R1's hands to help prevent her from scratching herself. V9 stated that it is his expectation of the nursing staff to perform an assessment, get a consent from guardian, and obtain a physician's order before ever implementing placing a sock or any other restraint device on a resident. V9 stated that the nursing staff should have obtained an order for mittens when V13 (primary physician) suggested it. The facility's Behavioral Assessment, Intervention, and Monitoring policy (revision date December 2016) documents in part under the section Policy Statement, 1. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. Under the section titled Assessment it documents in part 1. As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, and mental illness (bipolar, schizophrenia). 2. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: a. The resident's usual patterns of cognition, mood, and behavior; b. The resident's usual method of communicating things like pain, hunger, thirst, and other physical discomforts; and c. The resident's typical or past responses to stress, fatigue, fear, anxiety, frustration, and other triggers. 3. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: a. Onset, duration, intensity, and frequency of behavioral symptoms; b. Any precipitating or relevant factors, or environmental triggers (e.g., medication changes, infection, recent transfer from hospital); and c. Appearance and alertness of the resident and related observations. 4. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. Under the section titled Cause & Identification it documents 1. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition. Under the section titled Management it documents 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm 2. The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice. 3. The resident and family or representative will be involved in the development and implementation of the care plan. Resident and family involvement or attempts to include the resident and family in care planning and treatment, will be documented. 4. The resident and family/representatives will be informed of the resident's condition as well as the potential risks and benefits or proposed interventions .7. Interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent, or relieve the resident's distress or loss of abilities. 8. Interventions and approaches will be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. Under the section titled Monitoring it documents 1. If the resident is being treated for altered behavior or mood, the IDT (Interdisciplinary Team) will seek and document any improvements or worsening in the individual's behavior, mood, and function. 2. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. 3. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment .7. If any devices (restraints) are prescribed, the IDT (Interdisciplinary Team) will monitor the situation to ensure that they are beneficial to the individual (for example, enhancing function and improving symptoms) and are not causing complications or disabling the individual. a. This will be done frequently when such devices are first employed and regularly thereafter for as long as they are used. b. Over time, the staff will reduce the use or remove such devices, or will document why such attempts are not feasible.

Based on observation, interview and record review the facility failed to follow physician orders [REDACTED]. This failure resulted in R5's stage 2 pressure ulcer, the size of depth increasing to a stage 3 pressure ulcer, which required the need for further treatment. This failure also resulted in R2 having stage 3 facility acquired pressure ulcer. This affects two residents (R2 and R5) in a total sample of 6 residents reviewed for skin integrity. Finding Include According to Wound Care Specialist Evaluation note date 9/23/15, done by Z6 (Wound Care Doctor), R5 has a pressure ulcer on right buttock at a stage 2 that measures 4 x 3 x (not measurable) cm (centimeters) and a surface area of 12.00 cm2 and recommendations are to limit siting to 60 minutes, off-load wound, reposition per facility protocol and apply Silver Absorbing Agent-Once Daily, Dry protective Dressing daily. On 10/7/15 Wound Specialist Evaluation note per Z6 has an area to right buttock is an unstageble (due to necrosis) of at least 14 days duration. Surgical excision debridement of muscle. Measurements of 4 x 3 x (not measureable) cm and surface are of 12.00 cm2 and no change in wound progress with change in treatment for [REDACTED]. On 10/14/15 Wound Specialist note, per Z6, has area to right buttock has an unstageable necrosis pressure are of over 21 days duration. Measurements of 3.5 x 3 x 0.9 cm and surface is 10.50 cm2. States unstageable due to necrosis continue once daily Santyl and Calcium Alginate