Every finding on record at La Bella of Danville

Based upon observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse for one (R2) of three residents reviewed for abuse on a sample list of three residents. According to the Electronic Health Record (EHR) R2 has diagnoses including Dementia with Agitation, Syphilis, HIV, Delirium, Paranoid Personality Disorder, Cognitive Impairment, and Restlessness and Agitation.R2's undated care plan documents R2 is at risk for wandering and elopement, is dependent on staff for Activities of Daily Living (ADL), is at risk for falls, takes psychotropic medications, has behavior of placing self on floor, and has a potential for mood problems.R2's Minimum Data Sheet (MDS) Section C, dated 5/6/26 documents R2 has severe cognitive impairment.According to the Electronic Health Record (EHR) R3 has diagnoses including Alzheimer's Disease, Spastic Hemiplegia Affecting Left Dominant Side, Chronic Kidney Disease Stage 3B, Attention Deficit Disorder, Heart Failure, Restlessness and Agitation.R3's undated care plan documents R3 is at risk for wandering and elopement, is at risk for abuse related to Dementia, is dependent on staff for all ADL's, has a behavioral problem including being physical towards others related to Delirium, and is at risk for falls.R3's Minimum Data Sheet (MDS) Section C, dated 4/23/26 documents R3 has severe cognitive impairment.R3's Physician Order dated 4/23/26 documents new order for Haldol due to behavioral disturbance with aggression when redirected.R3's Physician Visit Note dated 5/19/26 documents R3 was seen today for routine psychiatric evaluation after staff reported increased evening agitation consistent with sundowning-type behavioral escalation.R3's Progress Note dated 5/26/26 documents R3 became agitated and was observed pushing another resident's wheelchair. R3 was combative with staff during intervention. R3's Progress Note dated 6/4/26 documents R3 was observed sitting in a chair in the hallway near the nursing station, and when another resident was passing by R3 became agitated and suddenly reached out, grabbing the other resident's wheelchair and refusing to let go. R3's undated Care Plan does not document any new interventions related to increased aggressive behaviors after 3/25/26 until 6/11/26.The Facility Investigation File dated 6/6/26 documents that on 6/6/26 R2 and R3 had a physical encounter while in the dining area of the locked unit. R3 had approached R2 and grabbed R2's coffee cup, R2 stated that it was R2's and took it back from R3 at which point R3 struck R2. Both residents were separated and neither had any injury. Both residents have severe cognitive impairment.On 7/16/26 at 2:00PM, R2 observed seating in wheelchair in front of nurses' station watching television. R2 appeared to be well groomed, odor free, and free of any injuries. R2 was pleasant and calm, showing no signs of agitation. R2 stated R2 feels safe in R2's environment, and no one here has ever harmed R2. R2 had trouble staying on topic and would often start talking about R2's job, family, and how R2 was going to get out of the facility once the doctor performed two tests on R2 to prove R2 didn't have the two diseases that kept R2 in the facility. R2 was unable to state what two diseases R2 was referring to. R2 had no recollection of the incident with R3.On 7/16/26 at 2:15PM, V4 Licensed Practical Nurse (LPN), stated that R3 has not had any physical altercations with another resident prior and since the incident with R2. V4 LPN stated that V4 could hear the commotion, but V4 did not see the physical altercation. R2 did complain of pain to the left side of R2's face after the incident which was relieved with an ice compress. R2 did not have any visible marks to R2's body. V4 stated that after the incident, R2 stated to V4 that R3 had taken R2's coffee cup and when R3 took it back from R2, R3 punched R2. V4 stated that after the incident, the psychiatric doctor adjusted R3's medications and that has been successful.On 7/17/26 at 10:05AM, V5 Certified Nursing Assistant (CNA) stated that R3 had taken R2's coffee cup and R2 took the cup back stating that it was R2's. V5 CNA separated R2 and R3 at that time. A few minutes later, V5 heard commotion in the dining area and saw R2 holding onto the hood of R3's jacket and hit R2 in the face with closed fist. V5 stated it appeared R3 made grazing contact with R2's face. R2 and R3 were immediately separated again, and nurse was notified of incident. V5 stated that prior to this incident neither R2 nor R3 had any physical altercations with other residents. V5 stated R3 would frequently get agitated but this was the only time R3 physically put R3's hands on another resident.R2's Follow up assessment dated [DATE] documents R2 complained of new pain to left forehead and left side of face. R2 received an ice pack for pain relief. Observations of R3 were made on 7/16/26 and 7/17/26 between the hours of 9:00AM and 3:30PM. R3 was well-groomed, free of odor, and free of visible injuries. R3 appeared calm and was often walking in hallways with a staff member or doing activity at nurses' station. At no time did R3 appear agitated or physical with another person. R3 refused to be interviewed. R3 has been on one-to-one observation since 6/8/26.Facility Abuse, Neglect and Exploitation Policy dated 2026 documents the facility will implement policies and procedures to prevent and prohibit all types of abuse including the identification, ongoing assessment, and care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

