Every finding on record at Integrity HC of Carbondale

Based on observation, interview, and record review the facility failed to develop individualized discharge plans that incorporated input and preferences from the resident, resident representative, and the interdisciplinary team to ensure safe and orderly transfer/discharge planning for 13 (R13, R14, R17, R18, R21, R22, R23, R24, R25, R27, R28, R30, and R31) of 27 residents reviewed for transfer and discharge in the sample of 46. This failure resulted in R27 and R30 experiencing feelings of upset/worry, sadness, or distress and would cause a reasonable person to feel the same emotions when given the news of having to relocate to another facility on very short notice. Findings include:On 9/15/25 at 1:35PM, V1 (Former Administrator) provided a list of residents still in the facility and stated there were still 19 in house as of this date/time. V1 said they have provided the IDPH (Illinois Department of Public Health) regional office a list of those residents that have been discharged to date and plan to send weekly updates. V1 said the list includes resident names, the location they were transferred to and the date/time they left. V1 stated the facility has plumbing issues that need addressed and the kitchen will need to have 3 feet of concrete dug up in order to replace old cast iron plumbing that has collapsed. V1 stated other areas of the facility's physical environment need remodeled as well, such as paint and flooring in some areas and they also plan to do those repairs while the kitchen plumbing is being replaced. V1 stated it's her understanding the facility owner plans to reopen the facility after repairs are complete and residents can return after completion. V1 stated the residents that have transferred out thus far have all gone to other homes owned by (name of facility's corporation) but they were given choices of where they wanted to go. V1 admitted that the facility did not provide written notices, however no residents were forced to go somewhere they did not want to go and all that have transferred agreed with their new placement. V1 stated the closure is temporary and not an emergency but these repairs do need to be done soon, and residents need to go to other facilities for them to complete the repairs. On 9/15/25 at 2:45 PM, V4 (Ombudsman) stated that he can't remember which day, either late Thursday afternoon (9/11/25) or early Friday morning (9/12/25) that residents were being transferred out of the facility. V4 said V1 (Former Administrator) told him there were plumbing issues that needed fixed, and it would take about 2 months. V4 said that he told V1 that residents need to be given a choice about where they go and V1 stated they were giving them choices. V4 was asked if the facility provided him notice of the resident transfers or temporary closure, and V4 stated no, the facility did not contact him. V4 stated he got word from someone at Adult Protective Services that the facility was transferring people out when they called to inquire about a bed opening, so they called V4 to see if he was aware and he was not. V4 stated he was concerned the facility may not be following proper procedures for transfers/closure or providing the required notices and discharge planning for safe/orderly transfers. On 9/16/25 at 9:31 AM, V1 stated the residents were given a choice of corporate sister facilities first, then if they didn't want that they gave options of other facilities that are close. 1. R27's admission Record documented an admission date to the facility of 8/6/25 and included diagnoses of anxiety disorder and depression. This document lists R27 as her own responsible party, with a daughter listed as an emergency contact. R27's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R27 is cognitively intact. R27's Care Plan included a Focus area of R27 at times presents with moderate sign/symptoms of anxiety, initiated on 8/13/25 with an intervention of encouraging R27 to talk about anything that may be on her mind, speak in a calm voice and actively listen and offer assistance by asking if there's something staff can do to help. Another Focus Area documents R27 at times demonstrates mood distress d/t (due to) depression, initiated on 8/13/25, with interventions to aid R27 in decreasing of hopelessness by including her with decision making, provide positive feedback, encourage expression of feelings, especially related to area of life outside of R27's control and communicate care, empathy, sensitivity and compassion for the resident and what she is going through. R27 also has a Focus area documenting she is alert and oriented x (times) 3 and is able to make needs known without difficulty, with an intervention to communicate with family/caregivers regarding capabilities/needs. R27 has a Focus area that she intends to be short term and return to community with support services after receiving therapy 6/8 months with an intervention that SSD (Social Service Director) will provide/assist R27 with information and/or applying for community resources/support services. R27's Care Plan did not include any updates or revisions to indicate planning for transfer or discharge, including a plan for therapy services, to another facility had occurred. A discharge MDS documented R27 was discharged from the facility on 8/31/25 for a short-term hospital stay. R27's Progress Notes include the following entries:9/3/25 at 3:13PM documented the facility received report from the hospital that R27 would be returning.9/3/25 at 6:01PM documented R27 arrived at the facility.9/4/25 at 10:49AM, labeled a Social Service Note, documented V1 (Former Administrator) contacted (R27's) daughter to discuss sending a referral to a sister facility due to this facility not currently receiving payment for medicaid/medicare. She was agreeable to the transfer and would like her to return to this facility when possible.9/5/25 at 10:26AM documented Resident left facility with bus driver from (name of sister facility located approximately 20 miles east of original facility). All meds (medications) and belongings sent with driver. Narcotics sent with signed acknowledgement. Report called to nurse on duty at (sister facility). Review of R27's progress notes and medical record show no reproducible evidence of an Interdisciplinary Team (IDT) meeting to discuss transfer/discharge options. The medical record does not include evidence of facility staff having any direct conversation or discussion with R27 regarding her preferences or options of available locations for transfer. R27's Receiving Facility admission Record documented an admission date to the receiving sister facility (approximately 20 miles east of the original facility) on 9/5/25 and listed R27 as her own responsible party. On 9/16/25 at 4:30 PM, R27 was observed in the new/receiving sister facility and was alert and oriented to person, place and time. R27 stated when she was at the original facility, about a week or more ago, she had to be sent out to the hospital and was supposed to go back to that facility after being discharged from the hospital. R27 said she discharged from the hospital on Wednesday (9/3/25) or Thursday (9/4/25) and went back to that facility for a day or so but on Friday (9/5/25) staff there told her she couldn't stay because they couldn't take any new admissions, so she had to come here (to the sister facility). R27 said she came here to the new facility on the same day she was told about not being able to stay at the previous facility. R27's facial expression/emotional affect while discussing these events appeared distressed. When this surveyor asked how R27 felt about the news that she would have to move, R27 stated that she felt very rushed and felt really anxious about the move because it happened so fast. R27 stated that she is ok now that she is here but was stressed at the time. When asked if R27 was given any other reason for her transfer, such as plumbing issues or building repairs, she stated there was no explanation as to why she had to leave except they couldn't take admissions, and she was considered a new admission since she had been sent out to the hospital. This surveyor again clarified that R27 did not come straight to the sister facility from the hospital and R27 stated no, she went to the original facility from the hospital, spent one or two nights there, then came here Friday (9/5/25). R27 stated she didn't want to go to another facility and just wants to get therapy and go back to her home and she didn't know if she was going to get therapy here. On 9/17/25 at 10:20 AM, R27 was observed in her wheelchair in the foyer area of the facility close to the nurse's station visibly upset and crying about wanting to get therapy here and be able to go home. R27 also voiced being upset about the pants she was wearing, stating they were not hers. R27 stated she doesn't have all her clothes here and that she had new clothes and doesn't know where they are. V15 (Receiving/Sister Facility Administrator) was kneeling by R27 and consoling her, offering reassurance that she would go check on her therapy and will help make sure they locate any clothes she may be missing. 2. R30's admission Record documented an admission date to the facility of 7/24/24 and included diagnoses of anxiety disorder and depression. R30's admission Record lists himself as responsible party with V17 (Family Member) listed as POA (Power of Attorney)/Healthcare Surrogate. R30's MDS dated [DATE] documented a BIMS score of 10, indicating R30 has moderate cognitive impairment. R30's Care Plan documented a Focus area that R30 wishes to return home when strong enough with an intervention that the facility will provide therapies needed as well as good nutrition designed to promote health and healing in order to help R30 meet his goals to go home. R30's Care Plan did not include any updates or revisions to indicate planning for transfer or discharge to another facility had occurred. R30 also had a Focus area documenting he is alert and oriented x (times) 3 with some confusion; he is able to make needs known without difficulty, with interventions to communicate with him/family/caregivers regrading resident's capabilities and needs and to discuss concerns about confusion, disease process, NH (nursing home) placement with him/family/caregivers. The medical record did not include evidence of facility staff having any direct conversation or discussion with R30 regarding his preferences or options of available locations for transfer. R30's Care Plan did not include any updates or revisions to indicate the interdisciplinary team did any planning for transfer or discharge to another facility. R30's Receiving Facility admission Record documented an admission date of 9/11/25 to the receiving/sister facility (approximately 20 miles east of the original facility). R30's Progress Note dated 9/10/25 at 11:44AM and authored by V5 (Social Service Director/SSD) documented R30 sitting in his room spouse (name) was there visiting. Spoke with the both of them no concerns. After visit spouse did come and talk to SSD informing that R30 is thinking/wanting to d/c (discharge) back home but stated that she is not able to care for him on her own and their home is not set up where he'd be able to manage getting around in his w/c (wheelchair). R30's Progress Note dated 9/11/25 at 1:37PM authored by V1 (Former Administrator) documented V17 (Family Member) was contacted by this administrator to discuss the need to move residents to another facility temporarily to complete the need extensive sewer repairs within the facility. Choices of available facilities within the geographical area were offered. V17 chose (name of sister facility approximately 20 miles east of original facility). Resident was notified of the move. Psychosocial needs met. No emotional distress noted. R30's Progress Note dated 9/11/25 at 6:04PM documented resident left facility via facility transportation will (sic) all current medications and belongings. All questions and concerns were addressed before leaving facility. On 9/16/25 at 4:20 PM, R30 was observed in the receiving/sister facility where he was recently transferred. When asked if R30 was recently transferred here, R30 said yes, he was. When asked if R30 received much notice prior to moving & he raised his voice and stated NO! They didn't tell me anything! R30 said the facility told him in the morning on Thursday (9/11/25) and moved him out that same day and he was not happy about it. R30 stated he was ok with being at the new facility now but was not happy about the short notice or having to move. R30 said he thought he had to move due to building repairs. On 9/17/25 at 2:35 PM, when this surveyor asked V17 (R30's Family Member) about R30's transfer to the sister facility approximately 20 miles away from the original facility, V17 stated I was so darn mad .I was there visiting him on Wednesday (9/10/25) and they didn't say anything about it. V17 said then on Thursday (9/11/25), she was notified by phone they would be transferring R30 to (name of sister facility). V17 did not remember being given a reason for the transfer, but said she maybe heard the maintenance man say something about gas lines being an issue at some point. V17 said there was no meeting held, or discharge planning discussed and no one at the facility went over any options with her. V17 said no one mentioned offering to make a referral to the other facility located in the same town (owned by a different corporation). V17 said she would have liked that option because she was able to visit R30 every Wednesday, Saturday and Sunday at the other facility because she lived close. V17 stated now she won't be able to visit R30 very often because she doesn't drive and would catch rides with family and friends, but the facility they transferred him to is a lot farther away. V17 stated at the time, R30 was really upset about moving. 3. R31's admission Record documented an admission date to the facility of 01/15/25 and included a diagnosis of unspecified dementia. This admission Record listed V18 (Family Member) as R31's responsible party/emergency contact #1. Other contacts listed included R31's granddaughter. R31's MDS dated [DATE] documented a BIMS score of 99, indicating R31 was unable to complete the interview. R31's Care Plan included a Focus area of R31 will be long term care with an intervention of making it as much of a home like atmosphere as possible to make sure she is comfortable and well taken care of, initiated on 1/15/25. The Care Plan did not include any updates or revisions to indicate planning for transfer or discharge to another facility had occurred. R31's Progress Notes included an entry on 9/12/25 at 10:25AM by V3 (Assistant Director of Nursing/ADON) that documented (granddaughter) was contacted to discuss the need to move residents to another facility in order to complete the needed extensive sewer repairs within the facility. Choices of available facilities within the geographical area were offered. (Name of granddaughter) chose (name of sister facility approximately 20 miles south of current facility). Resident was notified of the move. Psychosocial needs met. No emotional distress noted. The next progress note entry was dated 9/12/25 at 12:20PM, authored by V3 and documented (V2/Director of Nursing-DON) contacted V18 (Family Member) to discuss the need to move residents to another facility temporarily in order to complete the needed extensive repairs within the facility. Choices of available facilities within the geographical area were offered. V18 chose (name of sister facility 20 miles east of current facility). Resident was notified of the move. Psychosocial needs met. No emotional distress noted. R31's Progress note dated 9/15/25 at 3:09PM documented R31 left the facility via facility transportation all belongings sent along with medications, all concerns and questions addressed before departing. On 9/17/25 at 2:45 PM, when asked about R31's transfer and if she received any notice, V18 (Family Member) stated it was real short notice. V18 couldn't remember when but thought maybe the facility called to tell her on Wednesday (9/10/25) or Thursday (9/11/25) and then they moved her mom on Monday (9/15/25). V18 said they told her there was something going on with the building and residents needed to transfer. V18 said they first told her R31 would go to (name of sister facility approximately 20 miles south of current facility) but V18 said she told them absolutely not and denied that location, stating she didn't want her there. V18 then stated she told them she would just bring R31 home if they send her there, so they offered to transfer R31 to (another sister facility approximately 20 miles east of current location). V18 stated there was no discharge plan of care discussed, and they only mentioned transferring her mother to other facilities (owned by this corporation's name). R31 said they did not offer to make a referral to the other facility that is in the same town (different corporation). V18 said she lives in the town where R31 was and so do a lot of her family members so they were able to visit frequently, but with R31 being moved to (new town location) it will make it more difficult for everyone to visit. V18 said her mother has dementia but moving her so quickly like this would have upset her or made her anxious because she needs to be around family. On 9/30 at 3:25PM, V3 (ADON) stated she first called R31's granddaughter due to not being able to reach V18 because they needed a new contact number for V18. Once they got a hold of V18, she said she wanted R31 to go to (sister facility 20 miles east of facility), not (the sister facility 20 miles south). 4. R18's admission Record documented an admission date to the facility of 9/26/2024 and lists R18 as her own responsible party. There are several contacts listed with two being listed as emergency contacts. One emergency contact is identified as next of kin/cousin and the other is listed as a friend. Another person is listed as other with no relationship identified. R18's MDS dated [DATE] documented a BIMS score of 99, indicating R18 was unable to complete the interview. R18's Care Plan includes a focus area of R18 would like to return to the ALF (assisted living facility) she was at once she is strong enough to discharge. At this time, (R18) will be here for long term care. The goal documents R18 and her representative will meet with the social worker and nurse quarterly to review and update any changes to R18's plans for discharge. The intervention documented to arrange a meeting with the family/significant other to discuss what services might be needed and what services are available. Review costs, especially those not covered by insurance. Encourage family to express any concerns they have well in advance of the tentative discharge date once it is decided R18 is ready for discharge. There are no corresponding dates documented to show when this focus area was initiated nor any dates to show updates or revisions to indicate planning for transfer or discharge to another facility had occurred. R18's Receiving Facility admission Record documents R18 as her own Responsible Party, with the same contacts listed as described above. This admission Record lists an admission date to the receiving facility of 9/12/25. R18's progress notes dated 9/12/25 at 10:57AM authored by V3 (ADON) documented the person listed as Other on R18's admission Record was contacted to discuss the need to move residents to another facility temporarily in order to complete the needed extensive sewer repairs within the facility. Choices of available facilities within the geographical area were offered. The note further stated the person listed as other chose (name of sister facility approximately 20 miles east of original facility) for R18. Resident was notified of the move. Psychosocial needs met. No emotional distress noted. The next progress note entry was on 9/12/25 at 1:50PM noting Resident left facility via facility transportation will (sic) all current medications and belongings. All questions and concerns were addressed before leaving facility. On 9/30 at 3:25PM, V3 (ADON) was questioned as to why she called R18's contact listed as other to discuss options for R18's transfer as opposed to the friend or cousin listed. V3 stated, she would have just gone down the list of contacts in order and if the first person didn't answer, she called the second. V3 was asked if she knew what R18's relationship was to the person listed as other and V3 said she wasn't sure who that person was to R18. On 9/16/25 at 11:15 AM, R18 was observed in her new/receiving facility and stated she wanted to go back home. R18 did not remember the reason for coming to this facility and said she just was told she was coming here. When this surveyor asked about the current facility and her move here, R18 said she felt a little pressured and told this surveyor It's too big here, I want to go back home. 5. R28's admission Record documented an admission date to the facility of 12/21/22 and lists V16 (Family Member/Power of Attorney-POA) as her responsible party. R28's MDS dated [DATE] documented a BIMS score of 99, indicating R28 was unable to complete the interview. R28's Care Plan included a Focus area of R28 doesn't have plans for discharge at this time and will reside at the facility for long term care, with a goal of R28 and her representative will meet with the social worker and nurse quarterly to review and update any changes to R28's plans for discharge, and a corresponding intervention of, as necessary, meet with the resident/representative on a regular basis to discuss discharge plans. Provide the resident with an opportunity to express any thoughts or feelings. Address concerns as they arise. There are no corresponding dates documented to show when this focus area was initiated nor any dates to show updates or revisions to indicate any planning for transfer or discharge to another facility had occurred. R28's Progress Notes have an entry dated 9/11/25 at 2:31PM by V1 (Former Administrator) documenting V16 (Family Member/POA) was contacted by this administrator to discuss the need to move residents to another facility temporarily in order to complete the needed extensive sewer repairs within the facility. Choices of available facilities. V16 chose (name of sister facility approximately 20 miles east of current location). Resident was notified of the move. Psychosocial needs met. No emotional distress noted. The next entry on 9/11/25 at 6:03PM documented resident left facility via facility transportation will (sic) all current medications and belongings. All questions and concerns were addressed before leaving facility. On 9/17/25 at 1:50 PM, V16 (Family Member/POA) stated he is R28's POA but he also has a sister (R29) still at the facility and his brother is her POA. V16 stated both he and his brother are local to the facility and were able to visit frequently. V16 said R28's transfer to (sister facility approximately 20 miles east of this facility) was a giant inconvenience for everyone and they had very, very short notice. V16 said he thinks the facility called him Thursday 9/11/25 and said his mother was being transferred that day. V16 said he wasn't given a 30-day written notice or discharge plan for his mother. V16 said he thinks the staff at the facility were given short notice too and he felt bad for them. V16 said options weren't discussed with him regarding different places his mother could go, they only mentioned (name of sister facility approximately 20 miles east of this facility) but out of the other facility locations owned by the corporation, that would have been his choice anyway. V16 said on Monday 9/15/25, they had a very long meeting at the facility about the transfers. In attendance were him, his brother, his sister (R29) and V1 (Former Administrator). V16 said V1 told them the building needed repairs, and they can't have anyone in there during that time, so corporate told them they needed to get everyone out and repairs would take about 2-3 months to resolve. V16 said they were told deep cleaning and painting would also be done along with the repairs. V16 said his sister (R29) was not happy about having to transfer, saying she's very upset about it because V16 takes care of R29's dog at his home, so he comes to get R29 often to take her home to visit with her dog. V16 said the facility was saying there weren't any more rooms at the facility where his mother went, and R29 didn't want to go to their other facilities they suggested because they were far/not in convenient locations and she wouldn't be able to visit her dog as often, so now he and his brother are trying to find R29 somewhere closer to go, maybe an assisted living in the same town, if they can figure out the payment. V16 said the facility keeps saying they are going to move everyone back, but who knows. If so, V16 will be insistent that they bring R28 back. V16 said his mother has dementia but she has always been a pretty accommodating person so the move probably wouldn't have bothered her too much. 6. R23's admission Record documented an admission date of 7/29/25 and included diagnoses of unspecified dementia and bipolar disorder. This admission Record lists V32 (Family Member) as R23's responsible party/guardian. R23's MDS dated [DATE] documented a BIMS score of 15, indicating R23 is cognitively intact. R23's Care plan included a Focus area of resident does not have discharge plans. (V32) reported R23 will be a LTC (long term care) resident. The goal listed documents family will keep SSD informed of any changes with discharge potential or plans and the intervention listed states SSD will assist resident/family with information and support services as requested. There are no corresponding dates documented to show when this focus area was initiated nor any dates to show updates or revisions to indicate any planning for transfer or discharge to another facility had occurred. R23's Progress Notes include the following entries:On 9/11/25 at 7:43AM authored by V1 documented R23's POA (V32) was contacted by the DON to discuss the need to move residents to another facility temporarily in order to complete the needed extensive sewer repairs within the facility. Choices of available facilities within the geographical area were offered. (V32) chose (name of sister facility approximately 20 miles east of current location). R23 was notified of the move. Psychosocial needs were met. No emotional distress noted. The next entry is dated 9/11/25 at 8:20AM by V2 (DON) and documents resident and family notified of transfer to (name of sister facility approximately 20 miles east of current location) and agreeable for transfer, MD (medical doctor) notified and is agreeable with transfer. The next entry is dated 9/11/25 at 11:08AM and documents resident is to transfer to (name of sister facility approximately 20 miles east of current location), report called. Resident is to transport with family. On 9/11/25 at 11:25AM, V2 documented resident belongings and medications were sent with family for transportation, all questions and concerns were addressed prior to leaving, resident was in good spirits when leaving facility. On 9/11/25 at 11:34AM, resident has left the facility transported by his daughter. On 9/16/25 at 4:00 PM, R23 was observed in his wheelchair in the new facility. When asked how his move here went and if he had much notice, R23 stated he barely got any notice at all before having to leave the other facility and didn't receive anything in writing. R23 said he was told he needed to leave the same day they shipped him out. R23 said they packed up his bags and put them in the van to come here. R23 said they told him it was because of plumbing issues. R23 said choices of places to go weren't given to him, they just told him he was coming here. R23 said if he had been asked about where he would want to go, he might have wanted to look at (name of facility in another town/different corporation) because that's where he grew up, but he is ok being here now. 7. R25's admission Record documents admission to the facility on 5/31/25 and included diagnoses of schizoaffective disorder and depression. R25's admission Record also documents she has a POA. R25's MDS dated [DATE] documented a BIMS score of 06, indicating severe cognitive impairment. R25's Care Plan includes a Focus area documenting she will display signs/symptoms of depression/anxiety with an intervention of encourage her to express her feelings. R25's Care Plan also has a Focus area documenting she has impaired cognitive function and impaired thought processes; she is able to make most needs known without difficulty at this time, with corresponding interventions of communicate with the resident/family/caregivers regarding resident capabilities and needs, discuss concerns about confusion, disease process, NH placement with the resident/family/caregivers, and keep her routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. Review of the entire Care Plan revealed no Focus area for transfer/discharge and no dates of initiation on the focus areas or interventions. R25's Progress Notes include an entry by V1 (Former Administrator) dated 9/11/25 at 5:15PM documenting that R25's POA was contacted by this administrator to discuss the need to move residents to another facility temporarily in order to complete the needed extensive sewer repairs within the facility. Choices of available facilities within the geographical area were offered. R25's POA chose (name of sister facility approximately 20 miles east of current location). Resident was notified of the move. Psychosocial needs met. No emotional distress noted. A Progress Note entry on 9/12/25 at 1:59PM documents R25 left the facility via facility transportation will (sic) all current medications and belongings. All questions and concerns were addressed before leaving the facility. On 9/16/25 at 4:15 PM, R25 was observed in the dining room of the new facility. R25 appeared alert to person and was able to recall being transferred to this new facility. When asked about her move, R25 stated she was just verbally told she was moving the same day she left and didn't get a 30-day notice or anything in writing. R25 stated they packed my bags and away we went. R25 said they told her it was because the building needed work, but no one told her it was an emergency. R25 said she doesn't remember having any kind of meeting for discharge planning. 8. R24's admission Record documented admission to the facility on 2/23/22 and included diagnoses of generalized anxiety disorder and unspecified intellectual disabilities. This admission Record also lists V30 (Family Member) as R24's guardian/responsible party. R24's MDS dated [DATE] documented a BIMS score of 2, indicating severe cognitive impairment. R24's Care Plan includes a Focus area of R24 doesn't have plans for discharge and will reside at the facility for long term care, with an intervention documenting as necessary, meet with the resident/representative on a regular basis to discuss discharge plans. Provide the resident with an opportunity to express any thoughts or feelings. Address concerns as they arise. This focus area and intervention were initiated on 3/18/25 with no updates or revisions to indicate the interdisciplinary team did any planning for transfer or discharge to another facility. Another Focus area initiated on 3/9/22 documents R24 has impaired cognitive function and impaired thought processes r/t (related to) dx (diagnosis) MR (mental retardation) with interventions of discuss concerns about confusion, disease process, NH placement with the resident/family/caregivers, R24 needs assistance with all decision making, and keep his routine consistent to try and provide consistent caregivers as much as possible in order to decrease confusion. R24's Progress Notes include an entry on Sunday 9/14/25 at 9:00AM authored by V31 (MDS/Care Plan Coordinator) documenting spoke with POA (V30) and discussed the need to move residents to another facility temporarily in order to complete the needed extensive sewer repairs within the facility. Choices of available facilities

Based on interview and record review the facility failed to ensure a resident's bed was in the lowest position and the fall mat was in place on the floor next to the bed for 1 (R42) of 3 residents reviewed for falls in a sample of 46. This failure resulted in R42 falling out of a high bed with no floor mat beside the bed and sustaining multiple dark purple contusions to her face, neck, wrist, hand, and forearm, swelling to her eye, eyebrow and forehead area, along with skin tears to the right forearm and left hand. This past non-compliance occurred between 9/1/25 and 9/1/25. Findings include: This past non-compliance occurred between 9/1/25 and 9/1/25.Findings include:R42's admission Record documented an admission date of 1/5/22 and a discharge date of 9/3/25 and included diagnoses of dementia, cognitive communication deficit, weakness, unsteadiness on feet, chronic pain, and low back pain.R42's Minimum Data Set, dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 99, indicating the BIMS assessment was unable to be completed. R42's Care Plan documents R42 is a fall risk with interventions including in part, bed alarm while in bed, floor mat next to bed and R42 needs a safe environment with even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, the bed in low position at night, handrails on walls, personal items within reach.R42's progress note dated 9/1/25 at 1:20 AM documented Roommate yelled for staff to come into the room. Upon entering the room, (R42) was noted lying on the floor beside her bed, face down. Three staff assisted (R42) to turn over onto another blanket and she was then lifted back onto the bed. (R42) stated, I rolled out of the bed and landed on my face. (R42) had a 4cm (centimeter) straight skin tear on her right forearm that was cleansed and closed with steri strips. (R42) had a 6cm by 2cm skin tear on her left hand that was cleansed and closed with steri strips. (R42) had a contusion on each side of her forehead, larger on right side. Neuro (neurological) checks were initiated. (R42) is alert and able to communicate with staff. Pupils are equal and reactive to light. Tongue is midline.R42's progress note dated 9/1/25 at 4:29 AM documents Fall mat placed beside bed. Staff reminded to lower bed to lowest position when leaving the room.R42's progress note dated 9/1/2025 at 3:17 PM documents in part R42's right eye is swollen following her fall.R42's Risk Management document dated 9/1/2025 at 1:00 AM documents under Nursing Description: Roommate called out for staff. Entering the room, (R42) was noted laying facedown on the floor beside her bed. Under Description of Action Taken: This nurse was joined by two CNA's (Certified Nursing Assistants) and (R42) was rolled onto her back onto another blanket and lifted back into bed. She (R42) was assessed for injury. Staff to insure [sic] that bed is in it's [sic] lowest position when leaving the room. Mat placed beside bed.On 9/23/25 at 1:14 PM, V22 (Family/POA) stated she received a call from V28 (License Practical Nurse/LPN), the nurse that was working when R42 fell, stating R42 had fallen out of bed. V22 stated she was told the bed was left in the high position and there was no fall mat beside the bed so R42 had fallen directly on the floor, face first, out of a high bed. V22 stated R42 was not taken to the hospital. V22 stated V28 told her R42 wasn't that bad but she looks pretty banged up and did not ask her if she wanted R42 sent to the hospital for evaluation. V22 stated R42's roommate saw her fall and yelled for help. V22 stated they moved R42 to a different facility after this fall because she needed to get her out of that facility before they killed her. V22 stated R42 has been less alert and has not acted right since the fall and had some pain in her face and head after the fall for several days. V22 provided photographic evidence of R42 after her fall. V22 confirmed that the time stamp on each photo is correct. V22 stated the photos taken on 9/1/25 were taken at (name of facility) and the photos taken on 9/4/25 were taken at the facility R42 was transferred to after her fall. On 9/24/25 at 9:54 AM, V29 (CNA) stated she was working the night R42 fell out of bed. V29 stated she found R42 laying on the floor beside her bed. V29 stated the bed R42 fell out of was too high, it wasn't in the low position. V29 stated she was the only CNA working on that hallway at the time and she must have forgotten to put her bed back down to the low position after providing care. V29 stated the fall mat was not beside the bed, it was pushed under the bed. V29 stated she was very overwhelmed at that time because she was the only CNA on that hallway. V29 stated she was educated on lowering the bed when she is finished with care and putting the fall mat in place.On 9/25/25 at 9:25 AM, V28 (LPN) stated she was sitting at the nurse's station when a CNA came and got her saying R42 had fallen out of her bed. V2 stated when she entered the room R42 was laying directly on floor beside the bed and the bed was in a position that was close to the highest position. V28 stated she doesn't remember where the fall mat was, but it wasn't beside the bed because R42 fell directly beside her bed and landed on the floor. V28 stated she educated all the CNA's on night shift and all the incoming day shift CNA's to put the bed back in the lowest position and to have the fall mat in place beside R42's bed. V28 stated she did not hear a bed alarm. V28 stated she was in hearing distance of her bed alarm, stated she was about 20 to 30 feet away. V28 stated after the fall, R42 had contusions on both sides of her forehead. V28 stated she notified V22 (Family Member/POA) and a couple hours later she notified the doctor. V28 said V22 told her to see how R42 is doing later to decide if she needed to be sent to the hospital. V28 stated R42 was alert and communicating after the fall and her neurological checks were within normal range.On 9/24/25 at 3:17 PM, V19 (Medical Director) stated he was notified via confidential messaging system at 9:00 AM on 9/1/25 that R42 had rolled out of bed and the family requested she was not sent to the emergency room so R42 was not sent to the hospital. R42 was unable to be observed due to no longer being a resident at the facility, however photographic evidence dated 9/1/25 show dark purple contusions noted to the top of R42's right hand, wrist, and forearm. There were also Purple/blue contusions to the left side of R42's forehead with a scratch through the middle. R42's right eye had different shades of purple all around it and it was swollen shut. The swelling around R42's eye also went up into her eyebrow and forehead above the right eye. There was also some dried blood noted to her left temple area and on her nose. R42 also had a cut above her right eyebrow. Photographic evidence dated 9/4/25 shows R42 had different shades of contusions to her entire forehead with a cut on her right eyebrow, 2 more cuts above her left eyebrow, and one cut on the lateral side of her left eyebrow near her temporal area. R42's right eye had dark purple around it and some dark purple running down below here right eye onto her cheek. R42's right eyelid was dark purple with dark purple contusions around the right eye and running down onto her right cheek. R42 also had dark purple contusions going down from her right cheek down the right side of her neck. R42's right eyebrow was also swollen.On 9/22/25 at 10:00 AM, V1 (Former Administrator) stated R42's bed should have been lowered when care was finished before the staff left the room and the fall mat should have been on the floor beside R42's bed.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. Prior to the survey date, the facility took the following actions to correct the deficient practice:V1 (Former Administrator) held a Quality Assurance and Performance Improvement meeting during the interdisciplinary morning meeting on 9/1/25 documenting the following corrective measures: 1. Corrective actions will be accomplished for those residents found to be affected by the deficient practice: Ensure all fall interventions are in place for R42.2. How will you identify other residents having the potential to be affected by the same deficient practice: All residents at risk of falling have the potential to be affected by this deficient practice.3. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur: Facility nurse immediately educated staff on duty to ensure fall interventions are in place for R42, including fall mats and bed in lowest position. Facility immediately conducted a fall investigation with risk management and R42's care plan was updated. Inservice documentation noted staff education was completed on 9/1/25. 4. How will you monitor the corrective actions to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place: Administrator, Director of Nursing, and or designees will do random observations of fall interventions in place a minimum of 5 times per week for 4 weeks. Results of the observations will be discussed in the Quarterly Quality Assurance meeting times 2 with educational needs discussed as needed by the Facility Administrator/Director of Nursing or designee.