with dry protective dressing. On 10/19/15 at 9:30 AM, prior to E5 RN (Registered Nurse/wound nurse) treatment to R5 wound was visualized to be approximately 3.5 x 4.0 x 2.5 cm with a surface area of 12.00 cm2. On 10/22/15 at 10 AM, E5 stated that she had measured R5's wound to his right buttock the day before on 10/21/15 because Z6 had not been able to observe and assess the area because R5 had been out of the building during his rounds. E5 stated the measurement she had gotten for R5's area to his right buttock on 10/21/15 was 3.5 x 4.3 x 2.5. When asked if E5 had assessed surfaced area she stated no because she had never really been trained on how to do that and was not comfortable with how that was to be done at this time, so she usually just went by Z6's measurements. E5 also confirmed that prior to surveyor discussing with Z6 preference of cleaning product of normal saline instead of wound cleanser she was not aware of this. E5 stated she was not aware of Z6 preference and was not aware it changed the PH of the wound and was in the process of changing all the treatment orders to reflect that they are to be cleaned with normal saline instead of the wound cleanser she had previously been using. According to R5' s Treatment order dated 10/21/15 per Z6 he is to have area on right buttock cleansed with normal saline, pat dry, apply Santyl and [MEDICATION NAME] 0/1% ointment and Calcium Alginate, cover with dry protective dressing. Change two times a day and as needed. According to the 10th Edition Drug Information Handbook for Nursing 2009, [MEDICATION NAME] is a medication that is in the pharmacological category of a topical antibiotic. On 10/19/15 at 9:30 AM, E5 RN (Registered Nurse/wound nurse) was doing ordered treatment to R5 right ischium. R5 had no dressing on his pressure ulcer when E5 went to do ordered treatment. E5 stated the nursing assistance is to make nurses aware if the dressing falls off so it can be replaced immediately. E5 stated she did not know how long R5 had been without his dressing but stated R5 was soiled. R5 had feces noted around the borders of the wound bed. R5 took 4 x 4 gauze and wiped several times on ones side of the wound bed with gauze and stated he is oozing BM and I need to try to clean it some. E5 stated that R5 has a tendency to ooze stool and feces and at times it is difficult to keep his dressings and skin clean and dry. During this E5 was noted to wipe feces across the edge of the wound bed and into the wound bed. E5 then did not maintain a clean area during the process and failed to put down a barrier between the clean treatment supplies and R5's bedding and on the top of the treatment cart. E5 placed a plastic medicine cup with calcium alginate, santyl and tongue depressor, 4x4 gauze, abdominal dressing, scissors and tape on top of R5's contaminated bed linens. E5 then proceeded to do R5 ordered treatment with the contaminated items. E5 also had a bottle of wound cleanser that E5 had touched with feces-dirty gloved hand and then proceeded on multiple occasions to spray and then wipe and or re-touch the pressure ulcer during the procedure as well at treatment items after use, thereby, re-contaminating on multiple occasions. This same bottle of wound cleanser had also been handled by R5's feces contaminated hand and at no time was it cleaned after and was then placed back on top of treatment cart and at no time was cleaning of this area noted after. E5 also brought her treatment cart into the room from out into the hallway and on multiple occasions with her gloved hands opened the draws and grabbed supplies such as 4x4 gauze, santyl, calcium alginate abdominal dressing, medicine cup, tongue depressor, thereby contaminating her supplies. E5 was also noted to place tape on top of the outside surface of the pressure area when she secured the dressing. On 10/20/15 at 8:20AM, R5 was in the Dining Room Area in his wheelchair, at 9:00 AM he was in the hallway in wheelchair, at 9:30 AM and 9:50 AM he was in his doorway to his room up in his wheelchair and at 10:15 AM R5 remained up in his wheelchair. R5 was up on area for at least 115 minutes and the wound specialist recommendation is for no longer than 60 minutes. On 10/15/15, 10/19/15 and 10/20/15 there are multiple observations where R5 is not on a specialized Low Air Loss Mattress. On 10/21/15 at 9:50 AM, Z6 (Wound Doctor) stated he had been treating R5 for the pressure on his bottom. Z6 stated at the present it was unstageable but had originally started as a stage 2 pressure ulcer. Z6 stated it was very important for R5 to stay off of the area as much as possible, preferable in bed to help keep the pressure off of the area. Z6 stated CNA (Certified Nursing Assistant) need to notify the nurse as soon as possible when a dressing falls off because it needs