Based on interview and record review, the facility failed to provide residents and/or their representatives timely written notification of the reason for transfer out of the facility and failed provide notice to the Ombudsman of resident transfers for 9 (R21, R22, R23, R24, R25, R27, R28, R30, R31) of 9 residents reviewed for discharge process in the sample of 45. On 9/15/25 at 1:35PM, V1 (Former Administrator) provided a list of residents still in the facility and stated there were still 19 in house as of this date/time. V1 said they have provided the IDPH (Illinois Department of Public Health) regional office a list of those residents that have been discharged to date and plan to send weekly updates. V1 said the list includes resident names, the location they were transferred to and the date/time they left. V1 stated the facility has plumbing issues that need addressed and the kitchen will need to have 3 feet of concrete dug up in order to replace old cast iron plumbing that has collapsed. V1 stated other areas of the facility's physical environment need remodeled as well, such as paint and flooring in some areas and they also plan to do those repairs while the kitchen plumbing is being replaced. V1 stated it's her understanding the facility owner plans to reopen the facility after repairs are complete and residents can return after completion. V1 stated the residents that have transferred out thus far have all gone to other homes owned by (name of facility's corporation) but admitted that the facility did not provide written notices. V1 stated the facility closure is temporary and not an emergency but these repairs do need to be done soon, and residents need to go to other facilities for them to complete the repairs.On 9/15/25 at 2:45 PM, V4 (Ombudsman) stated that he can't remember which day, either late Thursday afternoon (9/11/25) or early Friday morning (9/12/25) that residents were being transferred out of the facility. V4 said V1 (Former Administrator) told him there were plumbing issues that needed fixed, and it would take about 2 months. V4 said that he told V1 that residents need to be given a choice about where they go and V1 stated they were giving them choices. V4 was asked if the facility provided him notice of the resident transfers or temporary closure, and V4 stated no, the facility did not contact him. V4 stated he got word from someone at Adult Protective Services that the facility was transferring people out when they called to inquire about a bed opening, so they called V4 to see if he was aware and he was not. V4 stated he was concerned the facility may not be following proper procedures for transfers/closure or providing the required notices and discharge planning for safe/orderly transfers. V4 confirmed he has not received any written notice of residents being transferred out. 1. R27's admission Record documented an admission date to the facility of 8/6/25 and included diagnoses of anxiety disorder and depression. This document lists R27 as her own responsible party, with a daughter listed as an emergency contact. R27's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R27 is cognitively intact. A discharge MDS documented R27 was discharged from the facility on 8/31/25 for a short-term hospital stay. R27's Progress Note on 9/4/25 at 10:49AM, labeled a Social Service Note, documented V1 (Former Administrator) contacted (R27's) daughter to discuss sending a referral to a sister facility due to this facility not currently receiving payment for medicaid/medicare. She was agreeable to the transfer and would like her to return to this facility when possible. On 9/5/25 at 10:26AM documented Resident left facility with bus driver from (name of sister facility located approximately 20 miles east of original facility). All meds (medications) and belongings sent with driver.Report called to nurse on duty at (sister facility). The medical record does not include evidence of facility staff having any direct conversation or discussion with R27 regarding her preferences or options of available locations for transfer, nor any evidence that a 30-day written notice of transfer was provided to R27. R27's Receiving Facility admission Record documented an admission date to the receiving sister facility (approximately 20 miles east of the original facility) on 9/5/25 and also listed R27 as her own responsible party. On 9/16/25 at 4:30 PM, R27 was observed in the new/receiving sister facility and was alert and oriented to person, place and time. R27 stated when she was at the original facility, about a week or more ago, she had to be sent out to the hospital and was supposed to go back to that facility after being discharged from the hospital. R27 said she discharged from the hospital on Wednesday (9/3/25) or Thursday (9/4/25) and went back to the facility for a day or so but on Friday (9/5/25) staff there told her she couldn't stay there because they couldn't take any new admissions, so she had to come here (to the sister facility). R27 said she came here to the new facility on the same day she was told about not being able to stay at the previous facility. When asked if R27 was given any other reason for her transfer, such as plumbing issues or building repairs, she stated there was no explanation as to why she had to leave except they couldn't take admissions, and she was considered a new admission since she had been sent out to the hospital. This surveyor again clarified that R27 did not come straight to the sister facility from the hospital and R27 stated no, she went to the original facility from the hospital, spent one or two nights there, then came here Friday (9/5/25). R27 stated she didn't want to go to another facility and just wants to get therapy and go back to her home and she didn't know if she was going to get therapy here. R27 stated she did not receive any written notice with a reason for transfer and did not receive a 30 notice at all. 2. R30's admission Record documented an admission date to the facility of 7/24/24 and included diagnoses of anxiety disorder and depression. R30's admission Record lists himself as responsible party with V17 (Family Member) listed as POA (Power of Attorney)/Healthcare Surrogate. R30's MDS dated [DATE] documented a BIMS score of 10, indicating R30 has moderate cognitive impairment. R30's Receiving Facility admission Record documented an admission date of 9/11/25 to the receiving/sister facility (approximately 20 miles east of the original facility). R30's Progress Note dated 9/10/25 at 11:44AM and authored by V5 (Social Service Director/SSD) documented R30 sitting in his room spouse (name) was there visiting. Spoke with the both of them no concerns. After visit spouse did come and talk to SSD informing that R30 is thinking/wanting to d/c (discharge) back home but stated that she is not able to care for him on her own and their home is not set up where he'd be able to manage getting around in his w/c (wheelchair). R30's Progress Note dated 9/11/25 at 1:37PM authored by V1 (Former Administrator) documented V17 (Family Member) was contacted by this administrator to discuss the need to move residents to another facility temporarily in order to complete the need extensive sewer repairs within the facility. Choices of available facilities within the geographical area were offered. V17 chose (name of sister facility approximately 20 miles east of original facility). Resident was notified of the move. Psychosocial needs met. No emotional distress noted. R30's Progress Note dated 9/11/25 at 6:04PM documented resident left facility via facility transportation will (sic) all current medications and belongings. All questions and concerns were addressed before leaving facility.On 9/16/25 at 4:20 PM, R30 was observed in the receiving/sister facility where he was recently transferred. When asked if R30 was recently transferred here, R30 said yes, he was. When asked if R30 received much notice prior to moving & he raised his voice and stated NO! They didn't tell me anything! R30 said the facility told him in the morning on Thursday (9/11/25) and moved him out that same day and he was not happy about it. R30 stated he was ok with being at the new facility now but was not happy about the short notice or having to move. R30 said he thought he had to move due to building repairs and when asked if he received a 30 day notice in writing prior to transfer, R30 said No!. On 9/17/25 at 2:35 PM, when this surveyor asked V17 (R30's Family Member) about R30's transfer to the sister facility approximately 20 miles away from the original facility, V17 stated I was so darn mad .I was there visiting him on Wednesday (9/10/25) and they didn't say anything about it. V17 said then on Thursday (9/11/25), she was notified by phone they would be transferring R30 to (name of sister facility). V17 did not remember being given a reason for the transfer, but said she maybe heard the maintenance man say something about gas lines being an issue at some point. V17 said there was no meeting held, or discharge planning discussed and no one at the facility went over any options with her. V17 said no one mentioned offering to make a referral to the other facility located in the same town (owned by a different corporation). V17 said she would have liked that option because she was able to visit R30 every Wednesday, Saturday and Sunday at the other facility because she lived close. V17 stated now she won't be able to visit R30 very often because she doesn't drive and would catch rides with family and friends, but the facility they transferred him to is a lot farther away. V17 stated at the time, R30 was really upset about moving. V17 confirmed she did not receive a 30 day written notice prior to transfer. 3. R31's admission Record documented an admission date to the facility of 01/15/25 and included a diagnosis of unspecified dementia. This admission Record listed V18 (Family Member) as R31's responsible party/emergency contact #1. Other contacts listed included R31's granddaughter. R31's MDS dated [DATE] documented a BIMS score of 99, indicating R31 was unable to complete the interview. R31's Progress Notes included an entry on 9/12/25 at 10:25AM by V3 (Assistant Director of Nursing/ADON) that documented (granddaughter) was contacted to discuss the need to move residents to another facility in order to complete the needed extensive sewer repairs within the facility. Choices of available facilities within the geographical area were offered. (Name of granddaughter) chose (name of sister facility approximately 20 miles south of current facility). Resident was notified of the move. Psychosocial needs met. No emotional distress noted. The next progress note entry was dated 9/12/25 at 12:20PM, authored by V3 and documented (V2/Director of Nursing-DON) contacted V18 (Family Member) to discuss the need to move residents to another facility temporarily in order to complete the needed extensive repairs within the facility. Choices of available facilities within the geographical area were offered. V18 chose (name of sister facility 20 miles east of current facility). Resident was notified of the move. Psychosocial needs met. No emotional distress noted. R31's Progress note dated 9/15/25 at 3:09PM documented R31 left the facility via facility transportation all belongings sent along with medications, all concerns and questions addressed before departing. R31's medical record did not include evidence that a 30-day written notice of transfer was provided to R31 or V18.On 9/17/25 at 2:45 PM, when asked about R31's transfer and if she received any notice, V18 (Family Member) stated it was real short notice. V18 couldn't remember when but thought maybe the facility called to tell her on Wednesday (9/10/25) or Thursday (9/11/25) and then they moved her mom on Monday (9/15/25). V18 said they told her there was something going on with the building and residents needed to transfer. V18 said they first told her R31 would go to (name of sister facility approximately 20 miles south of current facility) but V18 said she told them absolutely not and denied that location, stating she didn't want her there. V18 then stated she told them she would just bring R31 home if they send her there, so they offered to transfer R31 to (another sister facility approximately 20 miles east of current location). V18 stated there was no discharge plan of care discussed, and they only mentioned transferring her mother to other facilities (owned by this corporation's name). R31 said they did not offer to make a referral to the other facility that is in the same town (different corporation). V18 said she lives in the town where R31 was and so do a lot of her family members so they were able to visit frequently, but with R31 being moved to (new town location) it will make it more difficult for everyone to visit. V18 said her mother has dementia but moving her so quickly like this would have upset her or made her anxious because she needs to be around family. V18 confirmed she did not receive any written notice from the facility prior to transferring R31. 4. R28's admission Record documented an admission date to the facility of 12/21/22 and lists V16 (Family Member/Power of Attorney-POA) as her responsible party. R28's MDS dated [DATE] documented a BIMS score of 99, indicating R28 was unable to complete the interview.R28's Progress Notes have an entry dated 9/11/25 at 2:31PM by V1 (Former Administrator) documenting V16 (Family Member/POA) was contacted by this administrator to discuss the need to move residents to another facility temporarily in order to complete the needed extensive sewer repairs within the facility. Choices of available facilities. V16 chose (name of sister facility approximately 20 miles east of current location). Resident was notified of the move. Psychosocial needs met. No emotional distress noted. The next entry on 9/11/25 at 6:03PM documented resident left facility via facility transportation will (sic) all current medications and belongings. All questions and concerns were addressed before leaving facility.R28's medical record did not include evidence that a 30-day written notice of transfer was provided to V16.On 9/17/25 at 1:50 PM, V16 (Family Member/POA) stated he is R28's POA. V16 said R28's transfer to (sister facility approximately 20 miles east of this facility) was a giant inconvenience for everyone and they had very, very short notice. V16 said he thinks the facility called him Thursday 9/11/25 and said his mother was being transferred that day. V16 said he wasn't given a 30-day written notice or discharge plan for his mother. V16 said he thinks the staff at the facility were given short notice too and he felt bad for them. V16 said on Monday 9/15/25, there was a very long meeting at the facility and V1 told them the building needed repairs, and they can't have anyone in there during that time, so corporate told them they needed to get everyone out and repairs would take about 2-3 months to resolve. V16 said they were told deep cleaning and painting would also be done along with the repairs. 5. R23's admission Record documented an admission date of 7/29/25 and included diagnoses of unspecified dementia and bipolar disorder. This admission Record lists V32 (Family Member) as R23's responsible party/guardian. R23's MDS dated [DATE] documented a BIMS score of 15, indicating R23 is cognitively intact. R23's Progress Notes include the following entries:On 9/11/25 at 7:43AM authored by V1 documented R23's POA (V32) was contacted by the DON (Director of Nursing) to discuss the need to move residents to another facility temporarily in order to complete the needed extensive sewer repairs within the facility. Choices of available facilities within the geographical area were offered. (V32) chose (name of sister facility approximately 20 miles east of current location). R23 was notified of the move. Psychosocial needs were met. No emotional distress noted. The next entry is dated 9/11/25 at 8:20AM by V2 (DON) and documents resident and family notified of transfer to (name of sister facility approximately 20 miles east of current location) and agreeable for transfer, MD (medical doctor) notified and is agreeable with transfer. The next entry is dated 9/11/25 at 11:08AM and documents resident is to transfer to (name of sister facility approximately 20 miles east of current location), report called.Resident is to transport with family. On 9/11/25 at 11:25AM, V2 documented resident belongings and medications were sent with family for transportation, all questions and concerns were addressed prior to leaving, resident was in good spirits when leaving facility. On 9/11/25 at 11:34AM, resident has left the facility transported by his daughter. R23's medical record shows no reproducible evidence that a 30-day written notice was provided to R23 or V32. On 9/16/25 at 4:00 PM, R23 was observed in his wheelchair in the new facility. When asked how his move here went and if he had much notice, R23 stated he barely got any notice at all before having to leave the other facility and he didn't receive anything in writing. R23 said he was told he needed to leave the same day they shipped him out. R23 said they packed up his bags and put them in the van to come here. R23 said they told him it was because of plumbing issues. 6. R25's admission Record documents admission to the facility on 5/31/25 and included diagnoses of schizoaffective disorder and depression. R25's admission Record also documents she has a POA. R25's MDS dated [DATE] documented a BIMS score of 06, indicating severe cognitive impairment. R25's Progress Notes include an entry by V1 (Former Administrator) dated 9/11/25 at 5:15PM documenting that R25's POA was contacted by this administrator to discuss the need to move residents to another facility temporarily in order to complete the needed extensive sewer repairs within the facility. Choices of available facilities within the geographical area were offered. R25's POA chose (name of sister facility approximately 20 miles east of current location). Resident was notified of the move. Psychosocial needs met. No emotional distress noted. A Progress Note entry on 9/12/25 at 1:59PM documents R25 left the facility via facility transportation will (sic) all current medications and belongings. All questions and concerns were addressed before leaving the facility. R25's medical record shows no reproducible evidence that a 30-day written notice was provided to R25 or her POA. On 9/16/25 at 4:15 PM, R25 was observed in the dining room of the new facility. R25 appeared alert to person and was able to recall being transferred to this new facility. When asked about her move, R25 stated she was just verbally told she was moving the same day she left and didn't get a 30-day notice or anything in writing. R25 stated they packed my bags and away we went. R25 said they told her it was because the building needed work, but no one told her it was an emergency. R25 said she doesn't remember having any kind of meeting for discharge planning. 7. R24's admission Record documented admission to the facility on 2/23/22 and included diagnoses of generalized anxiety disorder and unspecified intellectual disabilities. This admission Record also lists V30 (Family Member) as R24's guardian/responsible party. R24's MDS dated [DATE] documented a BIMS score of 2, indicating severe cognitive impairment. R24's Progress Notes include an entry on Sunday 9/14/25 at 9:00AM authored by V31 (MDS/Care Plan Coordinator) documenting spoke with POA (V30) and discussed the need to move residents to another facility temporarily in order to complete the needed extensive sewer repairs within the facility. Choices of available facilities within the geographical area were offered. V30 agreeable to move R24 to either (two towns names listed) facility. Informed him that (name of town approximately 20 miles northeast of current facility) does not have an available bed at this time. He is agreeable to move him to (name of town approximately 20 miles east). Would like to be called so he can follow and learn where facility is located. The next entry documents on 9/14/25 at 9:15AM, out of facility with (V30) to church services. A progress note entry dated 9/15/25 at 3:04PM documented R24 left facility via facility transportation all belongings sent along with medications, all concerns and questions addressed before departing. R24's medical record did not include evidence that a 30-day written notice of transfer was provided to V30.On 9/17/25 at 10:27AM, R24 was in his room up in his wheelchair at the new facility visiting with V30. V30 stated R24 was at the previous facility for about 3.5 years and V30 visited him 3 times per week there. V30 said he only lives about a mile from that facility. V30 stated he thought maybe last Thursday 9/11/25 or Friday 9/12/25, someone mentioned R24 would need to move because they needed to remodel the facility and fix the sewer system. V30 said he was told it could take 3 months, then his assumption was that R24 could return there once repairs were finished. V30 said R24 came to this current facility on Monday 9/15/25. V30 said he didn't receive much notice and definitely didn't receive anything in writing. 8. R21's admission Record documented an admission to the facility on 4/25/25 and lists herself as her responsible party, along with two emergency contacts. V34 (Family Member) is listed as Emergency Contact #1. R21's MDS dated [DATE] documented a BIMS score of 15, indicating R21 is cognitively intact. R21's Progress Notes include an entry by V2 (DON) on 9/11/25 at 2:22PM documenting R21's POA, (V34) was contacted by facility administrator to discuss the need to move residents to another facility temporarily in order to complete the needed extensive sewer repairs within the facility. Choices of available facilities within the geographical area were offered. V34 chose (sister facility located approximately 20 miles east of this facility). Resident was notified of the move. Psychosocial needs met. No emotional distress noted. The next progress note entry on 9/11/25 at 3:30PM by V2 (DON) documented Resident left facility via facility transportation with all current medications and belongings. All questions and concerns were addressed before leaving facility. R21's medical record did not include evidence that a 30-day written notice of transfer was provided to R21.On 9/16/25 at 12:00 PM, R21 was in bed in her room at the new facility where she was transferred. R21 was alert and oriented to person, place and time and confirmed that she is her own responsible party. When asked about the transfer here, R21 stated she was transferred out the same day she was told she needed to move on 9/11/25. R21 said she wasn't given any written notice prior to transfer, she was just told her the reason residents needed to transfer was due to repairs needing done at the facility and it was her understanding that she could go back there when repairs are done. 9. R22's admission Record documented an admission to the facility on 6/9/25 and included a diagnosis of depression. R22's admission Record lists herself as responsible party with two family members listed as emergency contacts/POA's. R22's MDS dated [DATE] documented a BIMS score of 13, indicating R22 is cognitively intact. R22's Progress Notes included an entry dated 9/9/25 at 11:22AM by V5 (SSD) documenting: Submitted via email referral to (sister facility approximately 20 miles east of this facility) per Family/DON request, with confirmation. On 9/10/25 at 11:51AM by V2 (DON): (Name of sister facility approximately 20 miles east of this facility) accepted resident, resident will be transferred Saturday (9/13/25) 2pm from (this facility) to (sister facility) after scheduled dialysis with (local dialysis provider). On 9/10/25 at 1:48PM by V3 (ADON): Resident notified of acceptance to (sister facility). Resident agreeable to transfer. POA also notified and agreeable to transfer. Transfer set for Saturday 2pm. Nurse on duty notified. On 9/13/25 at 3:01PM: Resident transferred to (sister facility) via (sister facility) bus with CNA's (Certified Nurse Assistant).R22's medical record did not include evidence that a 30-day written notice of transfer was provided to R22 or family members.On 9/16/25 at 12:15 PM, R22 was observed in her room in bed at the new facility. R22 was interviewable and stated she arrived to this facility recently and thinks she was given maybe a week's notice but she didn't receive anything in writing. R22 stated she is her own responsible party. R22 said she was told she needed to transfer because the facility needed to work on the water pipes. R22 said she understood that she would be able to go back when the repairs are finished. On 9/17/25 at 11:06 AM, V13 (Chief Executive Officer) stated a month or two ago the Local Health Department shut down the facility's kitchen. V13 said they considered doing an emergency closure at that time but didn't want to do that to the residents. V13 said they couldn't find anything in the regulations stating they were doing anything wrong with transferring residents out to other facilities. V13 thought they were doing what was right with the temporary relocation. V13 said (name of plumbing company) stated it could be catastrophic if the cast iron plumbing collapsed. V13 then stated a different plumbing company (name of company) did the most recent repair work but they need to do a full facility evaluation once the residents are out of the building to see the scope of what they are dealing with. V13 said there are 19 residents still in house at this time. V13 said the plan is not to permanently close the facility and to let residents return once repairs are complete. When discussing concerns of the rushed nature of the moves, V13 stated, so what you are saying is we basically should have done this as an emergency evacuation. On 9/30/25 at 3:25PM, V3 (ADON) stated she can't remember the exact day, but thinks V1 told staff that the residents needed to transfer out of the facility due to repairs during a morning meeting maybe a few days to a week before she started making calls to families. V3 said that making the calls was more of the last thing they did before transferring residents out.

Based on observation, interview, and record review the facility failed to promote independence and autonomy with toileting by neglecting to utilize an available room with a functioning toilet for 1 (R40) of 3 residents reviewed for reasonable accommodation of needs/preferences in a sample of 46. Findings include:R40's admission Record documented an admission date to the facility on 7/7/25 and included diagnoses of Alzheimer's disease, dementia, anxiety disorder, and cognitive communication deficit. R40's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the BIMS assessment was unable to be completed. On 9/22/25 at 4:00 PM, V36 (Family Member) stated the bathroom in R40's room did not work from the time she was admitted there in early July of 2025. V36 stated R40 was able to take herself to the bathroom when she needed to go, but since the restroom was out of order in her room she would get confused and urinate in odd places. V36 stated she had urinated in laundry baskets, in the floor, and in trashcans while residing in that room. V36 stated since being moved to another room with a properly functioning toilet she has not gotten any reports of R40 urinating in inappropriate places. On 9/24/25 at 4:28 PM, V20 (Certified Nursing Assistant/CNA) stated R40 previously resided on South Hall. R40's previous room was observed on this date and time to be empty, but the attached [NAME] and Jill bathroom was observed to have the door closed with a locked padlock in place. This bathroom was shared with the room next to R40's, which was also empty on this date and time. V20 stated when R40 resided in this room, she would at times use the communal bathrooms down the hallway, but she would get lost or confused trying to find them and staff would have to show her to the communal bathroom. Surveyors noted two communal bathrooms on the South Hall that each had a shower stall and toilet/sink. On 9/25/25 at 9:49 AM, V2 (Director of Nursing) stated the residents that previously resided in the room next to R40's, where the shared bathroom was located, were dependent on staff for transfers and care, so they did not independently get up to use that restroom. In addition, R40's roommate was also dependent for care and didn't independently use that restroom. V2 stated R40 could get up to use the restroom but when that toilet stopped working and when R40 got covid, V2 talked to R40's family about using a bedside commode so she could remain close to the nurse's station and V2 said family was agreeable to that. V2 stated she did not have any knowledge of R40 being incontinent in inappropriate places. V2 stated she didn't think about moving the resident to a room with a working bathroom because she wanted to keep R40 close to the nurse's station. V2 stated R40 was in the room with a nonfunctioning toilet from admission until she was moved recently. Progress note dated 9/16/25 at 11:02 AM, documents Contacted (Name of family) informed that (R40) is being moved to North Hall (room number). She only asked that all her belongings be moved with her. No other concerns. On 9/25/25 at 9:43 AM, the shared restroom attached to R40's previous room was observed to have a clogged toilet. V6 (Maintenance Director) stated the bathroom toilet wasn't working and thinks it had not been functional since sometime in July due to a previous resident stuffing paper towels down it. V6 stated he plans to have the plumbing company look at it when they come to address the plumbing issues in the kitchen. On 9/25/25 at 12:09 PM, V20 (CNA) stated when she started working at this facility, which was in the beginning of August of 2025, R40 already had a bedside commode in her room. V20 stated R40 would get confused because she couldn't use the bathroom in her room and would urinate in the floor. V20 stated R40 urinated in the corner of her room one time and R40 used her wig to mop it up. V20 stated R40's bathroom was locked due to not functioning properly from the time she started working at this facility until R40 was moved to a different room. V20 stated since R40 was moved to a different room with a working bathroom she uses the bathroom in her room without any issues and has not urinated or defecated in the floor. On 9/25/25 at 12:13 PM, V26 (CNA) stated R40 was admitted to the room with the nonfunctioning toilet when she first came to the facility. V26 stated R40 had a bedside commode in her room because the bathroom in her room was not functioning properly, and the door was padlocked so R40 could not get into it. V26 said R40's room was connected to the room next door via a shared bathroom. V26 stated the bathroom door on R40's side was locked so she could not enter it from there, but it was not locked on the adjoining side so it could be entered from that room. V26 stated at one point, R40 got confused trying to find a bathroom so she went to the room next to hers that shared the adjoining bathroom, went into the bathroom and defecated and urinated onto a plastic cover that was covering the toilet due to it not being operational. V26 stated R40 also defecated in her closet at one point. V26 stated since R40 has been moved to the North Hall with a properly functioning bathroom, R40 is using her bathroom properly and has not urinated or defecated on the floor or in a closet. R40's Progress Note dated 8/12/25 at 7:42 PM documented under Required Daily Note: Resident (R40) compliant with meds today. Up ambulating and redirected back to her w/c (wheelchair). Memory deficit keeps her from complying at time. Incontinent of stool and deficated [sic] in her closet this afternoon. Area cleaned. Appetite remains poor and fluid intake is encouraged. POC (Plan of Care) continues. R40's Progress Note dated 8/31/25 at 6:15 PM documented under Required Daily Note: Resident up ambulating independently and redirected numerous times to her w/c . Vision is poor and is unable to determine distance and objects until they are up close. Appetite is good today. Fluids encouraged. Assisted to the bathroom as she gets lost finding it and unable to see where she is going. No s/sx (signs or symptoms) of pain or discomfort. She has been continent of B&B (Bowel and Bladder) today. No signs of distress noted. Assisted with all adls (activities of daily living). POC (Plan of Care) continues. R40's Progress Note dated 9/12/25 at 12:55 PM documented under Required Daily Note: Resident is alert and confused. Redirected multiple times today from other residents rooms. Noted resident pilfering through others belongings. Redirected back to her room for snacks. Was incontinent of urine x 1 on the floor. Poor eyesight and needs assist with toileting as she does not always see the toilet. No signs of pain. BG (Blood Glucose) readings wnl (within normal limits). Staff continues to redirect as needed. Staff assist with all adls (activities of daily living). POC (Plan of Care) continues. On 9/22/25 at 10:00 AM, V1 (Former Administrator) stated she wasn't aware of R40 urinating in the floor and not being able to find the bathroom in the hallway. V1 stated R40 should have probably been moved to a room with a properly functioning bathroom. V1 stated there were other open rooms that had a properly functioning toilet that she could have been moved to.

Based on interview and record review the facility failed to assess and provide pain medication after a fall for 1 (R1) of 3 residents reviewed for pain in a sample of 26. This failure resulted in R1 not receiving any pain medication for a hip fracture for several hours after a fall. A reasonable person would experience feelings severe pain and discomfort due to not receiving pain relief medication. This past noncompliance occurred between 8/25/25 and 8/26/25. Findings include:R1's admission Record documented an admission date of 4/27/2023 and diagnoses including chronic obstructive pulmonary disease, unspecified, gastrostomy status, dysphagia, unspecified, schizoaffective disorder, bipolar type, muscle weakness and moderate protein-calorie malnutrition.R1's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 07, indicating R1 had severe cognitive impairment.R1's Physician Order Summary documented Acetaminophen Oral Suspension. Give 5 ml via gastrointestinal tube every 6 hours as needed for mild pain related to muscle weakness (generalized) with a start date of 07/22/2024.R1's Progress note dated 8/25/2025 at 1:24 PM by V15 (Licensed Practical Nurse/LPN) documented heard R1 yelling out. Upon entering room, resident was on the floor, leaning on his right elbow, walker to his left side with no injuries noted, but complain of right inguinal and thigh pain.R1's Final Incident Report dated 8/25/2025 with time of incident documented R1 had an unwitnessed fall in his room. R1 ambulated independently with walker at baseline. R1 reported pain to right groin with imaging ordered in house. Imaging obtained on 8/26/2025 with results showing a displaced fracture to right femoral neck.The local Hospital emergency room imaging report for R1's right hip related to fall with pain and unable to weight-bear, dated 8/26/2025 documented an acute fracture of the right femoral neck with acute angulation.On 9/3/2025 at 12:51 PM, V18 (Certified Nursing Assistant/CNA) stated, she notified V15 (Licensed Practical Nurse/LPN) of R1's continued pain and not being able to perform his normal functions multiple times after his fall. V18 stated, V15 stated to her, R1 would have to wait. On 9/5/2025 at 10:32 PM, V15 (LPN) stated she did not give any pain medication to R1 after his fall event on 8/25/2025 or during her shift that day.On 9/5/2025 at 12:27 PM, V16 (Family) stated R1 did have a fall on 8/25/2025. V16 stated at the time of the fall when they contacted him, R1 had been having pain in his right groin/inner thigh. V16 stated, he came to visit R1 on 8/26/2025. V16 stated, R1 told him he was in pain when he asked him if he was hurting by pointing to his right inner thigh/groin area. V16 stated, he would assume that the facility would give R1 pain medication as ordered.On 9/4/2025 at 11:09 AM, V2 (Assistant Director of Nursing/ADON) stated she had been notified that R1 had fallen on 8/25/2025 in the afternoon. V2 stated, on 8/26/2025 around 4:00 PM the imaging company arrived in the facility to complete imaging pictures for R1 and R1 had still been in pain, so she contacted V16 to discuss sending R1 to the hospital for further evaluation. V2 stated, V16 agreed to have R1 sent to the local emergency room. V2 stated, R1 was transferred to the local hospital by ambulance around 4:15 PM. V2 stated, R1 had no documentation of pain medication given until Acetaminophen Oral Suspension (Acetaminophen) 5 milliliters for 8/10 pain on 8/26/2025 at 10:59AM.On 9/5/2025 at 1:28 PM, V17 (Physician) stated, he had been notified of R1's fall event from 8/25/2025. V17 stated, around 1:37 PM he received a text message to order imaging of the right hip for R1. V17 stated, he had not been notified of a pain assessment for R1, that R1 could not bear-weight or there was a delay in imaging. V17 stated, V15 (LPN) should have completed a better assessment of R1 after his fall event. On 9/9/2025 at 10:13 AM, V24 (Director of Nursing/DON) stated she had been notified on 8/26/2025 that R1 had a fall event the day before and she went down to assess R1. V24 stated, R1 did have pain to his right lower leg upon assessment. V24 stated, she requested for R1 to be administered pain medication while she contacted the imaging company to follow up on R1's order. V24 stated, pain should be assessed for all residents who have had a fall and R1 should have received pain medication with verbalizing pain to his right hip.R1's August Medication Administration Record (MAR) documented no pain medication was given on 8/25/2025. R1's MAR documents R1 received Acetaminophen Oral Suspension (Acetaminophen) 5 milliliters for 8/10 pain on 8/26/2025 at 10:59AM.The facility's Pain Management Policy (adapted/revised 2022) documented under Purpose: To facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. General Guidelines: The facility will achieve these goals through: Promptly and accurately assessing and managing pain to the greatest extent possible. Encouraging residents to self-report pain. Aggressively assessing pain in non-verbal and cognitively impaired residents. Increasing comfort and reducing to depression and anxiety in residents. Optimizing the residents' ability to perform activities of daily living. Monitoring treatment efficacy and side effects. A standard format for assessing, monitoring and documenting pain in both cognitively intact and cognitively impaired residents will be utilized. As part of a comprehensive approach to pain assessment and management, pain will be considered the fifth vital sign at the facility, along with temperature, pulse, respiration, and blood pressure. For the purposes of this policy, pain is defined as whatever the experiencing person says it is, existing whenever the experiencing person says it does.Prior to the survey date, the facility took the following actions to correct the non-compliance:1. On 8/26/2025, all nursing staff in-serviced on all falls to be reported to Director of Nursing and Assistant Director of Nursing, fall management, resident reports pain with a fall event or other incident should have an immediate imaging order placed, and if imaging company is unable to arrive at the facility the same day as order, staff will notify physician and family. Staff signed on in-service sheet including V15.2. On 8/26/2025 the Administrator and Director of Nursing will complete random education checks to ensure staff is knowledgeable on the process of obtaining immediate imaging for residents who fall with complaints of pain for a minimum of 5 times per week for 4 weeks.3. On 8/26/2025 implemented all fall reports to be reviewed, daily during the morning meetings and a weekly review to be completed with the interdisciplinary team on Thursdays to ensure all identifying changes, implementing new processes and monitoring changes. All items to be discussed in Quality Assurance meetings.4. On 8/26/25, the facility's Quality Assurance Committee met to review the above referenced fall. The Committee approved of the corrective Action Plan that had been submitted and reviewed the status of the plan without corrections.