to be cleaned and covered to help prevent infection and help with wound healing. Z6 stated during interview that he would have expected R5 to have already have been on a low air loss mattress and that it would possible end up at a stage 4 pressure ulcer and infected if good care was not taken. Z6 stated that because R5's pressure area is so near the anal opening it is even more important good incontinence care is given, soiled dressings are changed as soon as possible and if a dressing is off then the area needs to be covered or the area is not going to improve but get worse. Z6 stated any time there is a change the nurse should be making him aware or the primary care physician but he is available all the time. Z6 stated if a nurse is not sure about a treatment or how to clean or the order they should always call and clarify. Z6 stated his preference for wound cleansing wound be normal saline because the wound cleansers tend to change the PH of the wound which can cause more problems with wounds. Z6 stated that if wound are contaminated with urine or feces they are likely to become infected and require treatment with antibiotic therapy. Z6 stated that with pressure ulcers the most important things are to keep the treatment in place, keep the area clean and dry, provide proper nutrition, provide turning and reposition or off area as needed and provide a low air loss mattress. Z6 also stated it is important to remember with the use of a low air loss mattress to use it correctly and multiple layers of padding causes it to be ineffective as well as the adult briefs, this is why staff must check and change often. Z6 stated there seemed to be issues with staffing and leadership recently. On 10/20/15 at 9:45 AM, E5 stated she had only been the wound nurse since August 2015. E5 stated she did not feel she had a whole lot of training except to go over a manual and some information with E3 RN/RCD (RN/Regional Corporate Director) and that was only one day. E5 stated she had had no formal wound training and was not wound certified. E5 stated nursing is to measure wound when they are first are found or reported, then weekly then as they are needed. E5 stated if Z6 is see the resident she usually just uses his measurements. E5 stated weekly skin checks are to be documented on the residents TAR (Treatment Administration Record) but she as well as many of the other nurse have not been doing this recently, probably the last 4 weeks. E5 stated there had been a problem with treatments for at least 3 weeks. E5 stated there had been several occasions when she would come in on a Monday after working on a Friday and her wound dressing from the previous Friday would still be there or the resident would not have any dressing. E5 stated she had made the administrator and the Director of Nursing aware of these concerns at least two weeks ago when it first became an issue. E5 stated that if treatments are not getting done then they are never going to get better and she was concerned and as the treatment nurse she wanted to make sure thing were improving. E5 stated there were times other staff (E16, E17 RN and E18 LPN (Licensed Practical)) might find something on a resident on evenings or a weekend and not call the doctor but instead leave her a note in the treatment book and she would have to take care of it the next day or Monday morning. E5 said she knew this is not how things were supposed to be done but she never said anything to the other nurses. E5 stated there are also times the other nurses won't or don't know how to do measurements so she has to go behind them and do them when she isn't the one that found it originally. E5 stated the nursing aids are to let the nurses know if a treatment needs to be done, if a dressing is off and needs replace or if the resident has a new skin area. E5 stated she thought the problem was the facility is short staffed, there is lack of staff education and some staff does not understand the expectation. On 10/19/15 at 2:15 PM, E4 (Registered Nurse/Vice President of Clinical Services) stated when wound treatments are done the nurse should not wipe over the same area with the same surface more than one time, the nurse should have barriers between clean and dirty, if a dressing is off or coming of the staff should notify the nurse and it should be changed or replaced immediately, there should be specific orders of how to clean the wound and if the nurse is not sure the doctor should be contacted. E4 also stated that if urine or feces gets into a wound it would be contaminated and increase risk for infection. E4 stated treatment carts should not be taken into rooms because they are not clean and staff should just take in what they need. E4 stated doctors' orders and recommendations should be followed and addressed on the resident's