Based on interview and record review the facility failed to ensure timely treatment and care in accordance with professional standards of practice after a fall for 1 (R1) of 3 residents in a sample of 26. This failure resulted in R1 not getting immediate treatment for a hip fracture after a fall. A reasonable person would experience feelings of discomfort and distress due to not receiving timely after fall care. This past noncompliance occurred between 8/25/25 and 8/26/25. Findings include: R1's admission Record documented an admission date of 4/27/2023 and diagnoses including chronic obstructive pulmonary disease, unspecified, gastrostomy status, dysphagia, unspecified, schizoaffective disorder, bipolar type, muscle weakness and moderate protein-calorie malnutrition.R1's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 07, indicating R1 had severe cognitive impairment. This same document under section GG0120 Mobility Devices documented a walker used for ambulation and section I5600 Active Diagnosis documented a diagnosis of malnutrition (protein or calorie) or at risk for malnutrition.R1's Final Incident Report dated 8/25/2025 with time of incident documented R1 had an unwitnessed fall in his room. R1 ambulated independently with walker at baseline. R1 reported pain to right groin with imaging ordered in house. Imaging obtained on 8/26/2025 with results showing a displaced fracture to right femoral neck. R1's Progress note dated 8/25/2025 at 1:24 PM by V15 (LPN) documented heard R1 yelling out. Upon entering room, resident was on the floor, leaning on his right elbow, walker to his left side with no injuries noted, but complain of right inguinal and thigh pain.R1's Progress note dated 8/26/25 at 4:15 PM documents, EMS (Emergency Medical Services) arrived and transferred R1 to the local hospital. On 9/3/2025 at 12:51 PM, V18 (Certified Nursing Assistant/CNA) stated, she did work on 8/25/2025 when R1 had fallen in his room. V18 stated, she heard R1 hollering out from his room while she had been at the nurse's station. V18 stated, she went into R1's room with V24 (CNA) and found R1 on the floor. V18 stated, she requested V15 (Licensed Practical Nurse/LPN) to come to R1's room. V18 stated, V15 assessed R1 with V24 and then helped him back to bed. V18 stated, R1 had been complaining of pain in his groin area and unable to stand or do baseline activities. V18 stated, she notified V15 of R1's not being able to perform his normal functions multiple times after his fall and V15 stated, R1 would have to wait. V18 stated, no imaging was completed the day of the fall.On 9/3/2025 at 1:02 PM, V15 (Licensed Practical Nurse/LPN) stated, she had been working the day R1 had his fall event on 8/25/2025. V15 stated, V18 (CNA) and V24 (CNA) requested for her to come to R1's room. V15 stated, R1 had been on his right side in the floor when she entered his room. V15 stated, R1 had been helped back to bed by her and V24, she then notified V16 (Family) and V17 (Physician) of R1's fall. V15 stated, V17 ordered imaging pictures be taken of R1's right hip related to pain from the fall. V15 stated, she contacted the imaging company to schedule them to come to the facility for pictures. V15 stated, the imaging company returned a call and notified her that they would not be able to come to the facility until the next day. V15 stated, she did not notify the doctor that the imaging company could not come that day. V15 stated, R1 did still have pain throughout her shift and was unable to complete his baseline activities. V15 stated, she had been back to R1's room several times that day to see if he wanted to get out of bed. V15 stated, R1 probably should have been sent to the local emergency room for further evaluation that day after the imaging company could not complete the order, but she did not send him. On 9/4/2025 at 11:09 AM, V2 (Assistant Director of Nursing/ADON) stated, she had been notified that R1 had fallen on 8/25/2025 in the afternoon. V2 stated, she thinks R1 had been reaching for his crayons when he fell out of bed. V2 stated, per V15's (LPN) nursing note documented R1's fall, with notifications to V17 (Physician) and V16 (Family) and order for imaging pictures to be performed. V2 stated, on 8/26/2025 around 4:00 PM the imaging company arrived in the facility to complete imaging pictures for R1 and R1 had still been in pain after pictures were taken, so she contacted V16 (Family) via phone to discuss sending R1 to the hospital for further evaluation. V2 stated, V16 agreed to have R1 sent to the local emergency room. V2 stated, R1 was transferred to the local hospital by ambulance around 4:15 PM on 8/26/2025. V2 stated, the imaging order for R1 should have been initially order stat (immediate) and if the imaging company could not come out to complete the pictures then V16 (Family) should have been contacted to discuss further evaluation which would include R1 being sent to the local hospital. On 9/4/2025 at 11:24 PM, V28 (Imaging Company) stated, there is documentation on 8/25/2025 at 1:37 PM for R1 to receive an image order to the right hip. V28 stated, the order was not ordered stat (immediate). V28 stated, around 4:30 PM the technician on 8/25/2025 documented unable to complete order due to workload. V28 stated, at 5:05 PM, V31(Imaging Technician) documented V15 (LPN) notified images would not be completed today for R1 via phone. V28 stated, V31 (Imaging Technician) arrived in the facility on 8/26/2025 around 4:00 PM to complete R1's order. V28 stated, V31 completed the imaging picture and requested the picture to be read stat. On 9/4/2025 at 1:10 PM, V1 (Administrator) stated, R1 had been self-ambulatory during his stay in the facility. V1 stated, her understanding of R1's fall event on 8/25/2025 had been he self-reported by hollering out from his room and V15 (LPN) went down to R1's room to check on him. V1 stated, R1 did have some hip pain after his fall and V15 ordered a imaging picture through the imaging company. V1 stated, the imaging company came in on 8/26/2025 around 4:00 PM to complete the imaging pictures and there was a fracture shown and R1 had been sent out to the local hospital. V1 stated, the normal expectations after a fall event with pain would be to get an imaging picture ordered immediately and if the company could not come in to complete the order, the nurse should contact the physician to discuss further evaluation. V1 stated, V15 did not order the imaging pictures to be done stat. On 9/5/2025 at 1:28 PM, V17 (Physician) stated, he had been notified of R1's fall event from 8/25/2025. V17 stated, around 1:37 PM he received a text message to order imaging of the right hip for R1. V17 stated, he had not been notified of a pain assessment for R1, that R1 could not bear-weight or there was a delay in imaging. V17 stated, V15 (LPN) should have completed a better assessment of R1 after his fall event. On 9/09/2025 at 10:02 AM, V23 (CNA) stated, he did work the day R1 had his fall on 8/25/2025. V23 stated, R1 had been independent in ambulation. V23 stated, he heard R1 hollering for help from his room but does not recall what time. V23 stated, when he entered R1's room, R1 had been on his hands and knees in the floor with his crayons next to him. V23 stated, he called out for V15 (LPN) to come to R1's room to assess him. V23 stated, after V15 assessed R1, they helped him into his bed. V23 stated, he is not aware if R1 had any pain. V23 stated, later that same day, R1 used his call light for resident care. V23 stated, he attempted to help R1 up out of his bed to stand and R1 could not bear any weight on his right leg. V23 stated, R1 said he could not stand. V23 stated, he did notify V15 but not aware of any interventions at that time. V23 stated, he worked the next day on 8/26/2025 and V16 (Family) had hit R1's call light for him to get assistance to get dressed. V23 stated, at that time, R1 was telling V16 that he could not get up. On 9/9/2025 at 10:13 AM, V24 (Director of Nursing/DON) stated, she did not work on 8/25/2025 when R1 had his fall. V24 stated, she had not been notified of the fall event the day of. V24 stated, when she had been notified on 8/26/2025, she went down to assess R1. V24 stated, R1 did have pain to his right lower leg upon assessment. V24 stated, V16 (Family) was in the room during the assessment and asked about the imaging results to R1's right hip. V24 stated, she reviewed R1's chart and did not see any imaging results. V24 stated, she requested for R1 to be administered pain medication while she contacted the imaging company to follow up on R1's order. V24 stated, when she contacted the imaging company is when she found out that the order had been for yesterday. V24 stated, it is the facility policy that V17 (Physician), families and herself are to be notified of resident fall events. V24 stated, R1's imaging order should have been completed on 8/25/2025 and when imaging had notified V15 that they would not be able to complete it that day, R1 should have been sent out to the local emergency room for further evaluation.The local Hospital emergency room imaging report for R1's right hip related to fall with pain and unable to weight-bear, dated 8/26/2025 documented an acute fracture of the right femoral neck with acute angulation.Prior to the survey date, the facility took the following actions to correct the non-compliance:1. On 8/26/2025, all nursing staff in-serviced on all falls to be reported to Director of Nursing and Assistant Director of Nursing, fall management, resident reports pain with a fall event or other incident should have an immediate imaging order placed, and if imaging company is unable to arrive at the facility the same day as order, staff will notify physician and family. Staff signed on in-service sheet including V15. 2. On 8/26/2025 the Administrator and Director of Nursing will complete random education checks to ensure staff is knowledgeable on the process of obtaining immediate imaging for residents who fall with complaints of pain for a minimum of 5 times per week for 4 weeks.3. On 8/26/2025 implemented all fall reports to be reviewed, daily during the morning meetings and a weekly review to be completed with the interdisciplinary team on Thursdays to ensure all identifying changes, implementing new processes and monitoring changes. All items to be discussed in Quality Assurance meetings.4. On 8/26/25, the facility's Quality Assurance Committee met to review the above referenced fall. The Committee approved of the corrective Action Plan that had been submitted and reviewed the status of the plan without corrections.

Based on interview, observation and record review, the facility failed to assess adaptive equipment and pressure alarms in order to ensure safety and freedom for normal movement for 4 of 4 residents (R3, R5, R9, R18) reviewed for physical restraints in the sample of 26. Findings include:1. R5's “admission Record” documents an admission date of 7/17/25 and a discharge date of 8/25/25 with the following diagnoses in part; other frontotemporal neurocognitive disorder, frontotemporal dementia, dementia in other diseases classified elsewhere, unspecified severity, with agitation, history of falling, muscle weakness (generalized), difficulty in walking. R5's care plan documents that R5 is at risk for falls related to dementia, impaired cognition/safety awareness, use of antidepressant, antianxiety medications, history of falls, impaired gait/balance. This same document lists the following interventions, Lap [NAME] (positioning device) to be ordered and placed on delivery, until arrives staff to increase monitoring, with an initiation date of 7/31/25. Bed alarm on while in bed to notify staff of need for assistance, with an initiation date of 7/17/25. R5's medical record did not contain a restraint assessment for positioning device (lap [NAME]). R5's medical record did not contain an order for a positioning device. On 9/9/25 at 10:43am, V22 (Certified Nursing Assistant/CNA) stated that R5 was a [NAME], and she was strong, it was possible she could remove the velcro off the lap [NAME], but it was not something she could do on command or knew what she was doing. On 9/9/25 at 11:17am, V32 (Therapy Director) stated she can give recommendations for positioning devices, but she does not see too many residents in therapy because most of them are Medicaid and screening them for such devices is not something she regularly does. V32 stated that she worked with R5 right before she really declined. V32 stated R5 was physically very strong, she would get a grip on something, and you could not get it away from her. V32 stated R5 could walk, but she was not steady standing on her own and had some falls. V32 stated that R5 physically had the strength to remove the Velcro on her positioning device, but she did not think she could intentionally remove it. 2. R18's “admission Record” documents an admission date of 4/30/2022 with the following diagnoses in part, unspecified dementia, moderate, with other behavioral disturbance, personal history of traumatic brain injury, and epilepsy, unspecified, not intractable, without status epilepticus. R18's care plan documents that R18 is at risk for falls related to confusion, unsteady gait, use of w/c (wheelchair) for mobility, use of antidepressant and anti-anxiety medication, frequently incontinent of bowel and bladder. Has diagnosis of Dementia, TBI (Traumatic Brain Injury), Seizure disorder. Has poor safety awareness, BLE (Bilateral Lower Extremity) weakness. Attempts to transfer self/ambulate without assistance. This same document lists the following intervention, Trial lap buddy, order lap [NAME]. R18's medical record did not contain a restraint assessment for positioning device. On 9/4/25 at 1:43pm, R18 was not interviewable. R18 was observed in his wheelchair with a positioning device applied on lap. R18 was asked if he was able to remove positioning device. R18 pointed at positioning device, but after several attempts, did not seem to understand instructions. R18 was not able to demonstrate that he is able to remove positioning device on his own. On 9/4/25 at 2:04pm, V34 (Minimum Data Set (MDS) Coordinator) stated they do not do restraint assessments because they do not have restraints here. V34 stated R5 and R18 did not have restraint assessments for the lap huggers (positioning device), and they do not have to assess the residents because when they stand the Velcro releases. 3. R3's admission Record documents a date of birth is 2/14/1944 and an admission date of 9/26/24. This same document lists the following diagnosis: unspecified fracture of upper end of left humerus, subsequent encounter for fracture with routine healing, aphasia following cerebral infarction, diabetes mellitus with diabetic polyneuropathy, and muscle weakness. R3's most recent Minimum Data Set, dated [DATE] documents R3's had a BIMS score of 99, indicating R9 could not complete the interview. Section P that a bed and chair alarm is used daily. R3's Care Plan documented a focus are for risk for falls with interventions in place that included: Bed and chair alarm to notify staff d/t (due to) weight bearing status right foot with a date Initiated of 05/05/2025. There was no physician's order or assessment in R3's medical records for any alarms used by R3. On 9/5/25 at 11:45AM, observed V21 (Certified Nurse Assistant/CNA Supervisor) demonstrating R3's wheelchair alarm and bed alarm in place and working. R3 did not say anything when questioned about the alarms. 4. R9's face sheet documents a date of birth is 5/28/51 and an admission date of 3/20/24. This same document lists the following diagnosis: anxiety, depression and altered mental status. R9's most recent quarterly Minimum Data Set, dated [DATE] documents R9 has a BIMS score of a 10 documenting R9 is moderately cognitively impaired. Section P documents that a bed alarm is used daily. R9's care plan documents a focus area of R9 is at risk for falls related to use of anti-depressant, PRN (as needed) opioid use, requires assist of transfers and is incontinent of bowel and bladder. The goal for this area is to have falls/injuries minimized through management of risk factors while maintaining maximum independence/quality of life through next review. The interventions include on 4/4/25 bed alarm to be on when in bed to alert staff of attempting to self-ambulate. There is no physician's order or assessments for R9's bed alarm located in R9's medical record. On 9/5/25 at 1:00 PM, V1 stated that residents who have chair and bed alarms do not need orders, and they are just decided upon in interdisciplinary meetings as fall interventions. V1 stated that there are no assessments that go along with these alarms, and they are not considered a restraint. On 9/9/25 at 1:56pm, V1 (Administrator) stated they do not have a policy regarding physical restraints.

Based on record review and interview, the facility failed to use person centered behavior interventions and attempt less restrictive alternative treatments prior to administering as needed psychotropic medications for 1 of 3 residents (R5) reviewed for psychotropic medications in a sample of 26. Findings include:R5's admission record documents an admission date of 7/17/25 with the following diagnoses and a discharge date of 8/25/25 with the following diagnoses in part; other frontotemporal neurocognitive disorder, frontotemporal dementia, dementia in other diseases classified elsewhere, unspecified severity, with agitation, depression, unspecified, and anxiety disorder. R5's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 99, indicating that R5 was not able to complete the interview. Section N-Medications documents that R5 receives antipsychotics on a routine basis only.R5's Care Plan documents R5 uses medications with black box warnings. With interventions including but not limited to: Clonazepam: Combined with opioids may result in profound sedation, respiratory depression, coma and death. Limit dosages to the minimum required and follow patients closely for signs and symptoms of respiratory depression and sedation. Initiated: 8/4/25.Escitalopram: Increased risk of suicidal thinking and behavior in children, adolescents, and young adults. Risk must balance with clinical need. Reduction in suicidal risks in adults 65 and older. Date initiated:8/4/25. Haloperidol: Increased mortality in elderly patients with dementia-related psychosis. Not approved for patients with dementia related psychosis. Date Initiated: 8/4/25.R5's Care plan documents a focus of: demonstrates significant mood distress/depression related to depression diagnosis, with interventions including but not limited to; Emphasize relation skills to help increase coping. Focus on strengths and accomplishments to help R5 minimize dwelling on problems and perceived failures. Promote self-talk. Help R5 identify negative self-talk and its role in sustaining depression.R5's Care plan documents a focus of: has a history of aggressive, inappropriate, combative behavior, with a diagnosis of anxiety, with interventions including, but not limited to; communicating assertively that R5 must exercise control over impulses and behavior. Remind R5 of inappropriate behavior.R5's Care plan/behavior tracking records documents R5 will reduce combative behavior to zero weekly throughout the review. With interventions including, 1. Anticipate her needs and meet them timely. 2. Check often to see if she needs care, such as toileting or a drink. 3. Remind R5 we are here to help, and she is safe.R5's Care plan/behavior tracking records documents R5 will reduce signs and symptoms of anxiety with behavior disturbances to two times per week through next review. With interventions including, 1. Allow to express feelings and concerns. 2. Encourage to participate in activities. 3. Remind R5 we are here to help her, and she is safe.R5's Care plan/behavior tracking record documents that R5 will reduce signs and symptoms of depression to two times per week throughout the next review. With interventions including, 1. Allow to express her feelings/concerns. 2. Encourage to participate in activities. 3. Remind R5 we are her to help her, and she is safe.R5's Physician Order Sheet document an order for the following scheduled medications: Clonazepam oral tablet disintegrating tablet, give 0.5mg (milligram) tablet by mouth related to dementia, classified elsewhere, unspecified severity, with agitation, anxiety disorder, unspecified. Escitalopram Oxalate Oral tablet 10mg, give one 10mg by mouth one time a day related to depression, unspecified. The start date for both medications was 7/17/25. R5's Physician Order Sheet document an order for the following as needed medications: Clonazepam oral tablet 0.5mg, give 0.5mg as needed for anticonvulsant. Haloperidol Lactate Injection Solution, inject 5mg intramuscularly every 24 hours as needed for agitation, with a start date of 7/17/25. Haloperidol Lactate Injection Solution, Inject 5mg intramuscularly every 24 hours as needed for agitation, with a start date of 7/21/25 and an end date of 8/4/25. Haloperidol Oral Tablet 1mg, give 1mg by mouth as needed for agitation. Take 1mg nightly as needed for agitation, with a start date of 7/21/25 and an end date of 8/4/25. Haloperidol Oral Tablet 1mg, give 1mg by mouth as needed for agitation. Take 1mg nightly as needed for agitation, anxiety related to anxiety disorder, unspecified with a start date of 8/8/25 and an end date of 8/21/25. Hydroxyzine HCI oral tablet 25mg, give 25mg by mouth every 8 hours as needed for anxiety for 14 days, with a start date of 7/21/25 and end date of 8/4/25. Hydroxyzine HCI oral tablet 25mg, give 25mg by mouth every 8 hours as needed for agitation, anxiety related to anxiety disorder, unspecified. With a start date of 8/8/25 and end date of 8/21/25.R5's July Medication Administration record documents R5's as needed dose of Clonazepam was administered on 7/19/25 at 11:27am and 7/21/25 at 9:31pm.R5's July Medication Administration record documents R5's as needed Haloperidol Lactate Injection was administered on 7/21/25 at 1:20pm, 7/22/25 at 6:57am, 7/24/25 at 1:40am, 7/27/25 at 8:09pm, and 7/28/25 at 7:25pm.R5's July Medication Administration record documents R5's as needed Haloperidol oral tablet was administered on 7/20/25 at 11:05pm, 7/22/25 at 3:25pm, and 7/28/25 at 12:28am.R5's July Medication Administration record documents R5's as needed Hydroxyzine HCI oral tablet was administered on 7/20/25 at 8:07am, 7/21/25 at 8:37am, 7/24/25 at 8:57am and 7/28/25 at 8:20am.R5's care plan/behavior tracking records for July 2025 are blank on the 7a-7p shift on 7/17, 7/18, 7/22, 7/23, 7/24, 7/25, 7/28, 7/29, and 7/30. These same documents record on the 7p-7a shift on 7/18-7/31 the only intervention attempted was to allow R5 to express her feelings and concerns.R5's progress notes document on 7/19/2025 at 2:30pm, Resident was being combative hitting staff, refusing to rest in bed and refusing to stay in w/c (wheelchair). PRN (as needed) clonazepam given at 11:29am. Ineffective. Spoke with Psych NP regarding increased agitation and anxiety. Per Psych NP orders PRN Haloperidol IM injection given at 1:20pm. Resident is resting in bed at this time. signs of agitation has decreased. Plan of care ongoing.R5's progress notes document on 7/28/2025 at 12:28am, Administration Note -Note Text: Haloperidol Oral Tablet 1 MG Give 1 mg by mouth every 24 hours as needed for agitation for 14 Days. Resident very restless, attempting to get out of bed. Administered per PRN orders.R5 progress notes document R5 had falls on 7/19/25, 7/23/25 and 7/26/25. R5 did not suffer any injuries with these falls. On 9/9/25 at 10:43am, V22 (Certified Nursing Assistant/CNA) stated she cared for R5 quite often, on a variety of different shifts. V22 stated by the time they got R5 at the facility, her dementia had really progressed. V22 stated R5 was extremely active of body, moving constantly, often in repetitive motions. V22 stated it was like R5's body did not connect with her brain. V22 stated R5 was very restless at night, she needed one on one supervision. V22 stated during the day activity and management tried to help with R5 if they could, she had started therapy right before she got COVID and that had been a ton of help. V22 stated therapy would help walk R5 because she was constantly trying to get up and she was not steady at all and had some falls. V22 stated walking helped her settle down so much. V22 stated R5 was total care and had to be extensively assisted with feeding, which did take a lot of time. V22 stated she could walk but not independently or safely, she had to walk with staff. V22 stated R5 could speak, but her brain wasn't working correctly due to her dementia. V22 stated R5 did not make sense and there was no redirecting or reassuring her. V22 stated she could be combative at times. V22 stated she was not sure what R5's behavioral interventions actually were, but if she had her, she would give her a pillowcase to fiddle with or fold. V22 stated sometimes she would give her the pillow without the pillowcase because she liked the sound that it made when she scratched it and would settle her down a little bit.On 9/9/25 at 11:21am, V15 (Licensed Practical Nurse/LPN) stated when R5 first came in she was very active. V15 stated R5 was not technically a one on one, but they had to keep eyes on her all the time. V15 stated R5 was constantly wanting to stand and fidgeting. V15 stated R5 was super restless, and she would pull stuff off the desks, get a hold of people walking past her and trying to stand and she was super unsteady trying to stand unassisted. V15 stated if she was very restless and someone was available, they would walk with her and that was very helpful. V15 stated she did not specifically remember what R5's behavior interventions were but they always had to have eyes on her and things out of her reach. V15 stated she had an as needed order for a Haldol injection and she had to call the psychiatric Nurse Practitioner to get a one time order once because she was very combative. V15 stated when R5 first came she spoke, but it was nonsensical. V15 stated there was no redirection or discussing feelings with R5, her level of cognition at that point just was not there.On 9/9/25 at 1:09pm, V14 (Director of Nursing/DON) stated she did not believe V33 (Psychiatric Nurse Practitioner) saw R5 in person at admission. V14 stated they do monitor medications, and the psychiatric medications people admit on, she stated R5 was admitted on all these medications, and they weren't monitoring her specifically. V14 stated they do monitor for side effects of medications. V14 stated medications with black box warnings have things to monitor for in the care plan, but they do not have a place where they chart what they are monitoring for. V14 stated when R5 first admitted she would do one on one with her at times. V14 stated R5 did speak in the beginning, but agreed her level of cognition was severely impaired. V14 stated they should be reevaluating interventions for residents.On 9/9/25 at 1:56pm, V17 (Physician) stated R5 was discharged from the hospital to continue both orders for one scheduled benzodiazepine tablet, one scheduled antidepressant tablet, one as needed benzodiazepine tablet, one as needed anti-psychotic tablet and one as needed anti-psychotic injection, and one as needed Anxiolytic/Sedative tablet, up to three times a day. V17 stated he continued the medications because R5 was allegedly already taking them at the assisted living. V17 stated the reason she was taking them was because she was displaying increased agitation, he stated he believed she also was combative and had self-injurious behavior. V17 stated he had seen R5 in person on July 17,2025 when she was admitted to the facility.On 9/9/25 at 2:35pm, V33 (Psychiatric Nurse Practitioner) stated she followed R5 at her previous assisted living facility. V33 stated R5 was much more active at assisted living, and managing her behaviors and medications were challenging. V33 stated they tried all different things with R5, she was much more physically aggressive, was flipping tables and things of that nature. V33 stated in assisted living, they do not have the staff that they have in long term care, sometimes they don't even have nurses, so their ability to use non-pharmacological interventions is limited. V33 stated the facility continued all her orders for R5 from the assisted living, she stated the reason for all the as needed medications in assisted living because they will taper them down to as needed with the goal of discontinuing them eventually. V33 stated normally she would not order all these as needed medications in a long-term care facility because they have more staff and different regulations. V33 stated she can give suggestions for behavior interventions. V33 stated after looking over her notes she had suggested behavior interventions appropriate to her cognitive abilities, she stated R5 was severely cognitively impaired. V33 stated behavior interventions should always be the first line treatment, appropriate interventions should be done and documented before use of as needed medications. V33 stated as needed medications should be the last resort for all patients. V33 stated she had not seen R5 in person until after she had declined, she stated she didn't have her notes in front of her, but she believed it to be around 8/15/25.On 9/9/25 at 2:40pm, V1 (Administrator) was asked if R5's behavior interventions were person centered and appropriate, V1 stated that was a good question and declined to answer any further. V1 stated they did not have any policies regarding the use of psychotropic medications or chemical restraints.Facility policy titled, Care Planning - Interdisciplinary Team with a revision date of September 2013, documents under policy statement: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. According to https://reference.medscape.com/drug-interactionchecker, there are 7 significant interactions between the psychotropic medications that R5 was taking and require close monitoring: Escitalopram increases toxicity of Haloperidol by QTc interval. Use Caution/Monitor. Hydroxyzine and Haloperidol both increase QTc interval. Use Caution/Monitor. Hydroxyzine and Escitalopram both increase QTc interval. Use Caution/Monitor. Hydroxyzine and Clonazepam both increase sedation. Use Caution/Monitor. Hydroxyzine and Haloperidol both increase sedation. Use Caution/Monitor. Clonazepam and Haloperidol both increase sedation. Use Caution/Monitor. Haloperidol and Escitalopram both increase QTc interval. Use Caution/Monitor.

Based on observation and interview the facility failed to maintain floors and equipment in a safe and sanitary condition. This failure has the potential to affect all 50 residents living in the facility.Findings include:On 8/16/25 at 7:15 PM, the kitchen was observed to have various pieces of food lying on the floor around the cooking area. Black dirt/ debris was noted on the floor in various areas in the kitchen. The dishwashing area had various pieces of food on the floor with black dirt/ debris and dead cockroaches on the floor.On 8/20/25 at 10:28 AM, the kitchen was observed to have various areas of the floor with black dirt/ debris on it. The backsplash of the stove appeared to have a buildup of grease and other debris. The grease trap emptying from the griddle area of the stove had a large amount of grease on the floor under it measuring approximately 1 foot in diameter. On 8/20/25 at 10:15 AM, V6 (Dietary Manager) said she had only been employed in the facility for about a week. V6 said the kitchen was having some cleanliness problems because staff would not listen to her and would not clean up after themselves. V6 said the kitchen was disgusting.On 8/22/25 at 10:58 AM, V9 (Registered Dietitian) said she expected the kitchen to be clean and sanitary.The facility's 9/20/25 Resident List Report documented 50 residents residing in the facility.

Based on interview and record review the facility failed to provide 8 consecutive hours of Registered Nurse (RN) services 7 days a week. This failure has the potential to affect all 50 residents residing in the facility.Findings include:The facility's June, July, and August 2025 licensed nurse's schedules documented on June 7, 8, 14, 15, 21, 22, 28, and 29, July 6, 12, 13, 19, 20, 26, and 27, [DATE], 9, 10, 16, and 17 there was no RN working in the facility for a consecutive 8 hours.On 8/22/25 at 9:38 AM, V2 (Director of Nursing/ DON) verified on June 7, 8, 14, 15, 21, 22, 28, and 29, July 6, 12, 13, 19, 20, 26, and 27, [DATE], 9, 10, 16, and17 there was no RN working in the facility for a consecutive 8 hours.On 8/22/25 at 2:13 PM, V1 (Administrator) said the facility did not have a policy pertaining to 8 consecutive hours of RN services. V1 said the facility followed Illinois Department of Public Health (IDPH) staffing guidelines.The facility's 9/20/25 Resident List Report documented 50 residents residing in the facility.

Based on observation, interview and record review the facility failed to provide hot palatable foods for 4 (R2, R3, R7, and R9) of 12 residents reviewed for dietary services out of a sample of 12.Findings include:1.R7's admission Record documented an admission date of 6/23/21 with diagnoses including: type 2 diabetes mellitus, anxiety disorder, chronic pain syndrome. R7's 6/5/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R7 was cognitively intact.R7's Order Summary Report printed 8/21/25 documented a 1/20/23 diet order for low concentrated sweets, regular texture, thin liquid consistency, and offer double protein portions with all meals.On 8/16/25 at 5:55 PM, R7's evening meal tray was delivered containing 1 piece of cheese pizza, salad, breadstick, and ambrosia. R7 said the pizza was cold and unappetizing. R7 said he bought his own frozen hamburgers in case he did not like the main course being served. R7 said he was angry because for the noontime meal he had ordered 2 hamburgers, and the cook had burned them. R7 provided a picture on his cellular telephone of 2 hamburgers that appeared charred with black burned spots on the cheese.2.R3's admission Record documented an admission date of 12/31/24 with diagnoses including: chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease stage 3. R3's 6/6/25 MDS documented a BIMS score of 15, indicating R3 was cognitively intact.On 8/16/25 at 6:09 PM, R3's evening meal tray was delivered containing a piece of cheese pizza, salad, and breadstick. R3 said the pizza was cold and the breadstick was too hard to eat. R3 stated to staff take that back! I'm not eating that. Staff removed R3's meal tray and no substitution was offered.3. On 8/16/25 at 7:15 PM, a test tray was provided directly from the steam table. The temperature of the cheese pizza was taken with a metal stemmed thermometer calibrated on 8/16/25 at 5:30 PM using the ice point method. The temperature measured 116.2 degrees Fahrenheit, which felt too cool, and when tasted the pizza lacked flavor. The breadstick was sampled and was hard and crunchy.4. R2's admission Record documented an admission date of 10/9/23 with diagnoses including: chronic venous hypertension idiopathic with ulcer of bilateral lower extremity, type 2 diabetes, hypertension. R2's 6/27/25 MDS documented a BIMS score of 15, indicating R2 was cognitively intact.On 8/21/25 at 12:38 PM, R2 who was eating lunch stated the scalloped potatoes weren't cooked and were not good.5. R9's admission Record documented an admission date of 6/8/21 with diagnoses including: type 2 diabetes, chronic obstructive pulmonary disease, hypertension. R9's 7/3/25 MDS documented a BIMS score of 15, indicating R9 was cognitively intact.On 8/21/25 at 1:32 PM, R9 said the scalloped potatoes weren't completely cooked and her noon time meal tray was cold when it arrived. R9 said she always ate in her room, and her meal trays were always cold. R9 stated the food is so bad here. R9's noon time meal tray was sitting on her overbed table and only a few bites had been taken.6. On 8/21/25 at 12:40 PM, R7 said the scalloped potatoes were raw, crunchy, and gross.On 8/21/25 at 12:23 PM, the scalloped potatoes were sampled from the steam table and were undercooked and crunchy.

Based on observation, interview, and record review the facility failed to follow dietitian approved recipes and textures an failed to provide ordered supplements for 5 (R4, R5, R6, R7 and R12) of 12 residents reviewed for dietary services out of a sample of 12.Findings include:The facility's Diet Spreadsheet Week 1 day 7 for Dinner, documented residents receiving a mechanical soft diet should have been served ground swiss cheese sandwich with mayonnaise, soft cooked vegetables soft chopped ambrosia, and a soft garlic breadstick. The facility's Diet Spreadsheet Week 1 day 7 for Dinner, documented resident receiving a pureed diet should have been served pureed cheese pizza, pureed soft, cooked vegetables, pureed ambrosia, and pureed garlic breadstick.1. R12's admission Record documented an admission date of 8/6/25 with diagnoses including: sequelae of unspecified cerebrovascular disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness. R12's 8/15/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R12 was cognitively intact.R12's Order Summary Report printed 8/26/25 documented an 8/6/25 diet order for low concentrated sweets diet with mechanical soft texture and thin liquids.On 6/18/25 at 5:44 PM, R12 was severed a meal tray containing large pieces of cheese pizza dietary staff had torn up by hand, larger than 1 inch by 1 inch pieces of varying size, with some pieces containing the hard outer crust, a shredded lettuce salad, and a whole breadstick. V3 (Certified Nursing Assistant/ CNA) delivered R12's meal tray and told R12, I know there are some hard pieces in there (referring to the pizza) but if it is too much let us know. Don't choke on it. Tell us and we will see about getting you something else.On 6/18/25 at 5:54 PM, R12 was observed to be trying to bite though the pizza but was not able to.2. R5's admission record documented an admission date of 5/20/25 with diagnoses including: hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, vascular dementia, cerebellar stroke syndrome. R5's 5/28/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R5 was cognitively intact.R5's Order Summary Report printed 8/21/25 documented a 5/20/25 diet order for no added salt, mechanical soft texture, thin liquids consistency. R5's Care Plan Report documented a focus area with a 6/9/25 initiated date documenting in part .(R1) is a risk for nutritional deficit r/t (related to) dx (diagnosis) CVA (Cerebrovascular Accident) with left sided hemiplegia, dementia. with a with 6/9/25 initiated intervention documenting in part . Provide, serve diet as ordered.On 6/18/25 at 6:38 PM, R5 was served a meal tray containing large pieces of cheese pizza dietary staff had torn up by hand, larger than 1 inch by 1 inch pieces of varying size, with some pieces containing the hard outer crust, a shredded lettuce salad, and a whole breadstick. R5 was observed to be unable to bite through the hard outer pizza crust.On 6/18/25 at 7:09 PM, R5's meal tray was observed to have the breadstick with teeth marks on one end but was not bitten off. At that time R5 stated the breadstick was too hard for her to bite through.3. R6's admission Record documented an admission date of 9/12/24 with diagnoses including: dementia, mild cognitive impairment, major depressive disorder, R6's 8/1/25 MDS documented a BIMS score of 1, indicating R6 was severely cognitively impaired.R6's Order Summary Report printed 8/21/25 documented a 1/13/25 diet order for regular diet with pureed texture with honey thick liquids. R6's Care Plan Report documented a focus area with a 7/31/20 initiation date documenting in part .(R6) is on a NAS (No Added Salt) puree diet. (R6's) teeth are in poor condition. (R6) is able to feed himself after setup.On 6/18/25 at 6:04 PM, R6 was served the evening meal tray containing pureed pizza that was chunky more of a ground consistency not a smooth consistency, pureed green beans, and pureed ambrosia. R6's meal tray did not contain a pureed garlic breadstick.On 6/18/25 at 6:15 PM, R6 was observed to start coughing after taking a bite of the pureed/ ground pizza becoming red in the face. R6 was able to clear his airway on his own by coughing and did not require intervention by staff.R6's Progress Note on 8/17/25 at 4:19 AM progress note documented in part .The nurse on duty was notified that the resident choked during dinner. The nurse assessed the resident. The resident was not chocking or coughing upon assessment. Lung sounds were clear in all lobes. The MD (Medical Doctor) was notified and an order was placed to obtain a STAT X-ray with two views. The order has been placed.On 8/21/25 at 12:02 PM, V7 (CNA) said she was working on 8/17/25 during the evening meal. V7 said she saw R6 get choked on his beverages and said it was due to the dietary staff not thickening R6's beverages. V7 said after she ensure R6 was ok she returned R6's beverages and alerted the dietary staff R6 was supposed to receive honey thickened liquids.4.R4's admission Record documented an admission date of 4/30/22 with diagnoses including: dementia, personal history of traumatic brain injury, sensorineural hearing loss bilateral. R4's 5/30/25 MDS documented a BIMS score of 4, indicating R4 was severely cognitively impaired. eR4's Order Summary Report printed 8/21/25 documented a 7/22/24 diet order for regular diet mechanical soft texture with thin liquid consistency. R4's Care Plan Report documented a focus area revised on 3/23/35 documenting in part .(R4) is at risk for nutritional deficit r/t (related to) Dx TBI (Traumatic Brain Injury), dementia, rectal cancer. On 6/18/25 at 5:57 PM, R4 was served a meal tray containing large pieces of cheese pizza dietary staff had torn up by hand, larger than 1 inch by 1 inch pieces of varying size, with some pieces containing the hard outer crust, pureed green beans, and a whole breadstick. R4 was observed to be unable to bite through the hard outer pizza crust or the breadstick.5. R7's admission Record documented an admission date of 6/23/21 with diagnoses including: type 2 diabetes mellitus, anxiety disorder, chronic pain syndrome. R7's 6/5/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R7 was cognitively intact.R7's Order Summary Report printed 8/21/25 documented a 1/20/23 diet order for low concentrated sweets, regular texture, thin liquid consistency, and offer double protein portions with all meals. R7's Care Plan Report documented a focus area revised on 9/25/24 documenting in part . (R7) is at risk for complications with weight and nutrition r/t (related to) dx (diagnoses) DM (Diabetes Mellitus), obesity, hyperlipidemia, diabetic foot wound. with a revised 6/30/21 intervention documenting in part . LCS (low concentrated sweets) diet. Offer double protein portions all meals.On 8/16/25 at 5:55 PM, R7's evening meal tray was delivered containing 1 piece of cheese pizza, salad, breadstick, and ambrosia salad.On 8/22/25 at 10:58 AM, V9 (Registered Dietitian) said she expected physician orders for diets and supplements to be followed. V9 said residents with wounds were recommended to be served double portions of protein with all meals to assist with wound healing. V9 said if a resident with a wound was not being served the correct diet and supplements they would be at risk for the wound to decline. V9 said a resident with an order for double protein should have been served 2 pieces of pizza with the 8/16/25 planned evening meal.On 8/21/25 at 1:26 PM, R7 said he had a surgical wound to his left foot he was admitted with that had never healed.On 8/16/25 at 7:15 PM, a test tray was requested, and the outer pizza crust and the breadstick was very hard and crunchy.On 8/16/25 at 7:20 PM, V4 (Cook in Training) said she had been training in the kitchen for about a week. V4 said V5 (Cook) left prior to V4 finishing cooking the meal. V4 said she did not make any pureed breadsticks because V5 had told V4 not to. V4 said she was not sure why V5 told her not to make pureed breadsticks but V4 was just doing what she was told. V4 said V5 told V4 residents on mechanical soft diets could be served the shredded lettuce salad and the pizza just needed to be torn into smaller pieces.On 8/16/25 at 7:22 PM, V5 said she thought since the lettuce was shredded it would be ok to serve to the residents on a mechanical soft diet. V5 said a mechanical soft diet should have food cut up in 1 inch by 1 inch pieces and V5 was not sure if a resident on a mechanical soft diet should be served the hard crust on the pizza. V5 said she did not sample the breadsticks before serving them. V5 said if the breadsticks were hard, they should not be served to residents on a mechanical soft diet. V5 said she was not sure why V4 had not followed the Diet Spreadsheet for what residents on a mechanical diet should have been served. V5 said any puree should be a smooth texture.On 8/20/24 at 10:15 AM, V6 (Dietary Manager) said she expected pureed dishes to be a smooth cake batter like consistency without chunks. V6 said she expected mechanical soft dishes to be chopped or ground with no pieces being larger than a dime. V6 said pizza with a hard crust, hard breadsticks, and raw vegetables should not be served to a resident on a mechanical soft diet.On 8/22/25 at 10:58 AM, V9 (Registered Dietitian) said she expected staff to follow diet orders. V9 said she expected puree dishes to be the consistency of mashed potatoes or applesauce with no chunks. V9 said hard pizza crust, hard breadsticks, and shredded lettuce were not appropriate to be served to residents requiring a mechanical soft diet.The facility's 2022 Pureed policy documented in part .The Pureed Diet is designed for those individuals who have difficulty swallowing or cannot chew foods of the dental soft consistency. Foods that cannot be adequately pureed are substituted or altered as indicated on the menu spreadsheet. Pureed regular bread and specialty breads such as corn bread, muffins, garlic bread, etc., continue to be pureed as a separate menu item. Add measured amounts of hot liquid for cooked foods and cold liquid for cold foods (if required) and process until there is a smooth, pudding-like or smooth mashed potato consistency. Please note: some menu items do not require any liquid added during the pureeing process in order to achieve the desired pureed consistency.The facility's 2022 Dental Soft (Mechanical Soft) policy documented in part .This consistency modified diet is for individuals with limited or difficulty in chewing regular textured foods. As with any diet modification, this diet should be individualized to meet the resident's needs and chewing abilities. Generally, the diet consists of food of nearly regular textures but eliminates very hard, sticky, crunchy or hard to chew foods. Foods should be moist and fork tender. Meat is ground or chopped into bite-size pieces (1/2 inch or smaller) and should be held with a minimal amount of prepared broth, gravy, or other type of moistening agent (NO WATER) to keep the product moist. Hot ground meats should be topped with gravy or sauce at the point of service. Dry, hard crusty breads are excluded.The facility's November 2015 Therapeutic Diets policy documented in part .Therapeutic diets shall be prescribed by the Attending Physician. 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. 2. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet. 6. Routine menus are planned by the Food Services Manager, and approved by a Registered Dietitian for nutritional adequacy. The Food Service 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 provide dietary supplements for at risk residents or residents who have experienced weight loss for 3 (R1, R4, and R6) of 12 residents reviewed for dietary services out of a sample of 12. Findings include:1. R1's admission Record documented an admission date of 9/26/25 with diagnoses including type 2 diabetes mellitus, peripheral vascular disease, aftercare following surgical amputation. R1's 7/17/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, indicating R1 was severely cognitively impaired.R1's Order Summary Report documented a 10/19/24 diet order for regular diet, regular texture, thin liquids, health shakes at lunch and supper, offer extra butter/ margarin and sauces/ gravies at all meals.R1's Care Plan documents a goal as 10% and no signs or symptoms of malnutrition, with a revised date of 7/24/25. Interventions include: Provide and serve supplements as ordered with an initiation date of 10/16/24. R1's 8/5/25 Registered Dietitian progress note documented in part . (R1) with 11% WT loss/6mos (weight loss per 6 months). continue CCHO (Controlled Carbohydrate) diet. health shake to L and S (Lunch and Supper). Offer extra butter/ [NAME] (margarin), sauces/ gravies all meals to increase cals (calories). Encourage intakes.On 8/16/25 at 6:13 PM, R1 was served the evening meal tray containing a piece of cheese pizza, salad, breadstick, ambrosia, milk, and cool aide. R1's meal ticket documented R1 was supposed to receive a health shake, extra sauces/ gravies, and extra butter/ margarin. R1 did not receive a health shake, any extra sauces/ gravies, dressing for her salad, or any butter/ margarin.On 8/22/25 at 10:58 AM, V9 (Registered Dietitian) said she expected staff to provide residents with diets and supplements as ordered. V9 said she would recommend a health shake, extra sauces/ gravies, and extra butter/ margarin for residents with weight loss to increase their calorie intake.On 8/22/25 at 11:06 AM, V10 (Physician) said he expected physician orders to be followed. V10 said if a resident was not receiving the correct diets or supplements, they could have weight loss.2. R6's admission Record documented an admission date of 9/12/24 with diagnoses including: dementia, mild cognitive impairment, major depressive disorder, R6's 8/1/25 MDS documented a BIMS score of 1, indicating R6 was severely cognitively impaired.R6's Order Summary Report printed 8/21/25 documented a 1/13/25 diet order for regular diet with pureed texture with honey thick liquids, add extra butter/ margarin and extra sauces/ gravies to all meals, include pudding with 1 scoop of protein powder with lunch and supper. R6's Care Plan Report documented a focus area with a 7/31/20 initiation date documenting in part .(R6) is on a NAS (No Added Salt) puree diet. (R6's) teeth are in poor condition. (R6) is able to feed himself after setup.On 6/18/25 at 6:04 PM, R6 was served the evening meal tray containing pureed pizza that was chunky, more of a ground consistency, not a smooth consistency, pureed green beans, and pureed ambrosia. R6's meal tray did not contain a pureed garlic breadstick, any sauce or gravy, butter or margarin, or pudding.3. R4's admission Record documented an admission date of 4/30/22 with diagnoses including: dementia, personal history of traumatic brain injury, sensorineural hearing loss bilateral. R4's 5/30/25 MDS documented a BIMS score of 4, indicating R4 was severely cognitively impaired.R4's Order Summary Report printed 8/21/25 documented a 7/22/24 diet order for regular diet mechanical soft texture with thin liquid consistency, pudding at supper, extra butter/ margarin and extra sauces/ gravies with meals. R4's Care Plan Report documented a focus area revised on 3/23/35 documenting in part .(R4) is at risk for nutritional deficit r/t (related to) Dx TBI (Traumatic Brain Injury), dementia, rectal cancer. On 6/18/25 at 5:57 PM, R4 was served a meal tray containing large pieces of pizza dietary staff had torn up by hand, larger than 1-inch by 1-inch pieces of varying size, with some pieces containing the hard outer crust, pureed green beans, and a whole breadstick. R4 was observed to be unable to bite through the hard outer pizza crust or the breadstick. R4 did not receive any desert, pudding, butter/ margarin, sauce/ gravy.The facility's 2024 Weight Assessment and Intervention policy documented in part . The multidisciplinary tea will strive to prevent, monitor, and intervene for undesirable weigh loss for our residents. 4. The Dietitian will review the Weight Records each month to follow individual weight trends over time. 1. Interventions for undesirable weight loss may be based on careful consideration of the following: a. Resident choice and preferences; b. Nutrition and hydration needs of the resident; c. Functional factors that may inhibit independent eating. e. Chewing and swallowing abnormalities and the need for diet modifications. g. The use of supplementation and/or feeding tubes.

Based on observation, interview and record review the facility failed to provide dietary supplements, and the appropriate protein portion size to prevent further weight loss or weight maintenance for 9 of 11 residents (R1, R2, R3, R8, R9, R10, R11, R12, R13) reviewed for weight loss in a sample of 18. This failure further contributes to continued harm to R2 and R10, who have a documented history of severe weight loss. Findings include:1. R2's admission record documents an admission date of 01/09/22 with diagnoses including: chronic obstructive pulmonary disease, acute osteomyelitis of left ankle and foot, malignant neoplasm of upper lobe, anemia, protein calorie malnutrition, major depressive disorder, anxiety disorder, hypothyroidism, drug induced subacute dyskinesia, osteoarthritis, muscle weakness, and cognitive communication deficit.R2's order summary report documents a dietary order of regular diet with mechanical soft texture. Thin liquids consistency, ground meat extra gravy, (nutritional shakes) two times a day, 1 scoop protein powder in oatmeal at breakfast, vanilla pudding at supper, med pass 2 ounces at lunch and supper, (nutritional ice cream) two times a day, offer snacks throughout the day. Assist with meals in dining room and whole milk at breakfast for diet. This order was started on 07/22/24 with no end date listed.R2's Minimum Data Set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) score of 12 indicating resident is moderately impaired. Section GG documents R2's eating ability as supervision or touching assistance.R2's care plan documents a focus area of R2 is at risk for nutritional deficit related to diagnoses including malnutrition, underweight, poor appetite, and a diagnosis of anemia. R2 is on a regular mechanical soft diet with ground meat with extra gravy, nutritional shakes two times a day, 1 scoop of protein powder in oatmeal at breakfast (likes oats thicker), vanilla pudding daily at supper, and nutritional ice cream two times a day with a revision date of 01/18/24 with interventions including: provide and serve supplements as ordered dated 08/07/23, to be up and in dining room for all meals due to requires assistance with eating dated 04/21/25, add whole milk at breakfast dated 07/10/25 and offer snacks throughout the day dated 07/10/25.R2's nutrition progress note dated 07/08/2025 at 1:12 PM documents: mechanical soft ground meats with extra gravy. Percent of meal intakes is 51 - 100 %, supplement intake: health shakes two times a day, 1 scoop of protein powder in oatmeal at breakfast, vanilla pudding at supper, Med pass and nutritional ice cream. R2's current weight is 82 pounds with low body mass index and weight loss. R2's function is assistance with meals. R2's height is 64 inches and weight on 06/04/25 was 82 pounds with a BMI of 14 % and a December weight of 91 pounds. R2 has a 10 % weight loss over six months. R2's skin is at risk. Continue diet orders of mechanical soft ground meat with extra gravy, nutritional shakes two times a day, 1 scoop of protein powder in oatmeal at breakfast, vanilla pudding at supper and nutritional ice cream two times a day.R2's nurses note dated 07/03/25 at 10:23 AM documents: R2 had weight loss, medical doctor and resident notified and new interventions implemented.On 07/17/25 at approximately 1:01 PM, V4 (Dietary) ground the ham and mixed mayonnaise in with the ground ham, the ham was scooped onto paper plates with the baked beans and microwaved to reach 145 degrees Fahrenheit.On 07/17/25 at approximately 1:01 PM, V4 stated, she is going to mix mayonnaise in with the ham to make the mechanical soft ham because they do not have any gravy for the mechanical soft ham. On 07/17/25 at approximately 1:28 PM, R2 was served her lunch of mechanical soft ham, baked beans and applesauce. R2 did not receive the extra gravy, nutritional shake, or nutritional ice cream with her lunch.On 07/17/25 at 3:10 PM, R2 stated lunch was not enough food, she had asked for something else, but she did not get it. R2 stated, The lunch meal was awful.On 07/17/25 at 5:47 PM, R2 did not receive a health shake with her dinner.On 07/21/25 at 8:10 AM, R2 was brought to the dining room for breakfast. Her food was placed in front of her and plastic utensils placed in the food and the staff member walked away. R2 did not receive assistance or encouragement during breakfast with her meal and ate less than 25% of her meal.On 07/21/25 at 12:33 PM, R2 did not receive a health shake with lunch.On 07/21/25 at 6:46 PM, R2 did not receive a health shake with her dinner.2. R10's admission record documents an admission date of 09/06/17 with diagnoses including: dementia, essential hypertension, vitamin D deficiency, thiamine deficiency, alter mental status, Parkinson's disease, epilepsy, muscle weakness, and other symbolic dysfunctions.R10's order summary report documents a dietary order of regular diet with a pureed texture, thin liquids consistency, whole milk three times a day, health shake three times a day, (nutritional ice cream) with lunch and supper, super cereal (nutritional cereal) at breakfast, ice cream two times a day, melted margarine to hot sides at lunch and supper, offer pudding three times a day, 1 scoop of protein powder at all meals with an order date of 01/15/25 and no end date listed. R10's order summary report also documents a dietary order of house supplement two times a day for weight loss, fortified pudding at lunch and dinner with protein powder added with an order date of 01/15/25 and no end date listed.R10's minimum data set (MDS) dated [DATE] documents a brief interview of mental status of 99 indicating resident was unable to complete the interview. Section GG documents R10's eating ability as: not attempted due to environmental limitations (example, lack of equipment or weather constraints).R10's care plan documents a focus area of R10 is at risk for nutritional deficit relating to diagnoses of vitamin D and Thiamine deficiencies, hypertension, Parkinson's and dementia, R10 is on a regular pureed diet dated initiated 02/03/25. Goal: will maintain adequate nutritional status as evidenced by maintaining weight within 5-10% and no signs of malnutrition through review date, date initiated 02/03/25. Interview include: offer pudding two times a day dated initiated 03/24/25, Med pass as ordered at lunch dated initiated 07/18/25, regular pureed diet, whole milk three times a day, health shakes three times a day, nutritional ice cream at lunch and supper, super cereal at breakfast, ice cream two times a day, melted margarine/butter to hot sides with lunch and supper, offer pudding three times a day, one scoop protein power all meals, nutritional ice cream at lunch and supper dated initiated 07/02/25, attempt to assist her with eating at meal times as she allows dated initiated 02/03/25, provide and serve supplements as ordered date initiated 02/03/25.R10's dietary note dated 3/6/25 documents: registered dietician weight note: R10's height is 60 inches. January weight 96 pounds, February weight 85 pounds. Documenting a 11.5% weight loss in 1 month. Continue pureed, med pass three times daily, super cereal at breakfast, whole milk three times daily, ice cream twice daily, melted margarine on hot vegetables, magic cup at lunch and supper, health shakes three times a day. Discontinue fortified pudding with protein powder because supplement is not offered at this facility. Offer pudding twice daily. Encourage intakes. Monitor intakes and weights. R10's dietary note dated 07/08/25 at 2:06 PM documents: registered dietician weight note: R10's height is 60 inches and weight on 06/04 was 93 pounds with a BMI of 18%, March weight was 86 pounds with 8.1% weight gain over 3 months, the weight gain is desirable. R10 has variable meal intakes as reported. Continue pureed (diet), super cereal at breakfast, whole milk three times a day, ice cream two times a day, melted margarine on hot vegetables, nutritional ice cream at lunch and supper, health shakes three times a day, 1 scoop protein powder in all meals. R10 is being offered above nutritional needs. Encourage intakes and monitor intakes and weights. On 07/17/25 at 1:10 PM, R10 did not receive the whole milk, health shake, nutritional ice cream, ice cream, melted margarine, fortified pudding, or the protein powder with her lunch.On 07/17/25 at 2:45 PM, V3 (Business office Manager/Acting Dietary Manager) stated, they did not have any super cereal to serve for breakfast today (07/17/25) so R10 did not receive the super cereal for breakfast.On 07/17/25 at 5:42 PM, R10 did not receive the health shake or fortified pudding with her dinner.On 07/17/25 at 5:42 PM, R10 received her dinner. R10 did not make any effort to eat any food after it was set in front of her. At 6:00 PM, R10 received assistance with her dinner. On 07/21/25 at 12:22 PM, R10 did not receive the health shake, ice cream or pudding with her lunch.On 07/21/25 at 6:34 PM, R10 did not receive the health shake, ice cream, protein powder or fortified pudding with her dinner.On 07/21/25 at 6:36 PM, V14 (Certified Nurse Aide) stated, R10 needs assistance with eating.3. R3's admission record documents an admission date of 01/05/22 with diagnoses including: unspecified sequelae of unspecified cerebrovascular disease, dementia, essential hypertension, cognitive communication deficit, weakness, vitamin D deficiency, depression and chronic pain.R3's order summary report documents a dietary order of regular diet with a pureed texture with an order date of 05/20/25 and no end date listed. R3's order summary report documents a dietary order of health shakes with meals for weight loss with an order date of 07/22/24 and no end date listed.On 07/17/25 at 1:10 PM, R3 did not receive her health shake with her lunch.On 07/17/25 at 5:20 PM, R3 did not receive a health shake with her dinner.On 07/21/25 at 6:26 PM, R3 did not receive a health shake with her dinner.4. R16's admission record documents an admission date of 04/27/23 with diagnoses including: chronic obstructive pulmonary disease, gastrostomy status, dysphagia, paroxysmal tachycardia, schizoaffective disorder, bipolar disorder, moderate protein calorie malnutrition, muscle weakness, and encounter for surgical aftercare following surgery on the digestive system.R16's order summary report documents a dietary order of regular diet with a pureed texture, super cereal at breakfast, whole milk three times a day with meals, extra margarine/butter, sauces/gravies all meals with an order date of 10/19/24 and no end date listed.On 07/17/25 at 1:10 PM R16 did not receive the whole milk, or extra margarine/butter or sauces/gravies with his lunch.On 07/17/25 at 2:45 PM V3 (Dietary Manager) stated, they did not have any super cereal to serve for breakfast today (07/17/25) so R16 did not receive the super cereal for breakfast.5. R1's admission record documents an admission date of 11/11/2022 with diagnoses including: recurrent depressive disorders, unspecified intellectual disabilities, paranoid schizophrenia, essential hypertension, muscle weakness, and anxiety disorder.R1's order summary report documents a regular diet with regular texture with an order date of 07/22/24 with no end date listed.R1's dietary note dated 05/02/25 at 1:37 PM documents: variable meal intakes as reported. R1's height is 77 inches, and weight on 04/29 190 pounds, having a BMI (body mass index) of 22, no significant weight changes per monthly weights. However, reported weekly weights have declined with overall declining weight trend. Continue regular diet, offer whole milk at breakfast, (nutritional) shake daily, and encourage intakes.On 07/17/25 at approximately 1:40 PM ham slices were served, the slices were, sliced ham that was cut in half. All slices were similarly sized.On 07/17/25 at approximately 1:40 PM, R1 received a piece of ham that was approximately 1.75 ounces.On 07/17/25 at 2:26 PM, V3 (Dietary Manager) weighed one of the slices of ham, the ham weighed 1.75 ounces.On 07/17/25 at 2:26 PM, V3 stated, the ham should have weighed 3 ounces, therefore they did not give enough ham.The Diet Spreadsheet, Emergency menu dated 2025 for Day 5 Thursday documents, Lunch with a handwritten note of Grilled ham, applesauce, chips and baked beans. The portion sizes that were indicated were noted to be for Corned beef hash, canned green bean, assorted cookies and bread that had been marked out. 6. R8's admission record documents an admission date of 11/29/24 with diagnoses including: anxiety disorder, vascular dementia, atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation, sequelae of unspecified cerebrovascular disease, type 2 diabetes mellitus, seizures. Gastro-esophageal reflux disease without esophagitis, muscle weakness, and syncope and collapse.R8's order summary report documents a dietary order of: no added salt diet, regular texture with nutritional shakes with all meals for nutrition with an order date of 11/29/24 and no end date listed.On 07/17/25 at 1:20 PM, R8 did not receive her health shake with her lunch.On 07/17/25 at approximately 1:40 PM, R8 received a piece of ham that was approximately 1.75 ounces.On 07/17/25 at 5:35 PM, R8 did not receive a health shake with her dinner.On 07/21/25 at 6:46 PM, R8 did not receive a health shake with her dinner.7. R9's admission record documents an admission date of 08/28/2014 with diagnoses including: chronic obstructive pulmonary disease, sequelae of unspecified cerebrovascular disease, dementia, essential hypertension, anxiety disorder, dysphagia following unspecified cerebrovascular disease, major depressive disorder, and hypotension.R9's order summary report documents a dietary order of: regular diet with regular texture, whole milk three times a day, health shake two times a day with lunch and supper, offer pudding at lunch, ice cream at supper, peanut butter at snack time and extra margarine/butter at all meals and add 120 ml (milliliters) Med pass two times a day with meals related to weight loss with an order date of 07/22/24 and no end date listed.On 07/17/25 at approximately 1:40 PM, R9 received a piece of ham that was approximately 1.75 ounces.On 07/17/25 at 1:50 PM, R9 did not receive his health shake, pudding, or extra margarine/butter with his lunch.On 07/17/25 at 5:50 PM, R9 did not receive a health shake with his dinner.On 07/21/25 at 6:57 PM, R9 did not receive a health shake with his dinner.8. R11's admission record documents an admission date of 05/31/25 with diagnoses including: cellulitis or right lower limb, cellulitis of left lower limb, chronic obstructive pulmonary disease, severe protein-calorie malnutrition, essential hypertension, chronic pain syndrome, gastro-esophageal reflux disease without esophagitis, schizoaffective disorder, alcohol abuse, depression, and muscle weakness.R11's order summary report documents a dietary order of: regular diet with mechanical soft texture, high protein supplement twice daily between meals, moist soft foods, moistened ground meat, offer health shakes as supplement twice a day, include whole milk at breakfast, and super cereal at breakfast for diet with an order date of 05/31/25 and no end date listed.On 07/17/25 at 1:22 PM, R3 did not receive her health shake with her lunch.On 07/17/25 at 2:43 PM, V3 stated, they did not have super cereal yesterday (07/16/25) for breakfast, so R11 did not receive any super cereal.On 07/17/25 at 5:47 PM, R3 did not receive a health shake with her dinner.On 07/21/25 at 6:53 PM, R3 did not receive a health shake with her dinner.9. R12's admission record documents an admission date of 11/24/21 with diagnoses including: senile degeneration of brain, acquired absence of left leg above the knee, cognitive communication deficit, unspecified intellectual disabilities, anemia, vitamin D deficiency, hyperlipidemia, schizoaffective disorder, dysphagia, anxiety disorder, major depressive disorder, paranoid personality disorder, epileptic seizures related to external causes, hallucinations, and restlessness and agitation.R12's order summary report documents a dietary order of regular texture, assist with meals in dining room, super cereals at breakfast, whole milk at breakfast, nutritional ice cream at lunch and supper, health shakes three times a day with meals, include pudding at lunch, extra butter and gravy with meals with an order date of 09/26/24 and no end date listed.On 07/17/25 at approximately 1:40 PM R12 received a piece of ham that was approximately 1.75 ounces. On 07/17/25 at 1:40 PM, R12 did not receive her health shake, nutritional ice cream, pudding or extra butter and gravy with her lunch.On 07/17/25 at 2:43 PM V3 stated, they did not have super cereal yesterday (07/16/25) for breakfast, so R12 did not receive any super cereal.On 07/17/25 at 5:25 PM, R3 did not receive a health shake with her dinner.On 07/21/25 at 6:26 PM, R3 did not receive a health shake with her dinner.10. R13's admission record documents an admission date of 05/18/17 with diagnoses including: anemia, altered mental status, unspecified severe protein calorie malnutrition, essential hypertension, muscle weakness, vitamin B12 deficiency anemia due to intrinsic factor deficiency, hypocalcemia, age related cognitive decline, ocular hypertension, left eye, and cognitive communication deficit.R13's order summary report documents a dietary order of: regular diet with regular texture, offer whole milk with meals, snack three times a day, health shake two times a day, in between meals, super cereal at breakfast, whole milk with all meals, med pass 90cc (cubic centimeters) and health shake with all meals with an order date of 07/22/24 and no end date listed.R13's order summary report documents a dietary order of house supplement two times a day for supplements, (nutritional) shakes in between meals with an order date of 02/01/25 and no end date listed.On 07/17/25 at approximately 1:40 PM R13 received a piece of ham that was approximately 1.75 ounces. On 07/17/25 at 1:40 PM R13 did not receive her health shake or whole milk with her lunch.On 07/17/25 at 2:43 PM V3 stated, they did not have super cereal yesterday (07/16/25) for breakfast, so R13 did not receive any super cereal.On 07/17/25 at 5:45 PM, R13 did not receive a health shake with her dinner.On 07/21/25 at 6:56 PM, R13 did not receive a health shake with her dinner.On 07/23/25 at 9:47 AM, V18 (Registered Dietician) stated, Even on an emergency menu, I expected all extra sauces, butters, supplements, super cereals and all other interventions that have been indicated to be given. At all times I expect all supplements and interventions to be provided.The facility policy dated 09/2017 titled, Weight Assessment and Intervention documents: the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Interventions: 1. Interventions for undesirable weight loss may be based on careful consideration of the following: g. the use of supplementation and/or feeding tubes.