plan of care. Confirmed she had seen where in the month of October 2015 there were blank areas on multiple residents TAR (Treatment Administration Record) specifically on the weekend. E4 confirmed this would indicate these treatments were not completed. E4 stated the staff should do the treatment by the physician order [REDACTED]. E4 stated if a treatment does not get done for any reason then the physician should be made aware. E4 stated each resident is to have a weekly skin assessment as this is also to be documented on the TAR and there is to be and initial on the front of the sheet and on the back there should be some kind of narrative even if it stated there are no areas of concern or no skin issue, no open areas, etc. According to R5 Care Plan with Initiation date of 11/27/15 he is at risk for pressure ulcer/skin impairment related to mobility, problems with friction and shearing, dribbling at times during urination and probable nutritional risk and open area on right buttock pressure related and the goal is that he will be free from skin impairment. Interventions include: Provide pressure redistribution surface to bed, follow facility protocols for treatment of [REDACTED]. Wound doctor recommendations for only 60 minutes of time up in wheelchair are not found nor are preferences for cleansing agents. According to the facility policy titled Preventative Skin Care with review date of 1/14 it states the policy is to provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well groomed and free from pressure ulcers. Maintain wrinkle free, clean, dry bed linen. Keep incontinent residents clean and dry. According to the facility policy titled Decubitus Care/Pressure Areas with review date of 1/14 the policy is to ensure a proper treatment program has been instituted and is being closely monitored to promote healing of any pressure ulcer, once identified. Under Procedure: Upon identification of skin breakdown the following will be completed: the pressure area will be assessed and documented, complete all areas of wound assessment: size, depth, drainage, color, odor, and treatment. Notify the physician for treatment orders. The physician's orders [REDACTED]. The order must have specific frequencies. Initiate physician order [REDACTED]. According to R2's Wound Specialist Initial Evaluation dated 10/14/15 done by Z6 the resident has a stage 3 pressure ulcer on her right buttock that is greater than 3 days in duration and is 3 x 1.5 x 0.1 cm with a surface area of 4.50 cm2 with orders for collagen dressing every two days, clear occlusive dressing with calcium alginate. Also a stage 2 pressure ulcer to left buttock that is more than 3 days in duration and is 0.5 x 1 x not measurable cm and a surface area of 0.50 cm2 and is to have silver [MEDICATION NAME] with hydrogel daily with a clear occlusive dressing once daily. According to R2's Care Plan with initiation date of 2/27/15 she is at risk for pressure ulcer/impaired skin integrity related to decreased mobility and bowel/bladder incontinence and requires extensive/total assist with toileting. On 10/14/15 has open area to left and right buttock that are pressure related. R2's goal is that she will have intact skin, free of redness, blisters or discoloration. Under intervention states monitor/document/report to the doctor as needed changes in skin; to educate the resident/family/caregivers as to causes of skin breakdown; including: transfers/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, monitor nutritional status, serve diet as ordered. R2 also has a focus area that she is at risk for nutritional impairment related to impaired cognition and needs staff assistance with consumption and has to be fed by staff and she is also at risk for dehydration related to dependence for fluids and impaired cognitions and the goal is that she will not have any significant weight changes. One of the interventions include for the registered dietician to evaluate and make diet change recommendations as needed. R2's last review for this care plan was 8/9/15. According to R2's weight log on 8/7/14 she weighed 167.6 lbs. (pounds) and on 8/11/15 she weighed 144 lbs. which is a 23.6 lbs. weight loss in a year. However according to the dietary supervisor note dated 8/24/15, R5 is only down 20 lbs. in the last year and will continue to monitor and refer to dietician as needed. On 10/22/15 at 10:15 AM, E22(Dietary Supervisory) confirmed she had not been made aware of R2's pressure ulcers until 10/19/15 when the surveyor had brought it to her attention, when it was discussed with the Care Plan Coordinator(E9). E22 stated she was not aware of R2's pressure ulcers when they were put on the Care Plan on 10/14/15 or she would have at least started R2 on supplement of arginade and made the Registered Dietician aware so she was aware and could evaluate her if needed. According to R2's Skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review dated 9/2/15, 9/12/15 and 9/19/15 she had reddened areas on both the right and left buttock at this time. According to documents cream was only applied on 9/19/15. Each of these documents are signed that nurses assessed. According to R2's TAR (Treatment Administration Record) for September 2015 there are no weekly skin checks done but were to be done on the 7 PM- 7 AM shift on Wednesday or Saturday. There is an order to wash buttocks with soap and water, pat dry, apply zinc oxide daily as needed, however no documentation this treatment was ever administered. There is no documentation on this or in the nursing notes or in R2's chart that any physician was aware of any skin redness or irritation noted by the CNA's or that the nurses made the physician aware of R2's skin breakdown or impaired skin integrity. According to R2's Skin Monitoring: Comprehensive CNA Shower Review dated 10/7/15 she has redness on both the right and left buttock. E11 RN (Registered Nurse) has signed this on 10/8/15 and the intervention is that it was forwarded to the treatment nurse. According to R2's POS (Physicians Order Sheet) she did not receive orders for her redness noted on the 10/7/15 shower report until 10/9/15. At this time it is only identified at redness. No corresponding nursing notes can be found for these orders. According to R2's October TAR weekly skin checks are initialed on 10/1/15 and 10/8/15 however no documentation as to the finding could be found on this document or in R2's chart. On 10/20/15 at 2:30 PM, Z5 (Primary Care Physician) stated he had been made aware R2 had a pressure area with open area but he had not seen it but that is why he had referred it to Z6 (wound doctor) because that is why he utilizes him. On 10/21/15 at 9:50 AM, Z6(Wound Doctor) stated the first time he saw R2's pressure ulcer it was already open and he could not tell when it was originally open. Z6 stated that most time pressure ulcers that are at a stage 1 present as reddened not blanchable areas. Z6 stated a lot of time these are areas that people just think are areas of excoriation and redness but they are actual pressure ulcers at a stage 1. Z6 stated staff should measure these when they are found and then if they have open areas they should measure the open areas when they are found. Z6 stated he preferred nursing not use gauze with the [MEDICATION NAME] and hydrogel treatments that are covered with the occlusive dressings. Review of R2's chart and documents shows no information where facility staff identified or measured or notified physician of the open areas on her buttocks. First measurements of open areas for R2 are done by Z6 on the day he first saw the area. On 10/15/15 at 1:10 PM, E13 and E8 (CNA's) put R2 in bed. R2 was incontinent of urine and they placed her in bed on a low air loss mattress. The low air loss mattress was noted to have a tight fitted sheet on it and a sheet folded in fourths and a cloth incontinent pad over it. The dressing over stage 3 pressure ulcer on right buttock cheek was noted to be rolled partway off and back/coming off and exposing over a fourth of the wound bed. The dressing over the stage 2 pressure on the left buttock was also off at the corner with a small section uncovered. During incontinence care E13 was observed wiping urine over the exposed/open area of the wound. E13 also took urine soiled gloved and tried to re-cover dressing to right buttock with the soiled dressing unsuccessfully. E13 also did not change gloves after she finished her incontinence care and continued to provide care and contaminate all clean items with the soiled gloves (bed, linens, gown, chair, resident, bedside table, sit-to stand transfer lift, curtain, positioning pillows, bolster pillow etc). On 10/15/15 at 3:45 PM, when asked E5(Wound Nurse) if any staff had made her aware that R2's dressings were coming off when put to bed at 1:10 PM she stated No E5 confirmed stated staff are to make her aware if dressing are coming off as soon as they know. On 10/15/15 at 4:00 PM E5 was doing R2's treatment after being made aware by surveyor that the dressing was coming off and when she went to cleanse area. E5 used an incontinence wipe with aloe. When questioned, E5 stated that she had always used these that she just thought she had to get the area clean and this was ok. When asked if she had got clarification with any doctor she stated she had not thought about it. According to R2's TAR states to right buttock apply collagen and calcium alginate. Cover with clear occlusive dressing change every 2 days. Left buttock apply silverdene and hydrogel cover with clear occlusive dressing. Treatment is signed off as are done every day and no doctor