Based on interview, observation, and record review the facility failed to provide an adequate number of dietary staff to serve dinner in a timely manner. This failure has the potential to affect all 51 residents that reside at the facility.Findings include:The Resident List Report dated 07/17/25 documents 51 residents currently reside at the facility.On 07/17/25 at 2:47 PM, V1 (Administrator) stated, dinner is at 5:15 PM.On 07/17/25 at 2:47 PM, V3 (Business Office Manager/Acting Dietary Manager) stated, lunch is at 12:30 PM and dinner is at 5:15 PM.On 07/21/25 at 3:40 PM, V1 (Administrator) stated they had two kitchen staff members (V8 and V9 (Dietary Aides) not show up for work Sunday night (07/20/25). V1 stated, V6 (Dietary Aide) was called in to work.On 07/21/25 at 4:05 PM V6 (Dietary Aide) stated, she was called in to work on 07/20/25 and there were no other dietary staff present. V6 stated there were Certified Nurse Aides in the kitchen cooking grilled cheese and spaghetti sauce with meatballs. V6 stated, she received a text at 3:16 PM on 07/20/25 to see if she could come into work. V6 stated, the evening shift usually start about 1:30 PM. V6 stated, she was able to get to the facility at 4:00 PM and she just followed what they were already cooking because they had already started that and dinner was supposed to start at 5:15 PM, in an hour and fifteen minutes. V6 stated, some of the dinners did not go out until approximately 7:30 PM.On 07/21/25 at 4:10 PM, R18 stated, they did not eat until late on Sunday night (07/20/25) and CNA's did help cook because there was no dietary staff for a while. R18 stated, a couple residents did try to help by clearing trays and dishes. R18 was alert and oriented to person, place and time.On 07/21/25 at 4:14 PM, R17 stated she did not get her dinner until 7:38 PM last night (07/20/25) and it was a grilled cheese and some awful spaghetti sauce, but the grilled cheese was good. The CNA's went in and helped in the kitchen. R17 was alert and oriented to person, place and time.On 07/21/25 at 4:20 PM, R6 stated he did not get his dinner until late Sunday night, it was probably almost two hours late. R6 stated, it was grilled cheese and spaghetti sauce he thinks. R6 was alert and oriented to person, place and time.On 07/21/25 at 4:30 PM, R9 who was alert to person, place and time stated, dinner was late last night.On 07/21/2025 at 2:00 PM, V6 was the only person in the kitchen.On 07/21/25 at 3:05 PM, V6 was the only person in the kitchen.On 07/21/25 at 4:07 PM, V6 was the only person in the kitchen.On 07/21/25 at 4:12 PM, V1 stated there is more than one staff scheduled to be in the kitchen. V1 stated the second person is scheduled at 1:30 PM.On 07/21/25 at 4:12 PM (after surveyor asked where the second person was) V1 stated, let me text them and see if they are coming. V1 stated dinner is at 5:15 PM.On 07/21/25 at 5:00 PM, V6 was the only person in the kitchen.On 07/21/25 at 6:27 PM the first tray was served, at 6:58 PM hall trays were started to be served.The undated document titled, Meal Times documents: breakfast 7:30 AM, lunch noon, and dinner 5:30 PM.The Facility Assessment Tool dated 05/31/25 documents: average daily census 50, under the section titled, Staffing Plan the category listing: other (e.g. (example), department heads, nurse educator, quality assurance, ancillary staff in maintenance, housekeeping, dietary, laundry) the box is blank.The facility policy revised 07/2017 titled, Resident Nutrition Services documents: 2. Residents shall receive prompt meal service and appropriate feeding assistance. Reasonable efforts will be made to accommodate resident choices and preferences.

Based on observation, interview and record review the facility failed to prepare and distribute food in accordance with professional standards of food safety and failed to maintain appropriate sanitizer levels in the dish machine to prevent foodborne illness. This has the potential to affect all 51 residents living in the facility. Findings include:The facility, Resident List Report dated 07/17/25 documents there are 51 residents currently residing at the facility.On 07/17/25 at 11:45 AM, V1 (Administrator) stated the kitchen is currently closed down by the health department for pests and needing cleaning. V1 stated they are hoping the health department will open the kitchen today. V1 stated, the health department stated they could grill outside, they could just not use the kitchen.The Food Establishment Inspection Report dated 07/15/25 documents item #38 observation: live roach observed at time of inspection that crawled into the square mechanical/electrical compartment above the dish machine drain. General Comments: due to the number of foodborne illness risk factors and public health intervention violations as well as wastewater back up and live pests, the food service permit for (facility name) has been suspended until further notice. You are to cease operations immediately.On 07/23/25 at 8:20 AM, V16 (Local Health Department Inspector) stated she did not say the facility could grill outside and prepare the food in a different room at the facility. V16 stated, she asked V1 if they were getting food from outside, and that it was coming in to go containers, and she was told yes.On 07/17/25 at 11:50 AM, V3 (Business Office Manager/Acting Dietary Manager) stated, they grilled dinner outside on the grill last night (07/16/25) and breakfast that morning outside on the grill.On 07/17/25 at 11:30 AM, V17 (Dietary Cook) was grilling ham slices and warming baked beans on a residential sized grill on a grill outside the facility. At that time V17 stated he was directed by V1 to grill lunch outside and bring it inside and serve it.On 07/17/25 at 12:05 PM, V1 stated all trays were going to be staged and served from the room down the hall from the dining room. V1 stated, that is where they served breakfast from. This was a larger room that contained two eight foot white foldable tables, no handwashing sink or dish washing sinks.On 07/17/25 at 12:15 PM the food staging room contained a container of thickener sitting on one of the white tables with a scoop sitting in the container of thickener.On 07/17/25 beginning at 1:10 PM the first tray was served for lunch; all trays were sent out from the food staging room that was a side room approximately 20 feet down the hall from the dining room.On 07/17/25 between 1:10 PM and 2:23 PM all residents trays were served without any of the drinks covered.On 07/17/25 at 2:25 PM, V3 stated all items on every tray should have been covered, since every tray should have been treated as a hall tray.On 07/21/25 at 5:35 PM, V1 transferred ice to the residents glasses using her gloved hand after touching the ice machine, ice machine lid, and the ice scoop handle without any glove change or any hand hygiene in between.On 07/22/25 at 12:20 PM, V11 (Dietary Aide) transferred glasses onto the residents trays by the rims after touching the health shake cartons, the cooler door, and the gallon milk container with no hand hygiene in between.On 07/22/25 at 3:40 PM, the dish machine sanitizer was tested and measured 10 ppm (parts per million) chlorine.On 07/22/25 at 3:40 PM, V6 (Dietary aide) stated, the chlorine should be reading at least 50 ppm. V6 stated, she had not tested it yet today, she would think the morning shift had tested it. On 07/23/25 at 9:47AM, V18 (Registered Dietician) stated, when she was called and asked about an emergency menu, she reiterated they need to make sure safe temperatures were maintained, food was handled safely and prepared sanitarily. V18 stated she was told by V1 that the kitchen was shut down not that their food permit was suspended, so she directed as per the information she was given.

Based on interview, observation, and record review the facility failed to provide a clean, safe, sanitary environment for 14 residents of 14 residents (R1, R2, R3, R4, R6, R8, R9, R10, R11, R12, R13, R14, R15 and R16) reviewed for environment in a sample of 18.Findings include:On 07/17/25 at 3:10 PM, the air vent in the ceiling in the hall right outside a room where the meal trays were being staged and approximately 20 feet from the dining room on the North Hall, had a black substance covering approximately 50 % of the vent. On 07/17/25 at 2:58 PM, there was a black substance on the ceiling tiles around the air vent and on the air vent after the doorway leading to the North Hall. The black substance went from the vent to the wall on the right side of the ceiling on the other side of the entryway to the North Hall.On 07/17/25 at 4:40 PM, V2 (Director of Nursing) stated, she has seen mold or a black moldlike substance on the North Hall. She believes she brought it to V1's (Administrator) attention Tuesday (07/15/25) morning. V2 stated, it should be cleaned.On 07/21/25 at 10:05 AM, the same air vent in the ceiling in the hall right outside a room where the meal trays were being staged and approximately 20 feet from the dining room, had a black substance covering approximately 50 % of the vent. A Resident List provided by the facility dated documents, R1, R2, R3, R4, R6, R8, R9, R10, R11, R12, R13, R14, R15 and R16 reside on the north hall.The facility policy dated 06/2009 titled, Cleaning and Disinfection of Environmental Surfaces documents: environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens standard.

Based on interview, observation and record review the facility failed to provide food that appeared palatable and attractive for 7 of 7 residents (R2, R3, R6, R8, R10, R15, and R16) reviewed for dining in a sample of 18.Findings include:1. On 07/17/25 at 1:10 PM the individual serving of pureed ham was microwaved in a paper product bowl, the pureed ham was dry looking, crusty around the edges and a grayish color after being microwaved to be heated to a servable temperature. The microwaved pureed ham was served to R3, R10, R15, R16. R3's order summary report documents a dietary order of regular diet with a pureed texture with an order date of 05/20/25 and no end date listed.R10's order summary report documents a dietary order of regular diet with a pureed texture, whole milk three times a day, health shake three times a day, nutritional ice cream with lunch and supper, super cereal at breakfast, ice cream two times a day, melted margarine to hot sides at lunch and supper, offer pudding three times a day, 1 scoop of protein powder at all meals with an order date of 01/15/25 and no end date listed.R15's order summary report documents a dietary order of regular diet with a pureed texture and double desserts with all meals with an order date of 11/26/24 and no end date listed.R16's order summary report documents a dietary order of regular diet with a pureed texture, super cereal at breakfast, whole milk three times a day with meals, extra margarine/butter, sauces/gravies all meals with an order date of 10/19/24 and no end date listed.On 07/17/25 at 2:38 PM, V3 (Business Office Manager/Acting Dietary Manager) stated, the pureed food did not look appetizing after being microwaved.On 07/23/25 at 11:35 AM, V1 (Administrator) stated, the pureed ham did not look appetizing after being microwaved. 2. R2's Minimum Data Set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) score of 12 indicating resident is moderately impaired.R2's order summary report documents a dietary order of regular diet with mechanical soft texture, ground meat extra gravy, nutritional shakes two times a day, 1 scoop protein powder in oatmeal at breakfast, vanilla pudding at supper, nutritional ice creams two times a day. Assist with meals in dinning room and whole milk at breakfast for diet with an order date of 07/22/24 and no end date listed.On 07/17/25 at approximately 1:01 PM, V4 (Dietary) ground the ham and mixed mayonnaise in with the ground ham, the ham was scooped onto paper plates with the baked beans and microwaved to reach 145 degrees Fahrenheit.On 07/17/25 at approximately 1:01 PM, V4 stated she is going to mix mayonnaise in with the ham to make the mechanical soft ham because they do not have any gravy for the mechanical soft ham. On 07/17/25 at approximately 1:28 PM, R2 was served her lunch of mechanical soft ham, baked beans and applesauce.On 07/17/25 at 3:10 PM R2 stated, lunch was not enough food, she had asked for something else, but she did not get it. R2 stated, the lunch meal was awful. R2 was alert and oriented to person, place and time.3. On 07/17/25 at 1:50 PM the individual slices of ham were microwaved to bring the ham up to temperature and appeared dry and burnt around the edges.On 07/17/25 at 3:02 PM, R6 stated the food for the last two days has been messed up and sucky! R6 was alert and oriented to person, place, and time.On 07/17/25 at 5:45 PM, R8 stated dinner tonight is much better than dinner last night. Last night was not good. R8 stated, the ham today was no good either. The ham was dry and burnt. R8 was alert and oriented to person, place, and time.On 07/23/25 at 11:40 AM, V1 stated she does not know how she expected to have food prepared for 51 residents, with sides and gravy and brought to the appropriate temperature on a residential sized grill. It was poor planning. The facility policy dated 07/17 titled, Resident Nutrition Services documents: 4. Nursing personnel or feeding assistants will inspect food trays as they are delivered to ensure that the correct meal has been delivered, that the food appears palatable and attractive, and it is served at a safe and appetizing temperature.

Failures at this level require more than one deficienct practice statement. A. Based on observation, interview, and record review the facility failed to ensure a resident with dementia and a diffuse traumatic brain injury was adequately supervised to prevent elopements and failed to develop and implement new interventions to prevent elopements for 1 (R22) of 2 residents reviewed for supervision in a sample of 42. This failure resulted in R22 exiting the facility multiple times without staff knowledge, including on an unknown date in October or November of 2024 in which R22 walked approximately 0.8 miles from the facility down a busy street and across a busy highway in town, and was later located by facility staff walking around a business parking lot. This failure resulted in an Immediate Jeopardy. An Immediate Jeopardy situation identified to have begun on 06/15/2024, when R22 exited the facility without supervision and the facility failed to investigate the incident and failed to implement new interventions to prevent R22 from eloping. V1 (Administrator) was notified of the Immediate Jeopardy on 2/4/25 at 3:13 PM. The surveyor confirmed by observations, interview, and record review, the immediacy was removed on 02/4/2025, the facility remains out of compliance at a severity level two due to additional time needed to evaluate implementation and effectiveness of training. Findings Include: a) R22's Admission Record with a print date of 1/30/25 documents R22 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia, diffuse traumatic brain injury, major depressive disorder, anxiety disorder, and insomnia. R22's MDS (Minimum Data Set) dated 11/7/24 documents R22 has a moderate cognitive impairment. This same MDS documents under Section E-Behavior, R22 has a behavior of wandering and the wandering placed R22 at significant risk of getting to a potentially dangerous place. R22's Elopement/Wandering risk assessments dated 2/9/24, 5/7/24, 8/8/24, and 11/6/24 document R22 is at risk for elopement. R22's Progress Notes document the following: 2/10/24 8:43 AM, At approximately 0843 (8:43 AM) this writer was informed that resident was outside. Resident was escorted back inside facility. Resident came inside willingly. Full facility count was initiated, and it was confirmed that only this resident was outside. A head to toe assessment completed with no new skin issues noted or reported at this time, vital signs assessed, stable and recorded in EHR (Electronic Health Record). Resident was wearing Tie Dye shirt with grey sweat pants, non-skid footwear and a reflective vest, Administrator, DON (Director of Nursing), and MD (Physician) notified with NNO (no new orders) at this time Outside temp (temperature) 42 degrees, clear and sunny, Resident is currently in his room resting. Signed by V44 (Former DON/Director of Nurses) 6/15/24 9:31 AM, (R22) found in the parking lot by staff on arrival to facility. (R22) brought in by said staff and informed this nurse. Resident is well appearing. No scratches, no bruises, no injuries observed. Resident seen by this nurse approximately 30 minutes prior. Residents nurse and administrator notified. Signed by V45 (RN/Registered Nurse) 6/24/24 3:46 PM, Resident elopes through north hall emergency exit door. 2 staff ran to door upon alarms. The resident had already gotten to church parking lot by the time staff reached the resident. Signed by V45 (RN) 7/13/24 11:58 AM, Resident exited facility and was returned safely by staff. Head to toe assessment performed. All body systems are at baseline. No trauma to skin. All vitals WNL (within normal limits). Resident given ice water and re-educated that he needs staff to accompany him when going outside. Resident currently in his room being assisted with breakfast meal. Call light within reach. Signed by V45 (RN) 10/27/24 9:04 AM, Resident exits the building today. His 101 (sic) sitter was right behind him when he exited. Resident was redirected into the building safely. Skin assessment performed. No skin integrity issues present. Signed by V45 (RN) 11/21/24 8:52 AM, Resident exited the building and was returned safely by staff. Skin assessed. No injuries and skin intact. Provider notified. Vitals WNL. Signed by V45 (RN) This surveyor attempted to contact V45 (RN) who no longer works at the facility on 1/29/25 at 1:20 PM and again on 2/3/25 at 9:31 AM, with no answer. This surveyor requested a return call with each attempt and no return call was received. On 1/28/25 at 8:23 AM, R22 walked into the beauty shop where the surveyors were working. There was no staff present with R22 at this time. R22 then left the beauty shop by himself and walked to the south hall where an unknown staff member saw R22 wandering around and took R22 to the front of the building by the reception desk. The unknown receptionist gave R22 a donut and then an unknown staff member walking in the door put on a mask and took R22 with her to his hall. R22's Progress Notes document on 1/29/25 at 7:14 AM, At approximately 0707 (7:07 AM) this writer was informed that resident was outside. Resident was escorted back inside facility by staff. Resident came inside willingly. Full facility count was initiated, and it was confirmed that only this resident was outside. A head to toe assessment completed with no new skin issues noted or reported at this time, vital signs assessed, stable and recorded in EHR. Resident wearing blue shirt with blue sweat pants, non-skid footwear and a reflective vest, Administrator, DON, and MD notified with NNO at this time. Outside temp 40 degrees, clear and sunny. Resident is currently in his room resting in his bed. Signed by V23 (RN/Registered Nurse) On 1/29/25 at 12:19 PM, when asked if she did investigations on elopements, V1 stated she did not think she had any official documentation. V1 stated the tracking and trending they do for R22's elopements include reviewing the care plan and discussing them in the daily QA (quality assurance) meetings. The facility Daily QA (Quality Assurance) Meeting Notes included multiple pages and handwritten dates with no year documented on some of them. The QA Meeting notes document the following under Resident Behaviors. 6/17/24 (R22) out of facility door alarm sounding, seen by staff member, returned without incident 6/25 (initials of R22): North R (right) staff to alarm. 7/15 (initials of R22) South left, staff responded to alarm running, staff caught. 10/28 (initials of R22) North R (right) with 1:1 . 11/22 Admin Add on Notes: (initials of R22): South, turned around with no difficulty. On 1/29/25 at 9:15 AM, V6 (Certified Nursing Assistant/CNA) stated she came to work at 7:00 AM on 1/29/25 and was told R22 had left the facility. V6 stated she didn't know details about what happened. V6 stated she had been told V21 (CNA) was outside and happened to notice R22 in the parking lot. V6 stated it is hard to keep up with R22 while providing care to the other residents. V6 stated R22 has a 1:1 staff member because he likes to get out and she thinks someone is always with R22. V6 stated R22 also wears a safety vest like construction workers wear (reflective) to make R22 more visible. On 1/29/25 at 10:19 AM, V21 (CNA) stated she got to the facility around 7:05 AM on 1/29/25 and saw R22 running around the parking lot. V21 stated R22 was wearing pants, shirts, socks, and had a blanket. V21 stated the doors were not alarming and they were trying to find out which door R22 went out. V21 stated R22 got out of the facility a month or two ago and was walking down the road toward the stop sign by a (2 lane highway). V21 stated she didn't have any other information about that time. According to the website Google.com/maps, (road referenced) is approximately 0.3 miles from the facility. On 1/29/25 at 11:08 AM, V22 (CNA) stated she was responsible for R22 on night shift beginning on 1/28/25 and clocked out at 7:20 AM on 1/29/25. V22 stated she was giving report to the oncoming shift at 7:00 AM and R22 was doing laps around the facility. V22 stated R22 went into a room where they were covid testing staff around 7:10 AM. V22 stated R22 wasn't in his room when she did the walk through with the day shift staff relieving her, but she had just seen him walking around. V22 stated she wasn't aware he was found outside the facility, in the parking lot, until after she clocked out. V22 stated there were no door alarms sounding when she left. V22 stated if R22 had exited through any other hall exit door she wouldn't have heard the alarm. V22 stated she was not aware of R22 exiting the facility without staff supervision any other time. V22 stated R22 doesn't have a 1:1 staff on night shift because they don't have enough staff to provide it. V22 stated most of the time they have enough staff to keep R22 safe and meet the needs of the other residents. V22 stated R22 wears the safety vest at night in case he does elope. On 1/29/25 at 11:24 AM, V23 (RN) stated she works 12-hour night shift (7 PM to 7 AM). V23 stated on the morning of 1/29/25, she was giving report to day shift (V4 LPN/Licensed Practical Nurse) a little after 7:10 AM, when she was notified R22 had exited the facility and was in the driveway/parking lot. V23 stated she didn't hear a door alarm sound. V23 stated she looked at R22 to make sure he didn't have any injuries. V23 stated R22 had eloped before but it had been a while since he had. V23 stated R22 wears a reflective vest they take off when they put his pajamas on at night. V23 stated she had been told they couldn't use the wander guard system since it was considered a restraint. On 1/29/25 at 2:07 PM, V4 (LPN) stated she arrived at the facility around 6:30 AM on 1/29/25. V4 stated she was told R22 had eloped, and administration was checking to see which door he exited and checking the panels to see what alarms were going off. V4 did not have any other information related to this elopement. On 1/29/25 at 10:03 AM, V27 (CNA) stated he wasn't aware R22 eloped on the morning of 1/29/25. V27 stated R22 has a sitter with him, the doors are alarmed, and R22 won't leave the facility. V27 stated R22 has a tracker on his ankle, and they can track him if he would leave. V27 stated anyone who sees R22 should redirect him back to his area. V27 stated if R22 starts walking the sitter follows him but once he takes his medications, he is chill. On 1/29/25 at 11:36 AM, V12 (Maintenance Director) stated he was aware R22 had eloped on 1/29/25 and had already checked all the doors to make sure they were working correctly, and they were. V12 stated he makes daily rounds and hadn't had any door locks/alarms not working. At 11:41 AM on this same date, this surveyor walked with V12 to the exit door located near the beauty shop. V12 opened the door, and it alarmed as it should. This surveyor walked with V12 to see if the alarm could be heard on the halls the residents reside on and/or near the nurse's station. The alarm was no longer able to be heard after turning the corner and prior to reaching the nurse's station and/or resident room areas on the south hall. This surveyor and V12 walked toward the north hall and the alarm sound was no longer able to be heard near the entrance door of the dining room which is prior to the north hall nurse's station and resident room areas. V12 also confirmed he could not hear the alarms. When asked if they couldn't hear the alarms how would staff know someone had exited the facility, V12 stated, he knows they have a 1:1 staff sitting with R22, he wears a reflective vest, and V1 (Administrator) has something on her phone with R22's GPS (Global Positioning System) location. On 1/29/25 at 1:56 PM, V16 (CNA) stated she was not aware R22 had eloped on the morning of 1/29/25. V16 stated she wasn't sure what R22's interventions were to prevent elopement. V16 stated R22 has a consistent one to one staff from 8:00 AM to 3:00 PM but after 3:00 PM he pretty much does his own thing, especially if they are short staffed. On 1/29/25 at 9:28 PM, V24 (CNA) stated R22 doesn't have a 1:1 staff with him on night shift. V24 stated they watch him the best they can. V24 stated it is easy to watch him through the night it's in the morning when they are trying to get people up that is it harder. V24 stated R22 is very smart and has the concept of holding the door until it opens. V24 stated he wears the safety vest so people can see him if he gets out. V24 stated she was working when R22 eloped on 1/29/25 but he wasn't one of her assignments. V24 stated none of the alarms sounded. When asked if she could hear the alarms V24 stated, Not very well. V24 stated R22 is supposed to always have the safety vest on. On 1/29/25 at 9:38 PM, V18 (CNA) stated R22 has a staff member sitting with him throughout the day but not on nights. On 1/29/25 at 4:30 PM, V1 (Administrator) provided this surveyor with the facility undated Self-Identified Quality Assurance Plan of Correction documents, Problem Identified: Exit from facility. Resident did not leave grounds, resident not harmed or emotional upset. Returned to facility without difficulty. 1. Corrective action (s) will be accomplished for those residents found to have been affected by the deficient practice? (R22 initials) was immediately returned to the facility without complication and placed on 1:1 supervision .3. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur? Facility immediately checked all exit doors for alarm function. All alarms functioning and require a key to shut them off. Facility immediately did a resident head count to assure all residents accounted for. All residents were accounted for. Facility interviewed all staff, and no one answered an alarm and shut it off. Facility has educated all staff on duty and will educate all staff who haven't previously been educated for the next three days about monitoring door closure behind them when they come in the facility or when they leave the facility to make sure door closes securely and properly. Facility placed (R22's initials) on 1:1 supervision and will continue until re-evaluate by the IDT (Interdisciplinary Team) to decide if is safe to remove the supervision. Facility contacted the sister and will send referrals to all TBI (Traumatic Brain Injury) facilities that can be located in the state of Illinois. Facility has ordered additional door exit alarms for the three doors that are the furthest from the nurse's station as added precaution. Facility has ordered Stop Sign door guards to be applied at each exit door with the exception of the front lobby door where visitors and staff enter and exit many times a day. Staff will be educated to not remove the door guards. 4. How will you monitor the corrective action (s) to ensure the deficient practice will not recur .Admin (administrator), DON, and/or designees will do random observations of at least one staff member entering and exiting the facility a minimum of 5 times per week for 4 weeks. Admin, DON, and/or designees will do random observations of Stop Sign door guards properly applied to each exit door a 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 educational needs discussed as need by the Facility Administrator, DON, and or designee. Completion Date: 1/29/25. The untitled document dated 1/29/25 attached to this plan of correction documents 1/29/25 After investigation, IDT concluded that resident (R22) followed an employee out of a door. During investigation all door alarms were checked and functioning properly on 1/29/25. In addition, door alarms are checked daily by maintenance or designee. IDT identified QAPI (Quality Assurance and Performance Improvement) and implemented staff in-servicing immediately. On 1/30/25 at 12:02 PM, V28 (Family Member) stated the facility hadn't communicated with her at all recently. When asked how long it had been since the facility had called her with an update, V28 stated it had been a couple of months since she heard anything from them. V28 stated she was R22's surrogate mom and she was the only one they would contact regarding R22's condition and care. V28 stated she was told awhile back (date unknown) R22 had attempted to escape the facility. V28 stated that is the only elopement she was made aware of. V28 stated she hadn't been contacted by the facility at all the past few days. V28 stated she is concerned with the care R22 is getting because she is the one who always looks after him and she hadn't been getting any communication from the facility. On 1/30/25 at 1:15 PM, V1 (Administrator) stated they have a tracking tag on R22 so if he exits the facility, they call her or the Director of Nursing and they track where R22 is located. V1 stated they don't have a wander guard system because it would be expensive to implement in the building. V1 stated V31 (Social Services Director) was the staff member who contacted V28 (Family Member) after R22's elopement on 1/29/25. On 1/30/25 at 2:00 PM, V31 (Social Services Director) stated R22 eloped once while she was at the facility. V31 stated he made it to the facility parking lot. V31 stated he just gets out and the facility staff get him and bring him back in. V31 stated he doesn't make it very far. When asked if she called V28 (Family Member) to discuss possible placement in a TBI (Traumatic Brain Injury) facility after he eloped on 1/29/25, V31 stated she had not spoken with her and hadn't sent out any referrals. V31 stated she tries to call everyone's power of attorneys who are on her advocate list and V28 had never returned her calls. V31 stated, she (V28) is [NAME] (missing in action). V31 stated she had worked at the facility since 12/2023 and had never had contact with V28. V31 stated she had left a number for V28 to return calls and she had never called her back. When asked if she had attempted to contact V28 after R22 eloped on 1/29/25, V31 stated, No, I haven't tried to call her yet. On 1/30/25 at 10:04 AM, V7 (CNA) stated she had provided care for R22, and he elopes at times. V7 stated they can't hear the door alarms when they go off and R22 moves fast. V7 stated R22 got close to the next town one time and that is when they implemented the reflective vest. V7 stated they also put an air tag on his ankle. V7 stated R22 usually walks to the church located next to the facility. On 1/30/25 at 10:41 AM, R46, who is alert to person, place, and time, stated sometimes R22 will run out of the door. R46 stated R22 looks for food all the time, will take whatever he finds, and eat it. R46 stated R22 has made it out the door, run across the street, and made it into people's houses. R46 stated this occurred about a month and a half ago. R46 stated he also went towards the stop sign located at the corner of Old Murphysboro Road and Tower Road. On 1/30/25 at 1:32 PM, V29 (Medical Records/CNA) stated she had been working when R22 had eloped in the past. V29 stated R22 wanders and has a staff member who sits with him. V29 stated they try to have one 24 hours a day, but it doesn't always work that way. V29 stated R22 isn't afraid to just walk out the door. V29 stated she wasn't working when R22 made it to the next town or into neighboring houses but had heard about it and believes it was more than a year ago that it occurred. On 1/30/25 at 3:07 PM, V32 (CNA) stated R22 usually had a staff member sitting with him from 8 AM to 1 PM or 3 PM. V32 stated when R22 doesn't have a sitter the other aids can't always keep an eye on him. V32 stated most of the time R22 stays in his room. V32 stated the farthest R22 got was down Tower Road toward Old Murphysboro Road. V32 stated one time (date unknown) he did make it to the gym located close to the intersection of Old Murphysboro Road and New Route 13 (4 lane highway). V32 stated she was busy providing care to another resident that day and she thought V33 (CNA Supervisor) was the one who picked R22 up. V32 stated R22 didn't have a staff member sitting with him that day. V32 stated the front door was alarming and they were able to hear it. V32 stated R22 wasn't injured or upset when he returned to the facility. V32 stated she had heard R22 had gotten into the houses across the street from the facility but that was before she started working at the facility in 2023. On 1/30/25 at 3:16 PM, V33 (CNA Supervisor) stated she was working when R22 had eloped in the past. V33 stated R22 usually elopes at shift change when they are getting the residents up in the morning. V33 stated R22 made it to the gym located at the corner of Old Murphysboro Road and New Route 13. V33 stated it occurred around 7:00 AM. V33 was unable to recall the exact date but stated it was in October or November of 2024. V33 stated on that day, she saw R22 make a lap around the unit and when R22 starts wandering, they redirect him back to his room. V33 stated she happened to hear the alarm go off and she knew she needed to look for him. V33 stated she got in her car, and she went one way and other staff went another way. V33 stated she found him wandering around the gym parking lot (located at the intersection of Old Murphysboro Road and New Route 13), with a cup in his hand. V33 stated she got R22 in the car and took him back to the facility. V33 stated another time R22 left, he made it onto Old Murphysboro Road and was found near the funeral home (located 2 miles from the facility). V33 stated R22 had the reflective vest on and that happened a long time ago (unable to provide a date). V33 stated if it's quiet enough they can hear the alarms on the doors. According to the website Google.com/maps, the gym is located 0.8 miles from the facility and would take the average person 16 minutes to walk from the facility to the gym. On 2/3/25 at 10:02 AM, V43 (CNA) stated he remembered R22 exiting the facility without staff. V43 stated R22 likes to go through his bathroom into the adjoining room and out that room's door. V43 stated they immediately mobilized a search party and found him about 15 minutes later. V43 stated he believed it was V33 (CNA Supervisor) who located him that time. V43 was not able to remember the date it occurred but believed it was 2-3 months ago. V43 stated he knew R22 had eloped two other times and was trying to get into someone's residence and someone's car but that was probably two years ago. V43 wasn't sure if R22 had a 1:1 present with those elopements. V43 stated it is very hard to do 1:1 with him if no one is assigned to him. V43 stated it is very hard to keep track of him. On 2/6/25 at 10:22 AM, V51 (CNA) stated she was working when R22 eloped once. V51 stated she believed it was in December of 2024 but couldn't remember the exact date. V51 stated staff heard the alarm on the laundry room door, and all went to see why it was alarming. V51 stated R22 was found in a neighbor's yard by V45 (RN). V51 stated R22 didn't have staff with him and when they located him, he was trying to wrap himself in a blanket. V51 stated she didn't think he was gone long because the neighbors called the facility and believed it happened around 8:00 AM. On 2/6/25 at 9:40 AM, V50 (CNA) stated she was working when R22 eloped in the past. V50 stated she couldn't remember the exact date, but she knows the elopements occurred in 2024. V50 stated it happened twice. V50 stated one of the times (date unknown) she was in or near the dining room when a resident told her the door alarm was sounding on R22's unit. V50 stated as she went around the corner onto the unit, she could hear the alarm and see the door was cracked. V50 stated she spotted R22 across the main busy street, walking on the sidewalk, towards the stop sign located at the intersection of Tower Road and Old Murphysboro Road. V50 stated R22 was alone with no staff with him. V50 stated she yelled his name, and he kept walking. V50 stated she caught up to him close to the intersection, turned him around, brought him back to the facility, and notified nursing. V50 stated the other time she walked to the nurse's station on the north hall and heard the door alarm sounding. V50 stated she quickly walked to the door and when she looked out, she saw R22 outside without staff, walking toward the stop sign. V50 stated she caught up to him close to the intersection. V50 stated she didn't remember the date of these occurrences, but they were both in 2024. On 1/30/25 at 3:51 PM, V44 (Former Director of Nurses) stated she worked at the facility from 2/24/23 to 1/10/25. V44 stated R22 did leave the facility when she was working and he either went out the front door or out the door at the end of his hall and staff were with him. V44 stated when R22 doesn't have a sitter everyone keeps an eye on him. V44 stated they try to keep him away from the beauty shop hall since that door is the farthest away and hardest to hear. V44 stated she doesn't recall R22 ever making it to the gym located on Murphysboro Road and New Route 13. R22's current Care Plan documents a Focus area of (R22) is an elopement risk/wanderer AEB (as evidenced by) Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly, significantly intrudes on the privacy or activities of others. Date Initiated: 05/24/2022. The interventions documented for this Focus Area are, 1:1 sitter x (times) 72 hours. Medication review and adjustments made as ordered. Date Initiated: 06/01/2022 .Hydroxyzine as ordered for anxiety and restless behaviors. Date Initiated: 08/18/2023 .Allow him to sleep longer in the morning and offer snack upon waking up. Date Initiated: 08/21/2022 . Medications times changed, no meds to be given before 9 a.m. Date Initiated: 8/21/2022 .offer a more substantial snack such as peanut butter and jelly or appropriate substitute at bedtime. Date Initiated: 08/21/2022 Offer snack upon waking, Date Initiated: 08/21/2022 .Safety device monitor to right ankle-check for placement every shift and notify management (DON/Director of Nurses, ADON/Assistant Director of Nurses, Administrator) if it is not in place. Date Initiated: 8/11/2023 .Assess for fall risk. Date Initiated: 5/24/2022 Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Likes to listen to music. Date Initiated: 05/24/2022. Documents wandering behavior and attempted diversional interventions in behavior log. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist: Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 05/24/2022. Monitor for fatigue and weight loss. Date Initiated: 05/24/2022. Safety vest on at night. Date Initiated: 12/11/2024. R22's Care Plan/Behavior Tracking Record was reviewed from 1/2024 to 2/3/2025 and documents under Problem Statement, (R22) will wander putting his health and safety at risk. The Goal is documented as, (R22) will be easily redirected in the next review. With Interventions documented as, 1. Point in the direction you would like (R22) to go. 2. Get (R22) snacks/drink. 3. Redirect. 4. Refer to nursing as needed. These same records document R22 wandered 9 days in 1/2024, 6 days in 2/2024, 28 days in 3/2024, 16 days in 4/2024, 22 days in 5/2024, 28 days in 6/2024, 23 days in 7/2024, 30 days in 8/2024, 22 days in 9/2024, 17 days in 10/2024, 30 days in 11/2024, 26 days in 12/2024, 10 days in 1/2025, 2/1, 2/2, and 2/3. Each day R22 wandered has multiple episodes of wandering documented. The facility was unable to provide any behavior tracking specific to elopements. On 01/29/25 at 12:32 PM, V8 (MDS Coordinator) stated she was responsible for updating and implementing interventions on resident care plans. V8 stated R22 didn't have any new interventions implemented to prevent elopements in the year 2024. V8 stated she didn't implement any new interventions because R22 was never out of eyesight of staff. V8 stated she just implemented new interventions when she was directed to by the Administrator and Director of Nursing. When asked what their usual routine was if someone had a new event occur, V8 stated they discuss it in meetings and implement an intervention to try to decrease risk. When asked why they didn't do that each time R22 eloped, V8 stated, I couldn't tell you. V8 stated she didn't remember any details about R22's elopements and she didn't believe any notes were taken when they met. This surveyor reviewed the care plan interventions documented on R22's current care plan and asked V8 if R22 had eloped in December 2024 and if not why was there a new intervention of the safety vest documented on 12/11/2024. V8 stated she would have to check on it. On 1/29/25 at 1:48 PM, V8 (MDS Coordinator) stated the intervention of the vest was implemented before 12/11/24 it just wasn't documented on R22's care plan. V8 stated it was found when the previous regional nurse was doing a review of R22's record and she added it to the care plan. V8 stated she wasn't sure when they implemented the safety vest intervention. On 2/3/25 at 2:07 PM, V1 (Administrator) stated she was not able to locate any other documentation on R22's elopements for the year 2024. V1 stated the IDT (Interdisciplinary Team) had not met yet to determine if R22 was safe to not have a 1:1, 24 hours a day. V1 stated R22 was currently on 1:1, 24 hours a day. When asked why he wasn't on it on the night when I called and spoke with staff V1 stated, Ok. When did you call. This surveyor responded with 1/29/25 and asked again if he had 1:1, 24 hours a day. V1 stated, We are working on it. When asked what that meant, V1 stated, We are working to schedule 1:1, 24 hours a day. When asked does he currently have 1:1 supervision 24 hours a day, V1 stated, I will have to check with the person who does scheduling. This surveyor reviewed with V1 that V31 (Social Services Director) had stated she did not talk with V28 (Family Member) after the elopement on 1/29/25 and had not spoken with her since she started working at the facility. V1 stated they reached out to V28 and V28 didn't answer so they kept calling until they got a hold of her. V1 stated they spoke with V28 on 2/3/25. When asked if she could remember what happened each time R22's progress notes document an elopement, V1 stated possibly after reviewing everything. This surveyor reviewed with V1, the interviews documenting R22 was found at the gym located 0.8 miles from the facility and V1 stated she was not aware of that. This surveyor asked V1 if they should notify the family and physician with each elopement and V1 stated, I would have to check. When asked if she could say why there were no new interventions implemented after each elopement for the year 2024, V1 stated, I cannot. When asked if there should have been new interventions implemented, V1 stated, I am not sure. I will need to check. On 2/4/25 at 8:46 AM, V1 (Administrator) stated she couldn't remember the exact date the 1:1 staff supervision on day shift started for R22, but she believed it was in July or August of 2023. V1 stated they didn't implement that intervention to prevent elopements but had implemented it to keep R22 from taking other residents' food out of their rooms and they didn't set it up to have to be consistent with the time frames that R22 had 1:1 staff but they tried to have them during meal hours. On 01/30/25 at 2:19 PM, V34 (Physician) stated he was not notified that R22 had eloped and did not feel that he was safe in the community alone. V34 stated he was aware R22 had a history of wandering and stealing food but does not recall any communication regarding him leaving the facility. The facility Elopement/Missing Resident Procedure dated 2020 documents, Staff shall investigate and report all cases of missing resident .1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a[TRUNCATED]

Based on interview and record review, the facility failed to ensure physician's orders were followed, for 1 of 5 residents (R55) reviewed for significant medication errors in the sample of 30. This failure resulted in R55 missing three doses of long- acting insulin from 1/17/25 to 1/19/25, causing R55's blood sugars to be extremely elevated. This has the potential to lead to ketoacidosis which could result in coma and possible death. This failure resulted in an Immediate Jeopardy. An Immediate Jeopardy was identified to have begun on 01/17/25 at approximately 9:00 PM when the facility was unable to provide R55's scheduled long-acting insulin and did not notify the physician. The facility also failed to administer R55's long-acting insulin as ordered on 01/18/25 and 01/19/25. V1 (Administrator) and V2 (Director of Nursing), were notified of the Immediate Jeopardy on 02/04/25 at 3:13 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on 02/04/25, but the noncompliance remains at Level Two due to additional time needed to evaluate implementation and effectiveness of training. Findings include: R55's admission record documents an admitted [DATE] and list the following diagnoses in part; vascular dementia, mild with psychotic disturbances and type 2 diabetes mellitus. R55's MDS (Minimum Data Set) dated 01/24/25, documents a BIMS (Brief Interview for Mental Status) of 11, indicating that R55 is moderately cognitively impaired. Section I-active diagnoses documents an active diagnosis of diabetes mellitus. R55's care plan documents an initiation date of 01/28/25 for a focus area that states R55 is at risk for complications r/t (related to) dm (diabetes mellitus). R55's Physician's Order Sheet (POS) documents an order with an order date and a start date of 01/17/25 for Toujeo Solostar Subcutaneous Solution pen-injector 300 Units/ML, (Insulin Glargine) (long-acting insulin), Inject 70 units at bedtime for diabetes mellitus. R55's Physician's Order Sheet (POS) documents an order with a start date of 01/18/25 for Blood glucose per fingerstick as needed for signs/symptoms of hyperglycemia/hypoglycemia. On 01/27/25 at 10:03am, V36 (Family member) stated that they continued to ask the nurse about R55's meds the first couple of days of being in the facility because she wasn't getting all of them or her insulin, they continued to be told they were still working on it. V36 stated staff reported they were still working on her admission through Sunday. V36 stated R55 was not getting her blood sugar checked at meals either. V36 stated that R55 had her blood sugar checked four times a day at the hospital and she had continuous monitoring at home. On 01/29/25 at 12:01pm, V37 (Family member) stated R55 was admitted on Friday 01/17/25 in the evening, and it was a struggle all weekend getting her medications. V37 said that they asked the nurses several times from Friday to approximately Sunday or Monday for R55's medications and insulin's and they kept saying that they were working on getting her admitted still. V37 stated they asked staff several times to check R55's blood sugar around mealtime, which is what she did at home and at the hospital, but no one did. R55's progress notes document that on 01/17/25 and 01/19/25 Toujeo Solostar Subcutaneous Solution pen-injector (Insulin Glargine) (long-acting insulin) was not administered due to awaiting pharmacy delivery. R55's January 2025 Medication Administration Record (MAR) documents a blood glucose finger stick was started and administered by V42 (Registered Nurse/RN) on 01/18/25 and documents a blood sugar of 308. R55's January 2025 MAR documents no signatures on 01/17/25 or 01/19/25 for Toujeo Solostar Subcutaneous Solution pen-injector (Insulin Glargine) (long-acting insulin), indicating it was not administered. R55's January 2025 MAR documents a signature on 01/18/25 for Toujeo Solostar Subcutaneous Solution pen-injector (Insulin Glargine) (long-acting insulin) indicating that it was administered by V46 (Registered Nurse/RN), and a blood sugar of 411. V46 was unavailable for interview to explain how she was able to administer a medication that was not available in the facility or why she documented in the MAR a blood sugar of 411 and did not contact the physician. On 01/30/25 at 09:58am, V41 (Pharmacy medical records) reviewed medication orders for R55. V41 stated a new order was received from the facility for long-acting insulin on 1/17/25. V41 stated an emergency order was called to the backup pharmacy (a local pharmacy) on 1/17/25. V41 stated the order was never picked up by facility. V41 stated on 1/19/25, a nurse from the facility called to ask about it and the pharmacy informed them it was to be delivered later that evening or there was an emergency order called in to the backup pharmacy and they stated they will wait for the delivery. V41 confirmed the long-acting insulin was delivered on 01/19/25. V41 stated the facility would not be able to access their supply without contacting the pharmacy for a code to open the bin the medication was in. On 02/03/25 at 03:43pm, V2 (DON) stated that discharge orders from residents admitted from the hospital are to be put into the computer system as soon as possible, copied and then faxed to the pharmacy. V2 stated if they are not faxed by 8pm, they will not be received that day. V2 stated some medications, including insulin's are kept in the emergency kit in the medication room. V2 stated if they are not in there, they should contact the pharmacy and see if they can bring them on an emergency run or from the backup pharmacy (local pharmacy). V2 stated if it comes from the backup pharmacy, she believes they deliver it. V2 stated she was not aware that R55 missed multiple doses of long-acting insulin before she reviewed her admission packet on 1/20/25 or 1/21/25. V2 stated at that time she contacted V34 (Physician) to see if he wanted R55 to have sliding scale insulin. V2 stated that her process for new admission orders is that two nurses independently review the orders and then she will review the admission packet also. V2 stated she would have expected V34 be contacted with any missed doses of insulin or blood sugars above 300. On 02/03/25 at 12:03pm, V42 (RN) stated the process for admitting new residents with medications, is that the admitting nurse puts the orders in, and if they are not finished by the next shift, the oncoming nurse should finish them. V42 stated if she put an order in for an as needed (PRN) blood glucose fingerstick for R55, it was because it was either on her discharge sheet or ordered by the doctor. V42 stated that she did not notify the doctor of a blood sugar of 308 for R55 because they are not required to. V42 stated if they need medications, they call the pharmacy, if they cannot get them then they should notify the doctor. V42 stated on 01/19/25 when she was taking care of R55, her meds were still not available in the facility and she did not notify the physician. On 02/03/25 at 12:19pm, V4 (License Practical Nurse/LPN) stated when a new admit comes, they get discharge orders and the nurse that receives the resident is to put them in. V4 stated they are then checked by a second nurse and then by V2 (DON). V4 stated this is a new process that was put in place by V2 since she started a few weeks ago. V4 stated the process for obtaining medications is to call the pharmacy and order the medication, see if it is in the emergency supply and then the backup pharmacy. V4 stated she was not sure who's responsibility it was to get meds from the backup pharmacy, but she has seen them come via door dash from a local pharmacy before. V4 stated residents should not miss a dose of insulin and if that were to happen, the doctor should be notified. V2 stated she did R55's admission but could not recall what the situation was with R55's medications when she was admitted . On 01/30/25 at 02:19pm, V34 (Physician) stated on 01/17/25 he was notified late at night about R55 having a drug allergy and order clarification for a medication. V34 stated he was not contacted again until 1/21/25. V34 reviewed his communication with the facility and stated he had not been contacted at all about R55's insulin not being available or blood sugar until 1/21/25. V34 stated he was contacted on 01/21/25 by V2 (Director of Nursing/DON) about orders for sliding scale insulin for R55. V34 stated yes and he directed them to call his office if they were not familiar with his standard sliding scale. V34 stated he would expect to be contacted about any resident, not just a new resident, with a blood sugar of 308 and 411, especially the 411. V34 stated his expectation would also be that they recheck R55's blood sugar after numbers like that. V34 could not say for sure what would have happened or the level of harm that could have happened because everyone responds differently, but that he had not been notified of any of it. V34 stated his expectation would be for R55 to not miss any doses of insulin, especially if there was a script waiting at a pharmacy in town the same day. V34 stated his expectation would be to be notified in those instances. On 02/03/25 at 02:45pm, V26 (LPN) stated she was working on 01/17/25. V26 stated she did not recall the situation with R55 and not receiving insulin. After a review of R55's medication administration record (MAR), V26 verified she did not administer R55's insulin and she recalled being told in report from the day shift nurse that the medication was on its way. V26 stated she could not recall if she notified the doctor or not but should have. On 02/10/25 at 07:51am, V50 (Pharmacy medical records) stated it is the responsibility of the pharmacy couriers to pick up medications filled at the backup pharmacy. V50 stated she had no documentation as to why R55's insulin was not picked up from the backup pharmacy or that anyone from the facility contacted them about R55 until 01/19/25. V50 stated the facility did not attempt to obtain the medication from the Emergency kit for R55. V50 stated when the facility calls in the order to the pharmacy, if it is the emergency kit (E-kit), the pharmacy technician would advise them to pull from E-kit if it were available there. V50 stated the pharmacy technician would then walk them through the process and grant them access to the medication. V50 stated judging by the fact that an order was sent to the backup pharmacy immediately, the medication may not have been available in the E-kit. V50 confirmed there was not R55's type of insulin available in the facility emergency kit from 01/17/25-01/20/25. V50 confirmed there was no correspondence between the facility and the pharmacy from 01/17/25 and 01/19/25 regarding R55's insulin. According to the Mayo Clinic website (https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc-20371551), Diabetic ketoacidosis is a serious complication of diabetes. Under When to See a Doctor it documents Seek emergency care if: Your blood sugar level is higher than 300 milligrams per deciliter (mg/dL), or 16.7 millimoles per liter (mmol/L) for more than one test .untreated diabetic ketoacidosis can lead to death. According to the Center for Disease Control (CDC) website (https://www.cdc.gov/diabetes/about/diabetic-ketoacidosis.html), Diabetic ketoacidosis (DKA) is serious and can be life-threatening. Under Causes it documents Very high blood sugar and low insulin levels lead to DKA. The two most common causes are: .2. Missing insulin shots, a clogged insulin pump, or the wrong insulin dose. Under Testing it documents Go to the emergency room or call 911 right away if you can't get in touch with your doctor and if you're having any of these signs: Your blood sugar stays at 300 mg/dL or above . A facility document titled Administering Medications with a revision date of December 2012 documents under policy statement, Medications shall be administered in a safe and timely manner, and as prescribed. The Immediate Jeopardy began on 01/17/25 and was removed on 02/04/25 when the facility took the following actions to remove the immediacy and correct the deficient practice as confirmed through observation, interview, and record review. 1. 2/4/25 Facility has reviewed the following policies for education and implementation. -Medication Order Policy-Revision made to assure IDT review and reconcile all new admission medication orders within 24 hours of admission. 2. 2/4/25 at 5:30 PM DON educated by the Regional Clinical Director, on the following policies and procedures; Medication Order Policy. IDT to review all new admission medication orders within 24 hours. 3. 2/4/25 at 5:30 PM Staff education on the following policies and procedures by DON and Regional Clinical Director and/or IDT who received train the trainer training listed above. -Medication Order Policy -IDT to review all medication within 24 hours. -Alleged Completion date 2/4/2025 and ongoing prior to working next scheduled shift until 100% of employees are educated. -Clinical department new hires will be educated prior to starting any shifts by a member of the IDT that have been trained to provide the training. 4. 2/4/25 at 3:55 PM Nurses in serviced on Medication Order Policy including but not limited to medication reconciliation with hospital orders upon admission done by V2 (DON) and V39 (LPN). 5. 2/4/25 at 5:00PM IDT team in-serviced on revised Medication Order Policy with emphasis on all new admission orders should be reviewed within 24 hours completed by V8 (LPN, MDS/CP Coordinator) and V2 (DON) V39 (LPN) or clinical designee. 6. 2/4/25 at 5:35 PM. All resident medication order to medications on hand match back began by V3(Regional Director of Clinical Services), V2 (DON), V39 (LPN).

Based on interview and record review the facility failed to ensure a resident was free from neglect when they failed to assess, treat, and implement interventions to prevent pressure ulcers, accurately assess for skin breakdown, discontinue psychotropic medications as ordered by the physician, and provide oral care for 1 of 5 (R12) residents reviewed for neglect in the sample of 19. This failure resulted in R12 being transferred to the local hospital on 12/01/24 for altered mental status and possible sepsis. Once at the hospital it was determined R12 had received Haldol and Clonazepam without a physician order from 11/23/24 until 12/01/24. R12 had developed 15 new wounds including a Stage 2 and Stage 3 to his buttocks, a Stage 2 to the left knee, and two deep tissue injuries to his bilateral heels. R12 also had a buildup of a hardened yellow/brown coating with cracking and fissures noted to be covering the tongue from lack of oral care. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 11/23/24 when the facility failed to 1. Assess R12's skin upon return from the hospital on 11/23/24, 2. Put treatment orders in place for the pressure ulcer identified throughout R12's hospital stay 3. Identify, assess, treat, and notify the physician of the new pressure areas identified on R12's 11/30/24 shower sheet, 4. Discontinue psychotropic medications as ordered on the hospital discharge instructions on 11/23/24, and 4. Provide oral care per current standards of practice. V1 (Administrator) was notified of the Immediate Jeopardy on 12/11/24 at 1:30 PM. The surveyor confirmed by observations, interview, and record review, the Immediate Jeopardy was removed on 12/11/2024, but the noncompliance remains at Level Two due to additional time needed to evaluate implementation and effectiveness of training. Findings Include: R12's Admission Record with a print date of 12/5/24 documents R12 was admitted to the facility on [DATE] with diagnoses that include fracture of left femur, hypotension, diabetes, schizophrenia (diagnosis added on 11/07/24), bipolar disorder (added on 11/07/24) difficulty walking, and muscle weakness. R12's MDS (Minimum Data Set) dated 10/17/2024 documents R12 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R12 is cognitively intact. This same MDS documents R12 required partial to moderate assist for transfers, was independent for bed mobility, and was at risk for developing pressure ulcers. R12's local hospital records dated 12/01/24 documents R12 is more confused upon arrival to the hospital. R12's current Care Plan documents a Focus area of (R12) uses psychotropic medications (Escitalopram) r/t (related to) dx (diagnosis) depression, anxiety. Schizophrenia 10/9/24 Clonazepam for agitation, 10/27/24 Clonazepam increased, 10/29/24 Escitalopram decreased, 11/8/24 Haldol, Date Initiated: 05/03/2024. Interventions for this Focus area include, Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 05/03/2024 . R12's facility Progress Notes document the following: 11/17/24 - At 0700 (7:00 AM) resident was observed to be unresponsive and weak. VS (vital signs): 97.1, 122, 32, sat (oxygen saturation) 70, bp (blood pressure) 139/75. No purposeful movement on the left side. Unable to assess pupils. Ambulance called and resident transferred to (local hospital) ER (emergency room ). MD (physician) and POA (power of attorney) informed. 11/17/24 - Called for an update on the resident. Resident will be admitted IP (inpatient) for aspiration PNE (pneumonia). R12's local hospital record documents R12 was admitted to the local hospital on 11/17/24 and discharged back to the facility on [DATE]. R12's hospital record includes under Secondary Discharge Diagnosis, bed sore on buttock. This same hospital record documents under Hospital Course, .Patient advised to take Augmentin 875 for 3 days post discharge. He was also advised to stop taking Haldol and Clonazepam as the medications were held for the entirety of his admission and he had no psych issues . Under Active Issues Requiring Follow-up and Discharge Plan the hospital records document, .Please stop taking Haldol. Please stop taking Clonazepam . R12's facility Progress Note dated 11/23/24 documents, Resident's Haldol and Clonazepam discontinued by hospital at discharge. Antibiotic added Discharge medication list faxed to (name of pharmacy) and (V14/Physician) office. Provider notified of arrival. R12's facility Order Summary Report Active Orders as of 11/30/24 includes the following physician orders, Clonazepam 0.5 mg (milligrams) Give 0.5 mg by mouth three times a day for anxiety, with a start date of 10/27/24 and Haloperidol (Haldol) oral tablet 5 mg Give 5 mg by mouth three times a day related to schizophrenia, unspecified; bipolar disorder unspecified, with a start date of 11/08/24. There is no end or discontinue date documented for either physician order. R12's Progress Notes dated 11/24/24 at 2:57 PM signed by V18 (RN/Registered Nurse) documents, Clonazepam Tablet 0.5 MG, give 0.5 mg by mouth three times a day for anxiety Resident's medication was dc'd (discontinued) at the hospital. Reaching out for clarification on medication. R12's Medication Administration Record (MAR) dated 11/01/24 to 11/30/24 documents an order for Clonazepam 0.5 mg to be administered at 9:00 AM, 2:00 PM, and 9:00 PM. This MAR documents initials indicating Clonazepam 0.5 mg was administered at 9:00 PM on 11/23, 11/24, 11/26-11/30, at 9:00 AM 11/24-11/30/24 and at 2:00 PM 11/26-11/30/24. This same MAR documents the Clonazepam was held at 2:00 PM on 11/24 and 11/25/24. This indicates upon R12's return to the facility the Clonazepam was administered 20 times and held three times. This same MAR documents an order for Haldol 5 mg to be administered at 9:00 AM, 2:00 PM, and 9:00 PM with initials documented indicating R12 was administered Haldol at each dose time from 11/23/24 to 11/30/24. On 12/16/24 at 12:37 PM, V18 (Registered Nurse/RN) stated she was responsible for readmitting R12 to the facility after his return from the hospital on 11/23/24. V18 stated she charted the Haldol and Clonazepam had been discontinued in the progress notes. V18 stated when she returned to work the next day, she noticed they were still active on R12's medication list so she held them waiting for clarification. V18 stated she spoke with the night shift nurse (V19/RN) who said she had taken care of it and the medications were reinstated so she assumed the physician had given an order to resume them. On 12/28/24 at 10:00 AM, V19 (RN) stated V18 was the day shift nurse when R12 returned from the hospital, and she (V19) was the oncoming night shift nurse. V19 stated V18 reported to her R12's medications were discontinued by the hospital. V19 stated R12 doesn't have any medications ordered on night shift other than Tylenol. V19 stated she did not call the physician to clarify the medication orders from the hospital discharge. V19 stated she wouldn't have had a reason to look at those medications and/or orders since R12 didn't take medications on her shift and V18 had reported to her they were discontinued. On 12/4/24 at 2:35 PM, V5 (CNA/Certified Nursing Assistant) stated mid-November, R12 stopped eating, started refusing care, and became a two person assist. V5 stated it was a change in R12's condition and it worsened when he came back from the hospital on 11/23/24. V5 stated R12 would get up for meals before he went to the hospital and when he came back, he would barely eat and/or drink and even stopped yelling down the halls. V5 stated she reported this to an unknown nurse, and she thought the nurse assessed R12 and documented it. On 12/9/24 at 12:50 PM, V2 (DON/Director of Nurses) stated the Haldol and Clonazepam were started because R12 had extreme behaviors. V2 stated after it was discontinued at the hospital, she assumed V15 (Psychiatric Nurse Practitioner/Psych NP) had resumed the order when he returned to the facility and that was why he was still getting the medications. On 12/9/24 at 1:02 PM, V15 (Psych NP) stated the facility did not notify her R12 had been to the hospital and/or that the medication had been discontinued by the hospital physicians. V15 stated she looked back at her communication with the facility, and she got a message R12 needed a refill on his Clonazepam but was never notified by the facility the medication had been discontinued. V15 stated she hadn't seen R12 since 10/24/24 and her expectations would be that if a medication were discontinued while the resident was at the hospital it would stay discontinued when they returned to the facility. R12's Braden Scale dated 11/10/24 documents a score of 14, which indicates R12 is at moderate risk of skin breakdown. R12's Braden Scale dated 11/24/24 documents a score of 12, which indicates R12 is at high risk of skin breakdown. R12's current Care Plan documents a Focus area of (R12) is at risk for skin breakdown r/t (related to) requires assist with bed mobility, frequently incontinent of B & B (bowel and bladder). Has left side neglect. Date Initiated: 05/16/2024. This Focus area includes the following interventions, 10/30/24 cover spokes on left side of w/c (wheelchair) .8/27/24 Pad bed frame. This same focus area includes the following interventions initiated on 5/26/24, assist T & P (turn and position) at least every 2 hours and prn (as needed) Educate resident/family/caregivers of causative factors and measures to prevent skin injury Encourage good nutrition and hydration in order to promote healthier skin Follow facility protocols for treatment of injury .Keep skin clean and dry. Use lotion on dry skin . Monitor/document location, size and treatment of skin injury, if occurs. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to MD (physician) Offer toileting/check every 2 hours and prn (as needed) provide peri-care as needed Pressure relief mattress on bed and cushion in w/c (wheelchair) as preventative . Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface . R12's Order Summary Report Active Orders as of 11/30/24 documents a physician order for weekly skin checks with no orders documented for treatments to specific areas of skin breakdown and/or orders for interventions to prevent skin breakdown from 11/23/24 to 12/01/24. R12's Progress notes document. 11/23/24 12:49, Report received from (name of local hospital). Resident will be arriving today by EMS (emergency medical services). Resident is a Mechanical soft diet with thin liquids by mouth. Family declined to have resident's code status changed to comfort measures and will remain full code with current plan of care with an addition of PO (oral) abx (antibiotic). 11/23/24 15:51, Resident arrives at this time via EMS. R12's Initial Skin Alteration Record signed by V18 (RN), dated 11/23/2024 documents under Site, Resident refusing skin assessment, yelling to leave him alone. Able to assess visible skin. Resident pushing away this nurse when trying to assess. Wound [NAME] found (sic) to BUE (bilateral upper extremities). Several bruises and skin tears present Comments- healing skin tears to left arm noted. no signs of infection observed. resident not in pain at this time. this nurse unable to complete a head to toe assessment as resident was screaming no and resisting with physical pushing away of this nurse. Treatment Plan .Monitor skin tears . There are no measurements, assessments, or physician notification documented on this assessment. R12's medical record did not document any Initial Skin Alteration Records after 11/23/24. On 12/5/24 at 11:16 AM, V18 (Registered Nurse) stated she was working on 11/23/24 when R12 returned from the hospital. V18 stated she attempted to do a skin assessment, but he was resisting, and she didn't want to cause him distress. V18 stated she did see the dressings that had been applied at the hospital and looked under them and didn't see any open areas. V18 stated she meant to put an order in to remove and replace them every three days and just forgot to do it. When asked what interventions were implemented to prevent skin breakdown, V18 stated he had a pressure reducing mattress on his bed and a cushion in his chair. V18 stated they floated his heels and would try to reposition him hourly. R12's Weekly Skin Check dated 11/24/24 not signed until 12/04/24 by V18 (RN) documents under Site: Left antecubital- Resident refusing skin assessment, yelling to leave him alone. Able to assess visible skin. Resident pushing away this nurse when trying to assess. Wound found found (sic) to BUE. Several bruises and skin tears present Comments: healing skin tears to left arm noted, no signs of infection observed. resident no in pain at this time. This nurse unable to complete a head-to-toe assessment as resident was screaming no and resisting with physical pushing away of this nurse. will continue to monitor. This is the same narrative that was documented in R12's Initial Skin Alteration Record dated 11/23/24. On 12/9/24 at 9:59 PM, when asked if she completed the Weekly Skin Check dated 11/24/24, V19 (RN) stated R12 was sitting in his wheelchair, and she noticed the area on his arm was healed. V19 was asked if she assessed any other skin on R12 and she stated, No, I just looked at his arm. V19 stated they have another nurse who does all the treatments for south side. This surveyor reviewed with V19 that R12 wasn't located on that side and V19 stated she thought he was. This surveyor then asked V19 if she did a physical assessment of R12's skin from 11/23/24 until 12/01/24 and if she completed the 11/24/24 Weekly Skin Check and V19 stated, I don't remember. I usually just ask the CNA if the residents have any skin changes. On 12/9/24 at 12:50 PM, this surveyor reviewed the 11/23/24 initial skin assessment and the 11/24/24 weekly skin assessment with V2 (DON) and she stated the 11/24/24 assessment looks like it was copied and pasted from the 11/23/24 assessment. R12's Skin Monitoring: Comprehensive CNA Shower Review documents dark bruising to R12's left arm, heels as red, coccyx as dark red, a bandage to the inside of his inner right leg and a bandage on his left hip with V17's (CNA) signature dated 11/30/24. This Review documents V2 (DON's) signature with a date of 11/30/24 with no assessment of the new areas documented under Nurse Assessment. On 12/5/24 at 8:37 AM, V17 (CNA) stated R12's condition had declined when he returned from the hospital on 11/23/24. V17 stated R12 wasn't eating, drinking, and/or communicating as well. V17 stated she gave R12 a bed bath on 11/30/24 and found a bandage on his left hip that was looking a little rough. V17 did not remember if there was a date on the bandage that would indicate when it was placed. V17 stated when she rolled R12 over she noticed R12's coccyx was dark red, and his right hip was splotchy in color. V17 stated she was concerned R12 was mottling and then she removed his socks and noted that both of his heels were dark red as well. V17 stated there was a bandage on R12's inner thigh that didn't look as bad as the one on his left hip, but she again didn't know if there was a date on it. V17 stated she didn't remove the bandages, so she didn't know what his skin looked like under them. V17 stated she documented the areas on the shower sheet and told V2 (Director of Nurses) who was working as her nurse that night. V17 stated she told V2 she was worried R12 was dying and that his family needed to be notified. V17 stated she also reported the change in R12's condition to the oncoming shift and her supervisor (V21/CNA Supervisor). V17 stated R12 was sent out to the hospital two days later so she assumed someone heard her concerns. When asked what interventions were in place to prevent the pressure injuries from worsening, V17 stated there was a pillow under his left hip that was always there because of previous skin issues but that was the only intervention in place. V17 stated R12 was clean and dry when she changed him and that he was dependent on staff for all care. On 12/5/24 at 1:48 PM, V21 (CNA Supervisor) stated V17 told her R12's skin looked bad, but she didn't remember the date this occurred. V21 stated she asked V17 if she had reported it to the nurse and V17 told her she reported it to V2 (DON). On 12/5/24 at 12:04 PM, V2 (DON) stated she didn't remember signing off on the 11/30/24 shower sheet that documented the new areas of skin breakdown for R12. V2 stated she was working the floor that day and was told she had to get skin assessments on all the residents. V2 stated she attempted to get other nurses to assist her with it and was not able to get anyone to assist. V2 stated V17 (CNA) helped her by doing skin assessments and documenting them on the shower sheets. V2 stated she knew R12 was declining, not getting out of bed, not eating, and not drinking. V2 stated, I am really pi**ed off at myself and the building because I had zero help except for the CNA's who can't make calls or write orders. It can't be just me. I don't have any help at all. When asked if she ever assessed R12's skin, V2 stated, No. V2 stated the skin assessments were done on Sunday 11/30/24 but she didn't sign them until Monday, December 01, 2024. V2 stated she wished V17 had told her on Friday, how bad R12's skin was. When asked to clarify if R12's skin was assessed on Friday 11/29 or Saturday 11/30, V2 stated they were working midnight shift, and she wasn't sure if it was before or after midnight. V2 stated it was miscommunicated and they missed it. V2 stated if she had done R12's skin assessment she would have notified the physician and obtained orders for treatments. V2 stated they recognized there was an issue and have put things in place to make it better. V2 stated they are checking each morning during clinical rounds to make sure skin assessments are being done. V2 stated R12 should have had a head-to-toe assessment on 11/23/24 when he returned from the hospital and again before he went back to the hospital on 12/01/24. On 12/5/24 at 11:16 AM, V18 (Registered Nurse) stated she followed R12 closely even when she wasn't his nurse. V18 stated he wasn't eating well, and his oxygen dependence was increasing. V18 stated R12 didn't start showing skin breakdown until 11/30/24 and she was working on the other side that day. V18 stated she told his nurse she would be over there the next day and would look at him then. On 12/9/24 at 10:18 PM, V24 (CNA) stated she provided care to R12 between 11/23/24 and 12/01/24. V24 stated R12 was incontinent of bowel and bladder and was not able to turn and reposition himself. When asked what interventions were implemented to prevent pressure ulcers from developing, V24 stated they were turning and repositioning R12 and using pillows for support. V24 stated she was aware of the areas of skin breakdown on R12, and he had them for probably a couple of weeks. R12's facility Progress Notes document: 11/30/24 - 1907 (7:07 PM) Resident has a loss of appetite and motivation. Resident continues to take medication but not showing any improvement. This nurse will continue to monitor. Reported to nightshift nurse. If not showing improvement by mid shift tomorrow, will reach out to provider for further intervention. 12/01/24 - 14:06 (2:06 PM) Resident still not doing well and declining. Despite antibiotics, resident has not eaten in two days, has crackles throughout lung fields, febrile at 102.8 F (Fahrenheit), today extreme lethargy to the point where nursing judgement is that it is not safe to give PO (oral) medication. EMS (Emergency Medical Services) called for emergent send out for possible sepsis. Provider and POA (Power of Attorney) notified. Vital signs as follows: 154/64, pulse 138, respirations 28 and shallow with crackles and wheezes, Temp (temperature) 102.8, post Tylenol, O2 (oxygen) at 91 on 4 L (liters). 12/01/24 - 4:26 PM, (R12) admitted IP (in patient) for AMS (altered mental status) and sepsis r/t (related to) aspiration PNE (pneumonia). R12's local hospital records dated 12/01/24 documents Patient presents from the nursing home for altered mental status. He is somnolent. This hospital record documents under ED (Emergency Department) Triage notes, Per EMS, pt (patient) was recently discharged with pneumonia. Pt had a temp of 103.6 F, Tylenol was given at nursing home. Heart rate 130's and more confused this morning. Pt localizing to pain and shaking head to questions. Labored breathing. skin warm, Dry. mouth is extremely dry The physical exam dated 12/01/24 documents R12 is ill appearing and lethargic. Under Clinical Impression it documents, Altered mental Status, unspecified altered mental status type. Sepsis without acute organ dysfunction, due to unspecified organism Under Physical Exam R12's hospital record includes, .Skin: General skin is warm and dry. Comments: Sacral decubitus, multiple wounds left buttocks, left hip, heels, left arm - see photos R12's hospital records document under Wound Nurse Note, Wound care: Wound consult completed w/(with) dressings applied to the following POA Pis (present on admission pressure injuries): right medial heel: DTPI (deep tissue pressure injury) & (and) left lateral heel.: DTPI & coccyx: Stage 3 PI and Left buttock: Stage 2 PI and left lateral knee: Stage 2 PI; and skin tear located on the left elbow previously dressed per assigned RN (Registered Nurse). R12's hospital records document the following assessments of the pressure areas all dated 12/01/24. 1. DTPI right heel- measured 4.5 cm (centimeters) x 3.8 cm described as purple, painful, dry, intact, non-blanchable. 2. Pressure injury of left lateral heel measured 2 cm x 1.5 cm and described as non-blanchable, purple, dry, intact. 3. Stage 2 pressure injury left buttocks measured 0.6 cm x 0.7 cm x 0.1 cm and described as partial thickness, red moist, painful, blanchable with scant serous drainage. 4. Stage 3 pressure injury to midline coccyx measured at 1.5 cm x 0.9 cm x 0.2 cm and described as full thickness, moist, painful, with scant amount of serosanguinous drainage, and 5. Stage 2 pressure injury to left lateral knee measured at 0.9 cm x 0.5 cm x 0.1 cm and described as red, moist, with scant amount of serous drainage. Under Adult Neglect Assessment and Plan, R12's hospital record document, Patient has over 15 new wounds since last admission, he received Haldol and benzos (benzodiazepine) in the nursing home which were discontinued by our team at the time of the discharge (11/23/24), patient became somnolent due to this and stopped eating and was readmitted this time. Patient's son does not want him to go back to (name of facility) and is looking at other nursing home options. On 12/4/24 at 8:55 AM, V16 (Registered Nurse-hospital) stated he was familiar with R12. V16 stated R12 was admitted to the hospital on 11/17/24 and discharged back to the facility on [DATE]. V16 stated R12 had three wounds when he left the hospital on 11/23/24 that had dressings on them. V16 stated when R12 returned to the hospital on 12/01/24, R12 had 15 wounds and still had the same dressings on the original three wounds that was on when he was discharged on [DATE]. On 12/5/24 at 2:08 PM, V14 (Physician) reviewed R12's hospital records and stated the pressure areas on R12's hip deteriorated from 11/23/24 to 12/01/24. V14 stated the area on R12's trochanter increased in size from 11/23 to 12/01/24. When asked if the pressure ulcers/injuries were avoidable, V14 stated the areas on R12's heels would have been preventable. On 12/09/24 at 1:29 PM, V14 (Physician) stated if R12 was immobile from somnolence then it could precipitate him developing pressure ulcers. According to the Medical Dictionary located at the website Somnolency | definition of somnolency by Medical dictionary the definition of somnolent is 1. Drowsy; sleepy; having an inclination to sleep. 2. In a condition of incomplete sleep; semi-comatose. On 12/4/24 at 4:00 PM, V1 (Administrator) stated R12 had new areas identified on his 11/30/24 shower sheet. V1 stated there were no assessments, treatment orders, physician notification, or physician orders documented in R12's record related to the new areas. V1 stated her expectation would be for any new area of skin breakdown to be assessed and the physician notified for treatment orders. R12's hospital records with an admitted [DATE] documents under Dehydration- Assessment & (and) Plan Note, Nursing staff reported pt (patient) has had decreased PO (oral) intake since last admission, especially for the last 2 days during (sic) pt has had only a few bites to eat. Pts oral mucus membrane appeared dry with yellow crusts on tongue and palate. R12's local hospital records with an admitted [DATE] documents a photograph of R12's mouth that shows R12's tongue that is covered in a dry scaly cracking with fissures, with a thick residue that is yellow/white/brown in color. On 12/11/24 at 10:04 AM, V23 (RN/Hospital Shift Supervisor) stated when R12 was admitted to the hospital on 12/01/24 his mouth looked like the bottom of the Sahara dessert. On 12/4/24 at 2:35 PM, V5 (CNA) stated they offer oral care, but residents have the right to refuse it and they don't offer it to someone who is alert and oriented since they can ask for it if they want it. When asked if she provided anyone with oral care today (12/4/24) while she was working, V5 stated she did not. V5 stated one of the nurse's was wanting to set up a cart for them so oral care would be offered when the residents got up. When asked if she ever provided oral care for R12, V5 stated she didn't. V5 stated it was hard to provide care for R12 because he would refuse. On 12/5/24 at 11:16 AM, when asked about oral care, V18 (RN) stated it was an issue. V18 stated for Christmas she bought rolling carts and was going to have them put their morning care supplies on the cart. V18 stated she had a concern oral care wasn't being provided but it had been identified as an issue and a plan was in place to attempt to improve it. On 12/5/24 at 11:47 AM, V20 (Family Member) stated he had concerns about the care R12 was provided at the facility. V20 stated he was told by the nurse at the hospital R12's bandages/treatments were not changed after he left the hospital on 11/23/24 and the areas were worse. V20 stated he also had concerns R12 wasn't getting good oral care because every time he would go to the facility his lips were always dry and chapped and R12 was always thirsty. On 12/5/24 at 12:48 PM, V1 (Administrator) stated she had access to the pictures of R12's mouth that were taken at the local hospital during his emergency room evaluation on 12/01/24. V1 stated she was very disappointed with the way his mouth looked. When asked what her expectations were for oral care, V1 stated, I mean that it is to be done routinely. On 12/5/24 at 2:08 PM, V14 (Physician) V14 stated oral care is pretty darn important. V14 stated the stuff on his tongue could be food or cancer but he wasn't able to tell from the pictures and did not elaborate further on why oral care was important. On 12/18/24 at 3:00 PM, V39 (Physician) stated she provided care to R12 during his hospital stay beginning on 12/01/24. V39 stated R12 had been discharged from the hospital about a week (11/23/24) prior and when he returned to the hospital on 12/01/24, he had more pressure ulcers that had developed while at the facility. V39 stated when R12 was discharged from the hospital on 11/23/24 they had discontinued the Haldol and Clonazepam. V39 stated the facility continued to give R12 those medications. V39 stated those medications caused somnolence which in turn caused R12 to not eat and/or drink the way he should have. V39 stated this caused R12 to end up back in the hospital with dehydration. V39 stated R12 wasn't turned and repositioned while at the facility which led to R12 developing more pressure ulcers. V39 stated R12 was not provided oral care for probably 5-6 days leading to R12's tongue having the crusty build up on it that is evidenced in the photos that were taken at the hospital. V39 stated she considered these failures by the facility to be neglect. According to the National Library of Medicine found at A preventive care approach for oral health in nursing homes: a qualitative study of healthcare workers' experiences - PMC .Studies have reported that poor oral health affects older adults' wellbeing and is associated with issues pertaining to pain and problems with eating, swallowing and social interactions [3]. Impaired oral health can also have a negative impact on general health conditions such as cardiovascular disease and diabetes, and it can lead to malnutrition and aspiration pneumonia The facility Decubitus Care/Pressure Areas policy dated 9/2024 documents, The facility Decubitus Care/Pressure Areas policy dated September 2024 documents, Policy: To ensure a proper treatment program 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) The pressure area will be assessed and documented. 2) Complete all areas of a wound assessment following NPUAP (National Pressure Ulcer Advisory Panel) guidelines i) Document size, stage, site, depth, drainage, color, odor, and treatment (once obtained from the physician) 3. Notify the physician for treatment orders 4. Documentation of the pressure area must occur upon identification and at least once each week 8) Initiate problem area on care plan. The facility Change in a Resident's Condition or Status policy dated 2021 documents, Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) The facility Adverse Consequences and Medication Errors policy dated 2023 includes, .5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with the physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 6. Examples of medications errors include: a. Omission .b. Unauthorized drug-a drug is administered without a physician's order . The facility Administering Medications policy dated January 2024 documents, Medications shall be administered in a safe and timely manner, and as prescribed 3. Medications must be administered in accordance with the orders, including any required time frame . The facility Abuse Prevention Policy dated 2022 documents, residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Purpose: .The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents, including verbal, mental, sexual or physical abuse; corporal punishment; and involuntary seclusion. The facility has a no tolerance philosophy; persons found to have engaged in such conduct will be terminated Neglect is a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident .Neglect is also the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Immediate Jeopardy that began on 11/23/24 was remove[TRUNCATED]