notification as to why or need for clarification. During treatment, E5 did not remove dirty gloves at any time, instead she used those same gloves during the entire process to both remove the dirty, clean and apply new dressing for both the right and left pressure ulcers. E5 was also noted to place 2 x 2 gauze over the [MEDICATION NAME] and hydrogel mixture on the left buttock prior to placing the clear occlusive dressing. E5 stated she did this because these dressing seemed to fall off easy with this treatment and it usually worked a little better if she put the gauze on. When asked E5 if the doctor was aware of the concern she stated No . During R2's treatment E5 had no barriers down between the residents bedding the treatment supplies. E5 also wiped over the wound bed multiple times with the same surface there by contaminating further. On 10/19/15 at 10:30 AM, R2 was in bed on the low air loss mattress with fitted sheet, flat sheet folded in fourths and a cloth incontinence pad between the mattress and R2. On 10/20/15 at 3:00 PM, R2 was in bed on her low air loss mattress and had on a fitted sheet, flat sheet folded in fourths, cloth incontinence pad and disposable incontinent brief between the R2 and the low air loss mattress. On 10/19/15 at 11:30 AM, E6 LPN (Licensed Practical Nurse) stated she had not done R2's treatment either this past Saturday (10/17/15) or Sunday (10/18/15) because she had been too busy and there had been too little staff to get everything done. Review of R2's TAR for these dates had E6 documenting that she did the treatments for these days. No documentation can be found in R2's chart that the physician was made aware that these treatments were not done and corresponding recommendations or orders. On 10/20/15 at 11:00 AM, E2 RN/DON (Registered Nurse/Director of Nursing) stated E5 (wound nurse) had made her aware about 2 weeks ago that the treatments were hit or miss and biggest issues seems to be during the weekend. E2 stated there are issues with staffing, staff education and training. E2 stated stage 3 pressure ulcers do not happen overnight and not sure why measurements are not available until the one that are present with wound doctors' assessment. On 10/21/15 at 2:50 PM,E8 CNA, stated that they have been short nursing and CNA staff in the last 3-4 weeks and it is worse on the weekends. Stated there have been times he has left work on Friday and will see same dressing on resident the following Monday when he returns after weekend off. E8 stated had specifically seen this with R2. E8 stated treatments and dressings seem to be done hit or miss but is better if showers get done but in last 4 weeks showers have not been getting done due to short on staff. E8 stated, E6 (LPN) is bad about not doing treatments for resident and she just doesn't seem to want to do them. E8 stated, E17 (RN) will do them at times and then there are times she either won't have time or just won't do them. E8 stated he will tell the nurses about resident skin issues and they will just wait and tell E6 (wound nurse) instead of taking care of it when they find out about it. On 10/21/15 at 9:50 AM, Z6 stated he would want to be made aware if a treatment was not done for any reason. On 10/20/15 at 2:30 PM, Z5 stated he should always be made aware if a treatment is not done or medication is not given. On 10/19/15 at 2:15 PM, E4 RN/VPCS stated if treatments are not done then nurses are always to make the doctor aware. If they are not done then the TAR should not be signed and this would be a matter of falsification of documentations and absolutely not acceptable. Stated areas are to be measured when found not wait for wound nurse and any nurse can do measurements and should and should assess any area of skin breakdown. E4 stated weekly skin checks have not been done correctly. E4 stated there is not to be multiple layers of padding on low air loss mattress or tight fitted sheets because air cannot redistribute which is the purpose of these. According to the Physician Medication Order policy with a revision of 1/15 it states the policy is the medication shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in this stated. Under Policy Interpretation and Implementation states all drug and biological orders shall be written dated and signed by the person lawfully authorized to give such and order. Verbal orders for drugs and treatments shall be received by Licensed Nurses and Physicians. Verbal orders must be recorded immediately in the residents chart by the person receiving the order and must include the date and time the order was written. Orders must include: name and strength of the drug, quantity or specific duration of therapy, dosage and frequency of administration, route or administration if other than oral, reason or problem for which given.