Based on interview and record review the facility failed to ensure oral care was provided for 2 of 5 residents (R2 and R12) reviewed for oral care in the sample of 19. This failure resulted in R12 having a buildup of a hardened yellow/brown coating with cracking and fissures noted to be covering the tongue from lack of oral care. This failure would cause a reasonable person to suffer humiliation with physical and emotional discomfort. Findings Include: 1. R12's Admission Record with a print date of 12/5/24 documents R12 was admitted to the facility on [DATE] with diagnoses that include fracture of left femur, hypotension, diabetes, schizophrenia (diagnosis added on 11/07/24), bipolar disorder (added on 11/07/24) difficulty walking, and muscle weakness. R12's MDS (Minimum Data Set) dated 10/17/2024 documents R12 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R12 is cognitively intact. This same MDS documents R12 requires set up or clean up assistance with oral care. R12's current Care Plan does not document a Focus area or interventions specific to oral care. R12's local hospital record with an admitted [DATE] documents under ED (Emergency Department) Triage Notes, Pt (patient) localizing to pain and shaking head to questions. Labored breathing. Skin warm, Dry, mouth is extremely dry. R12's hospital records with an admitted [DATE] documents under Dehydration- Assessment & (and) Plan Note, Nursing staff reported pt (patient) has had decreased PO (oral) intake since last admission, especially for the last 2 days during (sic) pt has had only a few bites to eat. Pts oral mucus membrane appeared dry with yellow crusts on tongue and palate. On 12/11/24 at 10:04 AM, V23 (RN/Hospital Shift Supervisor) stated when R12 was admitted to the hospital on 12/01/24 his mouth looked like the bottom of the Sahara dessert. R12's local hospital records with an admitted [DATE] documents a photograph of R12's mouth that shows R12's tongue was covered in a dry scaly cracking thick residue that was yellow/white/brown in color. On 12/4/24 at 2:35 PM, V5 (Certified Nursing Assistant/CNA) stated they offer oral care, but residents have the right to refuse it and they don't offer it to someone who is alert and oriented since they can ask for it if they want it. When asked if she provided anyone with oral care today (12/4/24) while she was working, V5 stated she did not. V5 stated one of the nurse's was wanting to set up a cart for them so oral care would be offered when the residents got up. When asked if she ever provided oral care for R12, V5 stated she didn't. V5 stated it was hard to provide care for R12 because he would refuse. On 12/5/24 at 11:16 AM, when asked about oral care, V18 (RN/Registered Nurse) stated it was an issue. V18 stated for Christmas she bought rolling carts and was going to have them put their morning care supplies on the cart. V18 stated she had a concern oral care wasn't being provided but it had been identified as an issue and a plan was in place to attempt to improve it. On 12/5/24 at 11:47 AM, V20 (Family Member) stated he had concerns about the care R12 was provided at the facility. V20 stated he also had concerns R12 wasn't getting good oral care because every time he would go to the facility his lips were always dry and chapped and R12 was always thirsty. On 12/5/24 at 12:48 PM, V1 (Administrator) stated she had access to the pictures of R12's mouth that were taken at the local hospital during his emergency room evaluation on 12/01/24. V1 stated she was very disappointed with the way his mouth looked. When asked what her expectations were for oral care, V1 stated, I mean that it is to be done routinely. On 12/05/24 at 2:08 PM, V14 (Physician) V14 stated oral care is pretty darn important. V14 stated the stuff on his tongue could be food or cancer but he wasn't able to tell from the pictures and did not elaborate further on why oral care was important. On 12/18/24 at 3:00 PM, V39 (Physician) stated she provided care to R12 during his hospital stay beginning on 12/01/24. V39 referenced the pictures of R12's tongue that was taken at the hospital and stated the build up on his tongue was caused by not getting oral care. When asked how long someone would go without oral care for their tongue to get that build up on it, V39 stated she couldn't say for sure but probably 5 to 6 days. 2. R2's Admission Record with a print date of 12/2/24 documents R2 was admitted to the facility with diagnoses that include atrial fibrillation, diabetes, peripheral neuropathy, morbid obesity, hemiplegia, hemiparesis, and hypertension. R2's MDS dated [DATE] documents a BIMS score of 14, which indicates R2 is cognitively intact. This same MDS documents R2 requires set up/clean up assistance with oral care and is dependent on staff for transfers. R2s's current Care Plan does not document a Focus area, or interventions related to oral care. On 12/2/24 at 3:02 PM, R2 stated she doesn't get out of bed and her teeth don't get brushed. R2 stated the staff never bring her any care items for her teeth. On 12/4/24 at 11:16 AM, V4 (Anonymous) stated R2 would require set up assistance for oral care since she doesn't ambulate or transfer independently. V4 stated she had never set up or assisted R2 with oral care. On 12/4/24 at 1:54 PM, V34 (CNA) stated she gets to work at 7:00 AM, checks on the residents and then goes to the dining room to assist residents with breakfast. V34 stated she wasn't sure if night shift provided oral care. V34 stated she hadn't ever seen oral care provided and wasn't even sure if she had seen a toothbrush at the facility. This surveyor went with V34 to R2's room and asked if we could look for oral care supplies. R2 stated she didn't have any supplies in her room, and no one ever offered to get her supplies and/or assist her with oral care. On 12/4/24 at 2:48 PM, V33 (Anonymous) stated they had provided oral care to R12 in the past, but they had not provided any oral care to any resident today 12/4/24. When asked why V33 stated they had been running around like crazy and just hadn't done it yet. On 12/5/24 at 8:37 AM, when asked about oral care, V17 (CNA) stated they provide oral care on night shift, if the residents will let them. According to the National Library of Medicine the article titled A preventive care approach for oral health in nursing homes: a qualitative study of healthcare workers' experiences - PMC (PubMed Central) located at the website https://pmc.ncbi.nlm.nih.gov/articles /PMC11443800/ documents .Studies have reported that poor oral health affects older adults' wellbeing and is associated with issues pertaining to pain and problems with eating, swallowing and social interactions [3]. Impaired oral health can also have a negative impact on general health conditions such as cardiovascular disease and diabetes, and it can lead to malnutrition and aspiration pneumonia The facility Mouth Care/Oral Care policy dated December 2024 documents, Purpose: The purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth Reporting: 1. Notify the supervisor if the resident refuses the mouth care. 2. Report other information in accordance with professional standards of practice.

Based on observation, interview, and record review the facility failed to assess, treat, and implement interventions to prevent pressure ulcers, and failed to accurately assess for skin breakdown for 4 of 5 (R1, R2, R3, and R12) residents reviewed for pressure ulcers in the sample of 19. This failure resulted in R12 developing a Stage 2 and Stage 3 pressure ulcer to his buttocks, a Stage 2 pressure ulcer to his left knee, and two deep tissue injuries to bilateral heels. Findings Include: R12's Admission Record with a print date of 12/5/24 documents R12 was admitted to the facility on [DATE] with diagnoses that include fracture of left femur, hypotension, diabetes, schizophrenia (diagnosis added on 11/07/24), bipolar disorder (added on 11/07/24) difficulty walking, and muscle weakness. R12's MDS (Minimum Data Set) dated 10/17/2024 documents R12 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R12 is cognitively intact. This same MDS documents R12 required partial to moderate assist for transfers, was independent for bed mobility, and was at risk for developing pressure ulcers. R12's Braden Scale dated 11/10/24 documents a score of 14, which indicates R12 is at moderate risk of skin breakdown. R12's Braden Scale dated 11/24/24 documents a score of 12, which indicates R12 is at high risk of skin breakdown. R12's current Care Plan documents a Focus area of (R12) is at risk for skin breakdown r/t (related to) requires assist with bed mobility, frequently incontinent of B & B (bowel and bladder). Has left side neglect. Date Initiated: 05/16/2024. This Focus area includes the following interventions, 10/30/24 cover spokes on left side of w/c (wheelchair) .8/27/24 Pad bed frame. This same focus area includes the following interventions initiated on 5/26/24, assist T & P (turn and position) at least every 2 hours and prn (as needed) Educate resident/family/caregivers of causative factors and measures to prevent skin injury Encourage good nutrition and hydration in order to promote healthier skin Follow facility protocols for treatment of injury .Keep skin clean and dry. Use lotion on dry skin . Monitor/document location, size and treatment of skin injury, if occurs. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to MD (physician) Offer toileting/check every 2 hours and prn (as needed) provide peri-care as needed Pressure relief mattress on bed and cushion in w/c (wheelchair) as preventative . Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface . R12's local hospital record documents R12 was admitted to the local hospital on 11/17/24 and discharged back to the facility on [DATE]. R12's hospital record includes under Secondary Discharge Diagnosis, bed sore on buttock. R12's Order Summary Report Active Orders as of 11/30/24 documents a physician order for weekly skin checks with no orders documented for treatments to specific areas of skin breakdown and/or orders for interventions to prevent skin breakdown from 11/23/24 to 12/01/24. R12's Initial Skin Alteration Record signed by V18 (Registered Nurse/RN), dated 11/23/2024 documents under Site, Resident refusing skin assessment, yelling to leave him alone. Able to assess visible skin. Resident pushing away this nurse when trying to assess. Wound [NAME] found (sic) to BUE (bilateral upper extremities). Several bruises and skin tears present Comments- healing skin tears to left arm noted. no signs of infection observed. resident not in pain at this time. this nurse unable to complete a head to toe assessment as resident was screaming no and resisting with physical pushing away of this nurse. Treatment Plan .Monitor skin tears . There are no measurements, assessments, or physician notification documented on this assessment. R12's medical record did not document any Initial Skin Alteration Records after 11/23/24. On 12/5/24 at 11:16 AM, V18 (Registered Nurse) stated she was working on 11/23/24 when R12 returned from the hospital. V18 stated she attempted to do a skin assessment, but he was resisting, and she didn't want to cause him distress. V18 stated she did see the dressings that had been applied at the hospital and looked under them and didn't see any open areas. V18 stated she meant to put an order in to remove and replace them every three days and just forgot to do it. When asked what interventions were implemented to prevent skin breakdown, V18 stated he had a pressure reducing mattress on his bed and a cushion in his chair. V18 stated they floated his heels and would try to reposition him hourly. R12's Weekly Skin Check dated 11/24/24 not signed until 12/04/24 by V18 (RN) documents under Site: Left antecubital- Resident refusing skin assessment, yelling to leave him alone. Able to assess visible skin. Resident pushing away this nurse when trying to assess. Wound found found (sic) to BUE. Several bruises and skin tears present Comments: healing skin tears to left arm noted, no signs of infection observed. resident no in pain at this time. This nurse unable to complete a head-to-toe assessment as resident was screaming no and resisting with physical pushing away of this nurse. will continue to monitor. This is the same narrative that was documented in R12's Initial Skin Alteration Record dated 11/23/24. On 12/09/24 at 9:59 PM, when asked if she completed the Weekly Skin Check dated 11/24/24, V19 (RN) stated R12 was sitting in his wheelchair, and she noticed the area on his arm was healed. V19 was asked if she assessed any other skin on R12 and she stated, No, I just looked at his arm. V19 stated they have another nurse who does all the treatments for south side. This surveyor reviewed with V19 that R12 wasn't located on that side and V19 stated she thought he was. This surveyor then asked V19 if she did a physical assessment of R12's skin from 11/23/24 until 12/01/24 and if she completed the 11/24/24 Weekly Skin Check and V19 stated, I don't remember. I usually just ask the CNA if the residents have any skin changes. On 12/9/24 at 12:50 PM, this surveyor reviewed the 11/23/24 initial skin assessment and the 11/24/24 weekly skin assessment with V2 (DON) and she stated the 11/24/24 assessment looks like it was copied and pasted from the 11/23/24 assessment. R12's Skin Monitoring: Comprehensive CNA Shower Review documents dark bruising to R12's left arm, heels as red, coccyx as dark red, a bandage to the inside of his inner right leg and a bandage on his left hip with V17's (CNA) signature dated 11/30/24. This Review documents V2 (DON's) signature with a date of 11/30/24 with no assessment of the new areas documented under Nurse Assessment. On 12/5/24 at 8:37 AM, V17 (CNA) stated R12's condition had declined when he returned from the hospital on 11/23/24. V17 stated R12 wasn't eating, drinking, and/or communicating as well. V17 stated she gave R12 a bed bath on 11/30/24 and found a bandage on his left hip that was looking a little rough. V17 did not remember if there was a date on the bandage that would indicate when it was placed. V17 stated when she rolled R12 over she noticed R12's coccyx was dark red, and his right hip was splotchy in color. V17 stated she was concerned R12 was mottling and then she removed his socks and noted that both of his heels were dark red as well. V17 stated there was a bandage on R12's inner thigh that didn't look as bad as the one on his left hip, but she again didn't know if there was a date on it. V17 stated she didn't remove the bandages, so she didn't know what his skin looked like under them. V17 stated she documented the areas on the shower sheet and told V2 (Director of Nurses) who was working as her nurse that night. V17 stated she told V2 she was worried R12 was dying and that his family needed to be notified. V17 stated she also reported the change in R12's condition to the oncoming shift and her supervisor (V21/CNA Supervisor). V17 stated R12 was sent out to the hospital two days later so she assumed someone heard her concerns. When asked what interventions were in place to prevent the pressure injuries from worsening, V17 stated there was a pillow under his left hip that was always there because of previous skin issues but that was the only intervention in place. V17 stated R12 was clean and dry when she changed him and that he was dependent on staff for all care. On 12/5/24 at 1:48 PM, V21 (CNA Supervisor) stated V17 told her R12's skin looked bad, but she didn't remember the date this occurred. V21 stated she asked V17 if she had reported it to the nurse and V17 told her she reported it to V2 (DON). On 12/5/24 at 12:04 PM, V2 (DON) stated she didn't remember signing off on the 11/30/24 shower sheet that documented the new areas of skin breakdown for R12. V2 stated she was working the floor that day and was told she had to get skin assessments on all the residents. V2 stated she attempted to get other nurses to assist her with it and was not able to get anyone to assist. V2 stated V17 (CNA) helped her by doing skin assessments and documenting them on the shower sheets. V2 stated she knew R12 was declining, not getting out of bed, not eating, and not drinking. V2 stated, I am really pi**ed off at myself and the building because I had zero help except for the CNA's who can't make calls or write orders. It can't be just me. I don't have any help at all. When asked if she ever assessed R12's skin, V2 stated, No. V2 stated the skin assessments were done on Sunday 11/30/24 but she didn't sign them until Monday, December 01, 2024. V2 stated she wished V17 had told her on Friday, how bad R12's skin was. When asked to clarify if R12's skin was assessed on Friday 11/29 or Saturday 11/30, V2 stated they were working midnight shift, and she wasn't sure if it was before or after midnight. V2 stated it was miscommunicated and they missed it. V2 stated if she had done R12's skin assessment she would have notified the physician and obtained orders for treatments. V2 stated they recognized there was an issue and have put things in place to make it better. V2 stated they are checking each morning during clinical rounds to make sure skin assessments are being done. V2 stated R12 should have had a head-to-toe assessment on 11/23/24 when he returned from the hospital and again before he went back to the hospital on 12/01/24. On 12/5/24 at 11:16 AM, V18 (Registered Nurse) stated she followed R12 closely even when she wasn't his nurse. V18 stated he wasn't eating well, and his oxygen dependence was increasing. V18 stated R12 didn't start showing skin breakdown until 11/30/24 and she was working on the other side that day. V18 stated she told his nurse she would be over there the next day and would look at him then. On 12/09/24 at 10:18 PM, V24 (CNA) stated she provided care to R12 between 11/23/24 and 12/01/24. V24 stated R12 was incontinent of bowel and bladder and was not able to turn and reposition himself. When asked what interventions were implemented to prevent pressure ulcers from developing, V24 stated they were turning and repositioning R12 and using pillows for support. V24 stated she was aware of the areas of skin breakdown on R12, and he had them for probably a couple of weeks. R12's facility Progress Notes document: 11/30/24 - 1907 (7:07 PM) Resident has a loss of appetite and motivation. Resident continues to take medication but not showing any improvement. This nurse will continue to monitor. Reported to nightshift nurse. If not showing improvement by mid shift tomorrow, will reach out to provider for further intervention. 12/01/24 - 14:06 (2:06 PM) Resident still not doing well and declining. Despite antibiotics, resident has not eaten in two days, has crackles throughout lung fields, febrile at 102.8 F (Fahrenheit), today extreme lethargy to the point where nursing judgement is that it is not safe to give PO (oral) medication. EMS (Emergency Medical Services) called for emergent send out for possible sepsis. Provider and POA (Power of Attorney) notified. Vital signs as follows: 154/64, pulse 138, respirations 28 and shallow with crackles and wheezes, Temp (temperature) 102.8, post Tylenol, O2 (oxygen) at 91 on 4 L (liters). 12/01/24 - 4:26 PM, (R12) admitted IP (in patient) for AMS (altered mental status) and sepsis r/t (related to) aspiration PNE (pneumonia). R12's local hospital records dated 12/01/24 documents Patient presents from the nursing home for altered mental status. He is somnolent. This hospital record documents under the physical exam dated 12/01/24 .Skin: General skin is warm and dry. Comments: Sacral decubitus, multiple wounds left buttocks, left hip, heels, left arm - see photos R12's hospital records document under Wound Nurse Note, Wound care: Wound consult completed w/(with) dressings applied to the following POA Pis (present on admission pressure injuries): right medial heel: DTPI (deep tissue pressure injury) & (and) left lateral heel.: DTPI & coccyx: Stage 3 PI and Left buttock: Stage 2 PI and left lateral knee: Stage 2 PI; and skin tear located on the left elbow previously dressed per assigned RN (Registered Nurse). R12's hospital records document the following assessments of the pressure areas all dated 12/01/24. 1. DTPI right heel- measured 4.5 cm (centimeters) x 3.8 cm described as purple, painful, dry, intact, non-blanchable. 2. Pressure injury of left lateral heel measured 2 cm x 1.5 cm and described as non-blanchable, purple, dry, intact. 3. Stage 2 pressure injury left buttocks measured 0.6 cm x 0.7 cm x 0.1 cm and described as partial thickness, red moist, painful, blanchable with scant serous drainage. 4. Stage 3 pressure injury to midline coccyx measured at 1.5 cm x 0.9 cm x 0.2 cm and described as full thickness, moist, painful, with scant amount of serosanguinous drainage, and 5. Stage 2 pressure injury to left lateral knee measured at 0.9 cm x 0.5 cm x 0.1 cm and described as red, moist, with scant amount of serous drainage. On 12/4/24 at 8:55 AM, V16 (Registered Nurse-hospital) stated he was familiar with R12. V16 stated R12 was admitted to the hospital on 11/17/24 and discharged back to the facility on [DATE]. V16 stated R12 had three wounds when he left the hospital on 11/23/24 that had dressings on them. V16 stated when R12 returned to the hospital on 12/01/24, R12 still had the same dressings on the original three wounds that was on when he was discharged on [DATE]. On 12/18/24 at 3:00 PM, V39 (Physician) stated she provided care to R12 during his hospital stay beginning on 12/01/24. V39 stated R12 had been discharged from the hospital about a week (11/23/24) prior and when he returned to the hospital on 12/01/24, he had more pressure ulcers that had developed while at the facility. V39 stated R12 wasn't turned and repositioned while at the facility which led to R12 developing more pressure ulcers. On 12/05/24 at 2:08 PM, V14 (Physician) reviewed R12's hospital records and stated the pressure areas on R12's hip deteriorated from 11/23/24 to 12/01/24. V14 stated the area on R12's trochanter increased in size from 11/23 to 12/01/24. When asked if the pressure ulcers/injuries were avoidable, V14 stated the areas on R12's heels would have been preventable. On 12/09/24 at 1:29 PM, V14 (Physician) stated if R12 was immobile from somnolence then it could precipitate him developing pressure ulcers. According to the Medical Dictionary located at the website Somnolency | definition of somnolency by Medical dictionary the definition of somnolent is 1. Drowsy; sleepy; having an inclination to sleep. 2. In a condition of incomplete sleep; semi-comatose. On 12/4/24 at 4:00 PM, V1 (Administrator) stated R12 had new areas identified on his 11/30/24 shower sheet. V1 stated there were no assessments, treatment orders, physician notification, or physician orders documented in R12's record related to the new areas. V1 stated her expectation would be for any new area of skin breakdown to be assessed and the physician notified for treatment orders. 2. R1's Admission Record with a print date of 6/17/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include osteomyelitis of vertebra, sacral and sacrococcygeal region, diabetes, peripheral neuropathy, hypertension, obesity, and malignant neoplasm of large intestine. R1's MDS dated [DATE] documents a BIMS score of 15, indicating R1 is cognitively intact. This same MDS documents R1 requires substantial maximal assistance to roll left and right and is dependent on staff for chair/bed to chair transfer. R1's current Care Plan documents a Focus area of (R1) was admitted with a Stage III pressure ulcer to coccyx. Is at risk for breakdown r/t requires assist with bed mobility, has Foley catheter and colostomy Date Initiated: 06/28/2024. This Focus area includes the following interventions.skin prep as ordered to right heel until wound MD (physician) can assess. d/c (discontinue) 8/14/24 Date Initiated: 09/22/2024 . R1's Braden Scale dated 11/19/2024 documents a score of 14, indicating R1 is at moderate risk of skin breakdown. On 11/26/24 at 3:09 PM, R1 stated she had a few little sores on her buttocks that burned when they got wet. On 11/27/24 at 2:23 PM, R1's skin was observed with V2 (DON) present. There was an open area observed on R1's right buttocks and R1's right heel was mushy per V2 (DON). R1's Order Summary Report dated 12/02/2024 includes the following physician orders, Apply skin prep to bilateral heels Q shift to preserve skin integrity, every day and night shift . Order date 12/01/2024. R1's progress notes do not document an assessment of the areas identified during the observation on 11/27/24. On 12/2/24 at 1:22 PM, V2 (DON) stated she forgot to get and implement orders for the area that was identified on R1's hip on 11/27/24. V2 stated she had no excuse it just got dropped. On 12/4/24 at 3:37 PM, V24 (Wound Specialist) stated R1's heels were a little mushy and he recommend heel protectors. V24 stated when he looked at R1's buttocks today, 12/4/24 it was not open, and it looked like old scar tissue. V24 stated they didn't notify him of an open area on her buttocks. 3. R2's Admission Record with a print date of 12/2/24 documents R2 was admitted to the facility with diagnoses that include atrial fibrillation, diabetes, peripheral neuropathy, morbid obesity, hemiplegia, hemiparesis, and hypertension. R2's MDS dated [DATE] documents a BIMS score of 14, which indicates R2 is cognitively intact. This same MDS documents R2 is requires substantial to maximal assistance for rolling left to right. R2's Braden Scale dated 11/28/2024 documents a score of 13, indicating R2 is at moderate risk of skin breakdown. R2's current Care Plan documents a Focus area of (R2) is at risk for skin breakdown r/t (related to) requires assist with bed mobility, occasionally incontinent of Bladder and is continent of bowel, dx (diagnosis) obesity. Date Initiated: 12/21/2022. The interventions documented for this Focus area include, .Heel protectors on when in bed. Date Initiated: 08/29/2023. On 11/26/24 at 8:51 AM, R2 was in bed with blankets covering most of her body. R2 stated she doesn't get out of bed often since she had her stroke. R2 stated she has a pressure ulcer on her foot they have been treating. R2 stated they usually put a pillow under her feet, but her knee locked up yesterday, so they don't have it there. On 11/26/24 at 11:10 AM, V3 (LPN/Licensed Practical Nurse) was observed providing treatment and doing a skin check for R2. V3 stated R3's right heel was red and a little soft. V3 stated this was a new area and she would have to do a skin assessment and it would be documented in the electronic record once she had completed it. The Initial Skin Alteration Record dated 11/26/24 does not document the red soft area to R3's heel. R2's Order Summary Report dated 12/02/24 documents a physician order with a start date of 12/01/24 to, Apply skin prep to bilateral heels Q (every) shift to preserve skin integrity. This same report documents a physician order with a start date of 7/22/24 for Heel protectors to be in place when in bed every shift for skin integrity. On 12/2/24 at 1:22 PM, V2 (DON) stated the physician was notified of the new areas to R2's heel and she refused to allow them to float her heels. On 12/2/24 at 3:02 PM, R2 was observed lying in bed with bilateral heel protectors in place. On 12/4/24 at 3:37 PM, V24 (Wound Specialist) stated R2's heels looked ok today (12/4/24). V24 stated he encouraged heel protectors, not skin prep. When asked if he would expect heel protectors to be in place prior to skin breakdown, V24 stated it isn't a standing order, but it would definitely cut down on wound problems. 4. R3's Admission Record with a print date of 12/02/24 documents R3 was admitted to the facility on [DATE] with diagnoses that included diabetes, peripheral vascular disease, cirrhosis of liver, hypertension, and solitary pulmonary nodule. R3's MDS dated [DATE] documents R3 has a BIMS score of 05, which indicates R3 has a severe cognitive deficit. R3's current Care Plan documents a Focus area of (R3) is at risk of skin impairment r/t (related to) dx (diagnosis) DM (diabetes mellitus) with polyneuropathy, PVD (peripheral vascular disease) frequently incontinent of B & B (bowel and bladder), requires assist with bed mobility. He was admitted with Chest tube to right lung. Date Initiated: 10/31/2024. The interventions documented for this Focus area include, .drain fluid from chest tube right lung as ordered. Date Initiated: 12/01/2024 . Provided with bilateral elbow pads for prevention. Date Initiated: 11/20/2024. The same Focus area includes the following interventions initiated on 10/31/24, Educate resident/family/caregivers of causative factors and measures to prevent skin injury . Encourage good nutrition and hydration in order to promote healthier skin .Follow facility protocols for treatment of injury .Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. (etcetera) to MD (physician) Pressure relief mattress on bed and cushion in w/c (wheelchair). R3's Braden Scale dated 11/07/2024 documents a score of 16, indicating R3 is at low risk of pressure ulcers. R3's Weekly Skin Check dated 11/23/2024 documents under Comments, .Heels and bony prominences intact with the exception of right elbow which is being treated There is no assessment or description of the area on R3's right elbow. R3's Weekly Skin Check dated 11/24/24 documents under Comments, On (sic) continues tx (treatment) to groin, buttocks with protective cream and T& P (turn and position). Exception of right elbow which is being treated . There is no assessment or description of the area documented on this assessment. R3's Wound Specialist progress note dated 11/27/24 does not document a wound to R3's right elbow. On 11/27/24 at 8:54 AM, R3 was in his room, sitting in his wheelchair with long sleeved shirt on and no elbow pads were observed. On 11/27/24 at 1:47 PM, R3's skin was observed with V6 (Registered Nurse) present. V6 removed the dressing to R3's right elbow and a pinpoint open area was observed with yellow/white slough appearing tissue observed surrounding the open area. V6 stated R3 doesn't normally wear anything on his elbows to protect them. V6 stated there is always a bandage in place and he usually wears long sleeves. On 11/27/24 at 1:57 PM, V8 (CNA/Certified Nursing Assistant) stated R3 doesn't wear elbow pads but the dressing is always on. On 11/27/24 at 2:01 PM, V7 (CNA) stated she wasn't aware R3 was supposed to be wearing elbow pads. V7 stated she hadn't seen any elbow pads in his room, and she had taken care of R3 twice this week and twice last week. On 12/4/24 at 3:37 PM, V24 (Wound Specialist) stated he at first thought the area on R3's elbow was a skin tear. V24 stated on his last visit the area was seeping with a lot of fluid and he thought it went all they way into the joint space. V24 stated he didn't know how beneficial elbow pads would be. When asked if there was an open area and the resident was continually applying pressure would cushion of some kind prevent it from worsening, V24 stated, Maybe. On 12/2/24 at 1:22 PM, V2 (Director of Nurses/DON), stated she had never seen R3's care plan intervention for elbow pads. V2 stated the area started as cellulitis and they started him on antibiotics and then she didn't like the way it looked so she had him seen by V24 (Wound Specialist). The facility Decubitus Care/Pressure Areas policy dated September 2024 documents, Policy: To ensure a proper treatment program 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) The pressure area will be assessed and documented. 2) Complete all areas of a wound assessment following NPUAP (National Pressure Ulcer Advisory Panel) guidelines i) Document size, stage, site, depth, drainage, color, odor, and treatment (once obtained from the physician) 3. Notify the physician for treatment orders 4. Documentation of the pressure area must occur upon identification and at least once each week 8) Initiate problem area on care plan.

Based on interview and record review, the facility failed to correctly assess a resident for risk of falls upon transfer/admission and ensure fall prevention interventions were in place for one (R2) of 3 residents reviewed for risk of falls in the sample of 9. This failure resulted in R2 falling, fracturing her right humerus and sustaining right hand injuries including fracture of the 3rd digit, fracture of the distal phalanx of the 4th digit and amputation of the distal tip of the 4th digit. Findings Include: R2's Admission Record documents an admission to the facility on [DATE] with a Primary Diagnosis of Covid-19 and that R2 was admitted from a local sister facility. This same document shows R2 was discharged on [DATE] at 10:43AM back to the sister facility and length of stay was 10 days. R2's Admission record from the previous/sister facility documents an original admitted [DATE]. R2's Fall Risk assessment dated [DATE] from the discharging/sister facility notes R2 had a score of 14. The same document notes if the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. The facility document titled Fall from the discharging sister facility dated 9/1/22 at 0243 (2:43am) notes that R2 was attempting to self-transfer to the wheelchair to use the restroom, but her legs got weak, and she fell . This same report documents R2 had no injuries, and notes the following immediate action taken: VA (visual aid) placed in room to use call light when needing assistance. R2's corresponding Fall Risk assessment dated [DATE] at 0243 (2:43am) from the discharging sister facility notes that after the fall described above, R2 was scored a 12 on this assessment. This document notes if the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. R2's medical record at the admitting sister facility shows no evidence of a Transfer or Admission progress note on 9/1/22 to document the time of transfer/admission or reason for admission to this facility. R2's Fall Risk Assessment completed after transfer to the admitting sister facility dated 9/1/22 at 11:56am documents a fall risk score of 5.0. The same document notes if the total score is 10 or greater, the resident should be considered at HIGH RISK for falls. The facility policy titled Fall Management with review date of 2019 notes the admitting nurse and assigned CNA (Certified Nurse Aide) and/or designee 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. R2's undated Baseline Care Plan documents an admitted [DATE] to the admitting sister facility and documents the following under the section titled Safety Risks: No history of falls and no use of alarms or any other safety devices. Under the section titled Comments is written Here R/T (related to) + Covid (positive Covid), assess resp (respiratory) status. V13 (Registered Nurse/RN) signed as completing this document on 9/1/22. This document makes no mention of R2's fall on 9/1/22 that occurred at the previous facility hours before admission, nor is there documentation of an intervention for a visual aid to be placed in R2's room to use call light when needing assistance. A Fall note dated 9/6/22 at 0200 (2:00am) documents R2 was found in her room on her back with her legs facing back toward her bed and her right arm was above her head. Blood was noted to be coming from right hand after cleaning area noted right ring fingertip was missing, found tip of finger laying away from her next to door. R2 stated she was getting up to go to the bathroom. R2's Fall investigation documents a date of 9/6/22 completed by V2 (Regional Clinical Director) and states Call received at approximately 2:20am from charge nurse (name of V12/LPN) informing of a fall that occurred with (R2). (R2) sustained an injury to her right hand ring finger and pain to shoulder and hip. Staff working the Covid unit at the time of fall was (V12) and (V10/CNA). This document further notes that V12 stated that she and V10 were making bed check rounds together and were across the hall from R2's room. As they were finishing up with care on another resident, V10 heard a noise across the hall and heard R2 yell. V10 went immediately to the room and summons V12. They both had to squeeze through the door as R2 was in front of the door laying on the floor. V12 assessed R2 at this time, R2 was laying on her right side/back with right hand behind her head. V12 noticed blood and when she assessed she noted that injury was to right hand ring finger. V12 noted that the tip of finger was missing and was noted on the floor by the door. R2 also complained of right shoulder pain. V12 noticed that the bed was in high position. V12 also noted that call light was on the bed. V12 stated that right before they went into the room across the hall she glanced into R2's room and she was sleeping with bed in lowest position. R2 had an electric bed. V12 also stated that they were in the room across the hall providing care for a few minutes. Notifications were made and resident was transferred to the hospital via EMS. V10's interview documents that she and V12 were working together on bedchecks and were across the hall from R2. As they were finishing up the care, she heard a noise from the room across the hall so she went to check on (R2) and squeezed open the door a little and saw (R2) on the floor so she yelled for V12. V12 came immediately and they both squeezed through the door and V12 started assessing (R2). V10 said she also noticed that the bed was in the high position. V10 said that (R2) was then transferred to the hospital by ambulance. V10 stated that she had taken R2 to the BSC (bedside commode) 3 times prior to the fall. She stated that she did well on the transfer to and from the bed and BSC. When I asked V10 if (R2) was alert and oriented prior to fall and she stated yes she seemed good. (R2) arrived back to the facility at around 6:20am. She has sutures to right hand ringer finger and dx (diagnosis) of fx (fracture) to right shoulder. (R2) has a sling in place. (V2) requested maintenance do a check on the bed for proper functioning and for any sharp edges or areas on the bed. No issues noted with the bed from the maintenance department. Fall interventions have been put into place upon hospital return of Fall Mat, education to resident on bed remote and to keep bed in lowest position, and maintenance check on bed. Intervention put into place to reduce risk of fall. Investigation continued: Review of hospital records and radiology reports: 3 view Right Shoulder: Transverse fx of surgical neck of the proximal right humerus, mildly displace of greater tuberosity. Right hip: No findings, no acute osseous abnormality. Right Hand: amputation of distal tip of the 4th digit with fx of 4th distal phalanx. Resident has to follow up with ortho and this report was given to (name of discharging sister facility). A local hospital emergency Department note dated 9/6/22 documents a wound debrid/explore was done to R2's right ring finger and notes Ronger of distal phalanx performed with undermining and flap closure. The same emergency department note also documents an x-ray of right hip 2 view include pelvis was performed with impression of no acute osseous abnormality, x-ray of right shoulder 2 plus view was performed and impression notes a transverse fracture of the surgical neck of the proximal right humerus. There is a mildly displaced fracture of the greater tuberosity, x-ray of right hand 3 plus view notes impression that a fracture of the tuft distal phalanx of the third digit. There is amputation of the distal tip of the fourth digit with fracture of the distal phalanx of the fourth digit. Emergency Department note also notes a splint application to the right upper arm and comments were discussed with orthopedic surgeon on call for outpatient follow up. emergency room note also documents R2 will be getting discharged and heading back to the facility soon. On 10/13/22 at 10:25AM, V12 (RN/Registered Nurse) said that V10 and herself were in the room directly across the hall from R2's room on the COVID unit. V12 said she had been up and down the hall all night and that R2's bed was in the lowest position. V12 said she was walking back to her medication cart when V10 yelled at her. V12 said that R2's door was hard to open and had to squeeze to get in. V12 said that R2's bed was not in its lowest position at that time. V12 said that R2 had an electric bed. V12 said that R2 was in the floor in front of the door with her head against the wall and her hand behind her head. V12 said she saw blood but it was not a lot so she figured it was not from her head since a head wound bleeds a lot. V12 said she got R2's hand and noticed the tip of R2's ring finger was missing. V12 said the tip of the finger was to the right of R2 and her head was to the left of the door. V12 said they used a blanket to pull R2 away from the door just far enough to get the door open. V12 said that R2 never pushed her call light or yelled for help as they were just across the hall and would have heard her. V12 said that while being a resident at the facility, R2 would have increasing confusion in the evenings. V12 said that R2's daughter told her that R2 had fallen at the previous facility after R2's fall at this facility. V12 said she did not admit any of the residents from the sister facility and was not aware she was a high risk for falls at the other facility. R2's MDS (Minimum Data Set) dated 9/8/22 documents a BIMS (Brief Interview for Mental Status) score of 09, which indicates moderate cognitive impairment. Section G of the same MDS documents R2 requires extensive assistance with transfers - how resident moves between surfaces including to and from bed, chair, wheelchair, standing position and the support provided is one-person physical assist. The same MDS notes that R2's balance during transitions and walking is not steady, only able to stabilize with staff assistance. On 10/12/22 at 8:00 am, R2 was interviewed back at the original sister facility. R2 had a sling on her right arm. When questioned about the fall at the other facility, R2 said she didn't remember what happened and said honey, that was a long time ago. On 10/13/22 at 10:07am, V13 (RN/Registered Nurse) said that she admitted a lot of the residents to the COVID unit from the sister facility. V13 said she was upset over not getting a call from the sister facility to give report on any of the residents she received. V13 said she completed the fall risk assessment as well as other admission assessments on R2 based on talking to R2 and looking at her medications. V13 said she can't answer if she received a transfer sheet or not. V13 said she was never told that R2 had fallen prior to her arrival, or she would have changed the way she did her fall risk assessment. V13 said it is frustrating when you know nothing about a resident. V13 stated she usually puts a progress note in on residents she admits saying what time they arrived and other pertinent information. V13 said if there is not a progress note in R2's medical record, she guesses she did not have time to do it. On 10/13/22 at 11:30am, V2 (Regional Clinical Director) said that it is her understanding that report was called from the (discharging) sister facility. V2 stated that they do not send care plans; V2 said they send Physician Orders, MARS (Medication Administration Records), TARS (Treatment Administration Records) and the face sheet. V2 said that they transfer COVID positive residents from the (discharging) sister facility due to that facility being small causing them to have to share shower rooms with non-COVID positive residents. On 10/13/22 12:27pm, V14 (Interim DON/Director of Nursing) at the discharging facility stated that when they send a resident to another facility, they send Physicians Orders, TARS (Treatment Administration Records), MARS (Medication Administration Records), medications and the resident face sheet. V14 said they usually use a transfer sheet when a resident goes to the hospital. V14 said the nurse always calls report also. V14 said she is not sure if fall risk assessments were sent. On 10/13/22 at 3:35pm, V11 (LPN/Licensed Practical Nurse) said she was the nurse at the (discharging/sister) facility that discharged R2 to come to this (admitting/sister) facility. V11 said she called the facility prior to sending R2 and two other residents that were sent at that time. V11 said that there were three residents that went (transferred) the morning of 9/1/22 and others went later. V11 said she did not get the name of the nurse she called report to. V11 said she informed them that R2 had a fallen at their facility in the early morning on 9/1/22 before she was sent. V11 said she also told them she had no apparent injuries, was positive for COVID, there were no areas on concerns, had chronic pain management with pain meds being scheduled. V11 said that she sent a copy of R2's MAR, physician's orders as well as all of R2's medications. V11 said she did not send a transfer sheet or care plan. On 10/18/22 at 2:20pm, V10 (CNA) said she came in at 7pm the evening of 9/5/22 and had assisted R2 to the bedside commode 2 times prior to R2 falling. V10 said when she checked on R2 each time, she noticed R2 may be trying to do too much herself, so she helped her to the commode. V10 said R2 transferred well. V10 also said the last time she helped R2 to the bed side commode was about 2 hours prior to her fall and that when V10 returned to R2's room, R2 had put herself back to bed. V10 said she told R2 to not do that and to be sure and call for help.

Based on record review and interview the facility failed to provide adequate nutrition and hydration to prevent dehydration for 1 of 2 residents (R2) reviewed for nutrition and hydration in the sample of 12. This failure resulted in R2 being readmitted to the hospital in Acute [MEDICAL CONDITION] with Dehydration and a Urinary Tract Infection. Findings include: R2's 03/15/18 Minimum Data Set (MDS) shows that R2 was admitted to the facility on [DATE] with a feeding tube, a weight of 75 pounds and diet orders of NPO. The MDS documents R2 was unable to complete the Brief Interview for Mental Status (BIMS) which indicates R2 is severely cognitively impaired. The MDS also documents R2 has unclear speech, usually understands and is usually understood. The Facility's Admission Nursing Assessment per V4 (Licensed Practical Nurse) states R2 arrived at the facility on 03/08/16 at 5:00pm with a weight of 86 pounds. The Facility Weights List Report, per V10, documents R2's weight of 75 pounds on 03/10/18. The MAR documents a weight of 75 pounds on 03/12/18. The 03/13/18 and 03/14/18 Daily Skilled Nurse's Notes documents a weight of 84 pounds. On 03/15/18, V27 wrote a new order for daily weights x 7 days to begin 03/15/18. There are no weights recorded on 03/15/18 or 03/16/18 for R2. On 03/27/18 at 9:33am, V29 (Hospital Nurse) stated the hospital records document R2 weighed 42.5 kilograms (kg) (93 pounds) on 03/05/18 and 42.4 kg (93 pounds) on 03/16/18. R2's 03/08/18 Inpatient Discharge Summary states R2 was discharged to the Long Term Care Facility (LTCF) with [DIAGNOSES REDACTED]. The records state R2 was sent to the LTCF for Physical Therapy, Occupational Therapy, Speech Therapy and Intravenous (IV) therapy. The 03/08/18 Discharge Medications and Instructions documents R2 is to be on a Continuous Tube Feeding of [MEDICATION NAME] 1.2 at an initial rate of 10ml (milliliters)/hour with a goal rate of 50ml/hour, Tube Feeding water flush of 20ml every 2 hours, Check Residual every 4 hours, if less than 30ml, increase by 10ml until goal of 50ml/hour is achieved. The records state R2 is on an Adult NPO (Nothing Per Os) Diet. On 03/20/18 at 11:30am, V2 (Regional Clinical Director) stated R2 was admitted to the facility on [DATE] with orders for a continuous tube feeding and was NPO. V2 stated he called V9 (Registered Dietician) on 03/09/18 to inform V9 of a new admit with a tube feeding because it is protocol. V2 stated V9 increased the tube feeding at that time and V27 (Physician) approved the order. On 03/22/18 at 1:46pm, V9 (Registered Dietician) stated she was notified of R2's admission by V2, who asked if the [MEDICATION NAME] tube feeding could be changed to Glucerna, because the facility did not have [MEDICATION NAME] available at that time. V9 stated she did not have a problem with this and recalculated the rate for the Glucerna and the flushes to provide adequate nutritional needs. (Glucerna 1.5 at 10ml/hour, increase by 10ml every 6 hours until goal of 35ml/hour continuous obtained.) V9 stated the initial flush order for R2 was too low and she also adjusted the free water flushes. V9 stated she was not provided R2's height and weight at this time, she was just asked by V2 if Glucerna could be used in place of [MEDICATION NAME]. V9 stated she then recalculated the rate of the Glucerna based off the hospital admission order. V9 stated she gave a verbal order to V2 to increase the water flushes to 240ml every 4 hours, but V2 is saying V9 wrote down 40ml every 4 hours. V9 stated the usual flush order to maintain hydration is over 100ml every 6 hours, adding she would not order 40ml flushes every 4 hours. V9 stated she did not make a note of this conversation. V9 stated she saw R2 for the first time in the facility on 03/12/18 and at that time met with V26 (Surrogate) who did not want R2 tied down to the tube the entire day so she recommended nocturnal feedings. V9 stated she informed V2 of this recommendation and that an email with the recommendation would be sent to V3 (Director of Nurses) and V10 (Dietary Manager). V9 stated when she evaluated R2, there was no weight documented and she asked for R2 to be weighed while she was at the facility. V9 stated R2 was weighed and a weight of 75 pounds was recorded. V9 stated she calculated the nutritional value needed to run the Glucerna at night to include the free water flushes. V9 stated she emailed this assessment of R2 on 03/12/18 along with the recommendations to V3 and V10. V9 stated when she returned to the facility on [DATE] she was informed by a floor nurse that R2 had been admitted to the hospital. V9 stated in this discussion she found out the nurse was not aware of the nocturnal tube feeding recommendation and she again sent the email to V3 and V10. V9 stated, I believe I made my effort to make that change. They had the email. On 03/22/18 at 3:30pm, V2 stated the facility did not receive an email with any dietary recommendations from V9. V2 stated V3 (Director of Nurses) was off from 03/09/18 to 03/20/18 and is not available at this time to check her emails. V2 stated V10's last day at the facility was today (03/22/18) and already left. At this time, V2 went to V8 (Dietary Manager as of 03/22/18) and had her check the emails. V8 did find an email from V9 that was sent to V10 on 03/12/18 and again on 03/15/18 with the dietary recommendations. V9's Dietary Recommendation for R2 dated 03/12/18 states: Recommendations: Add/Change: 1. Switch to nocturnal TF (Tube Feed) to allow Resident less time connected to feeding tube. 2. 10 hour nocturnal TF from 2000-0600. 3. Glucerna 1.5 via PEG at goal rate of 85ml/hour. 4. 220 ml free water flushes every 6 hours. The 03/09/18 Nutritional Assessment per V10 has no height or weight documented. The document has only R2's admitted , date of birth, [DIAGNOSES REDACTED]. The Assessment is grossly incomplete. The 03/12/18 Facility's Nutrition Assessment per V9 states R2's Ideal Body Weight (IBW): 52.2 kg (115 pounds) with a Body Mass Index (BMI) of 13.3. Resident significantly underwt (underweight). Significant protrusion of clavicle, minimal adipose underlying triceps with fingers overlapping, moderate orbital and temple depression. On 03/27/18 at 9:20am, V8 stated V10 did give her a copy of the Nutritional Assessment that she is to do on every new admission, adding V10 highlighted the areas that need assessed/filled out. At this time, V10 showed this surveyor the highlighted Nutritional Assessment which details; in part, height, weight, IBW, diet order/tube feed order, food allergies [REDACTED]. The 03/08/18 Medication Administration Record (MAR) documents R2's admitting [MEDICATION NAME] 1.2 order is 10ml and increase to goal of 50ml, flush every 2 hours with 20ml water. The first notation on the MAR of the [MEDICATION NAME] infusion is on 03/09/18 with no time indicated. (Per the Admission Nursing Assessment, R2 was admitted on [DATE] at 5:00pm). The MAR documents on 03/09/18 the [MEDICATION NAME] was discontinued and a new order was received for Glucerna 1.5 at 10ml/hour, increase by 10ml every 6 hours until goal of 35ml/hour continuous obtained. On 03/27/18 at 1:25pm, a phone interview was conducted with V22 (Registered Nurse-RN). V22 stated she worked on 03/08/18 from 6:00am to 6:00pm. V22 stated when she came to work at 6:00pm, V4 was completing all of the admitting paper work and prepared the MAR and sent the orders to the pharmacy. V22 stated she recalls R2 did have a PEG tube, but no tube feeding was started during her shift and she did not flush the PEG tube because she did not have the MAR when she was passing medications and was not aware of a flush order. V22 added she does not recall if R2 was NPO. On 03/27/18 at 1:30pm, V2 stated he started the Glucerna at 10:00am on 03/09/18 as stated on the MAR and he mistakenly signed out the [MEDICATION NAME] on 03/09/18, adding the [MEDICATION NAME] was never started. There is no documentation on R2's MAR that indicates R2 received any water flushes until 03/09/18 at 8:00am. The MAR documents V27's 03/09/18 gradual increase to achieve the goal rate of the new Glucerna order was not recorded as being completed by the nursing staff. The MAR documents the nursing staff continued with sporadic signing out of the Glucerna increase each day from 03/09/18 - 03/16/18 with multiple areas on the MAR being blank. V9's 03/09/18 flush order increase of 240ml every 4 hours and 03/12/18 change to 220ml every 6 hours is not documented on the MAR. (Only the 40ml/hr every 4 hours free water flushes are signed out on the MAR from 03/09/18 to 03/16/18.) The inconsistent and incomplete recording on the MAR by the nursing staff does not provide the information needed to calculate R2's nutritional or hydration intake. There is no documentation in R2's medical records indicating V27 was notified of V9's 03/12/18 dietary recommendation. Further, there is no documentation of Intake and Output monitoring or if gastric residuals were monitored at any time from 03/08/18 to 03/16/18. On 3-20-18 at 11:30 a.m., V2 stated R2 was readmitted to the hospital on [DATE] due to an abnormal chest x-ray and electrocardiogram. The 03/16/18 2:03pm Emergency Department (ED) History and Physical documents R2 was sent to the ED following a routine chest x-ray and found to have right lower lobe infiltrates and abnormal laboratory readings. The records document in part: Blood Urea Nitrogen (BUN) 59 (7-17 mg (milligrams)/dL (deciliters)), Creatinine 1.6 (0.5-1.1mg/dL), [MEDICATION NAME] 3.1 (3.5-5.0 grams/dL), Uric Acid 6.5 (2.5-6.2 mg/dL), Urine Leukocyte Esterase Large (Negative). The records state R2 was admitted to the hospital with [REDACTED]. Is cachectic has increased skin turgor and dry mucous membranes. It appears she has an acute [MEDICAL CONDITION] which I think is due to dehydration. I do think her leukocytosis is also from dehydration based on her clinical assessment. The records state R2 is admitted for observation of the dehydration. The 03/16/18 Hospitalist History and Physical per V28 (Hospital Physician) documents R2 is a poor historian, but answers with short phrases and yes/no, appears distressed, sick looking, dehydration, cachectic, thin. PEG tube in place and an indwelling urinary catheter. V28 further documents, Dehydrated though she has a PEG tube. Questioning why she was not given enough fluids via the PEG tube. Dry skin, contraction metabolic alkalosis, high uric acid and high BUN going with dehydration. V28 documents R2 has [MEDICAL CONDITION] and failure to thrive with an adult BMI (Body Mass Index) less than 19 kilograms/square meters. On 03/28/18 at 8:20am, V28 (Hospital Physician) stated he did not provide R2's care prior to her readmission to the hospital on [DATE]. V28 stated when R2 presented to the hospital on [DATE] she appeared distressed, sick looking, dehydrated, cachectic and thin as his medical records document. V28 stated R2 was in Acute [MEDICAL CONDITION], Dehydrated and had a Urinary Tract Infection, adding R2 was totally out of it, lethargic and not responding. V28 stated R2 had a swallowing problem and was not taking water orally and was NPO. V28 stated water must be provided and is the most important. V28 stated even if the facility did not get the tube feeding started until the next day (03/09/18), a patient who is not eating still needs to drink. V28 stated R2 did have the markers of dehydration with a high Uric Acid, high BUN and was in metablolic alkalosis. V28 stated regardless of R2's water flush order being 20ml of water every 2 hours or 40ml every 4 hours, the specific orders should be changed based on the daily needs of the patient. V28 stated the order is not permanent and the facility has the liberty to change the fluid intake as needed. V28 stated if a patient has dehydration issues, the water intake needs to be increased. V28 stated R2's condition was not critical and was able to be reversed. V28 added the issue here is more of awareness by the facility, not negligence. The Facility's (Adapted/Revised (YEAR)) Enteral Nutrition policy states in part, 5. The Dietitian will monitor residents who are receiving enteral feedings, and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. 7. Residents receiving enteral nutrition will be periodically reassessed for the continued appropriateness and necessity of the feeding tube. Results of these assessments will be documented and any changes will be made to the care plan .