Based on observation, interview and record review the facility failed to provide call lights for five (R14, R15, R16, R17, R18) residents out of 12 residents reviewed for Physical Environment in a sample list of 35 residents. Findings include:On 6/18/26 at 10:20 AM, R18 was observed sitting in his wheelchair in his room without a call light assigned to his living space. There was no temporary call system in place and no portable bell or other device available to summon staff.On 6/18/26 at 10:21 AM, V32 Registered Nurse (RN) searched for a call light for R18 and stated R18 did not have any type of call light or even a location on the wall where a call light could be connected.On 6/18/26 at 10:22 AM, R18 stated he had not been given a call light or a bell. R18 stated that if he needed assistance he would have to yell for help. R18 stated he lived at the end of the hallway and commented, Good luck getting someone to hear him yelling.On 6/18/26 at 10:31 AM, R16 and R17 were observed without call lights or any other means of contacting staff. There was no temporary call system in place and no portable bell available.On 6/18/26 at 10:32 AM, R17 stated he had been shipped to the South Building after the storm damaged his previous room. R17 stated he could try to yell for help if he needed assistance. R17 stated he shared the room with R16, R20, and R21 but the other roommates were frequently out of the room and would not be available to assist him.On 6/18/26 at 10:40 AM, R14 and R15 were observed without call lights or any other means to summon staff. There was no temporary call system in place and no portable bell available.On 6/18/26 at 11:35 AM, R15 stated she and R14, along with other residents, had been thrown in these rooms after the severe storm damaged their previous rooms. R15 stated the facility should have ensured the rooms were decent enough to live in before relocating residents. R15 stated she understood the moves had to occur quickly but believed staff should have returned to verify residents had everything they needed in their new rooms.On 6/18/26 at 3:00 PM, V14 Regional [NAME] President of Clinical Services stated all residents should have a means to contact staff. V14 stated that if a traditional call light was unavailable, residents should be provided with an alternative method, such as a hand bell. V14 stated the facility would immediately verify that all residents had a way to summon staff.On 6/18/26 at 3:45 PM, V27 Registered Nurse/Infection Preventionist was observed distributing hand bells to residents whose rooms did not have functioning call light systems and demonstrating how to use the bells to summon staff.The facility's policy titled Call Lights: Accessibility and Timely Response, revised 6/18/26, stated the call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.The facility failed to ensure relocated residents had an accessible means to summon staff after being moved following storm damage. Five residents were left without functioning call lights or any temporary alternative, requiring them to yell for assistance if they needed help. The facility acknowledged residents should have had an alternative call system and did not implement one until after the survey identified the deficient practice.

Based on observation, interview and record review the facility failed to provide privacy curtains for five (R14, R15, R16, R17, R18) residents which also affected their roommates R19-R25 out of twelve residents reviewed for Physical Environment in a sample list of 35 residents. Findings include:On 6/18/26 at 10:23 AM R18 did not have a privacy curtain in his area of the room. R18 stated, You learn to lose your modesty in this facility. R18 stated he would like to have a privacy curtain. On 6/18/26 at 10:24 AM V32 Registered Nurse (RN) obtained R18's vital signs and blood glucose level in R18's room with R22 (R18) roommate present and observing care for R18 being provided. On 6/18/26 at 10:30 AM R16 and R17 did not have privacy curtains in their shared room. R16 and R17 share a room with R20 and R21. R17 stated 'God and everybody sees what goes on over here'. On 6/18/26 at 10:41 AM R14 and R15 do not have privacy curtains in their room. R14 and R15 share a room with R24 and R25. On 6/18/26 at 10:38 AM V28 Certified Nurse Aide (CNA) stated R14, R15, R16, R17 and R18 do not have call lights or privacy curtains. V28 CNA stated there is no way to provide privacy. V28 CNA stated she tries to use her body to form a shield. V28 CNA stated the residents deserve an actual privacy curtain. On 6/18/26 at 11:36 AM R15 stated it is embarrassing to have to dress and undress in front of others. R15 stated she would like to have a privacy curtain.On 6/18/26 at 3:05 PM V14 Regional [NAME] President of Clinical Services stated all residents should be provided privacy. On 6/18/26 at 3:07 PM V1 Administrator confirmed R14, R15, R16, R17 and R18 do not have privacy curtains. V1 Administrator stated all resident should have a privacy curtain. V1 Administrator stated all five of these residents were relocated to the South building after the North building where they previously resided had storm damage. V1 stated those residents were moved from 6/6-6/8/26 to their current rooms. V1 stated the facility should have provided privacy curtains when the residents were moved. On 6/23/26 at 9:05 AM R22 stated he is glad R18 (R22) roommate was given a curtain. R22 stated he was tired of seeing R18 in his underwear.On 6/23/26 at 9:15 AM R25 stated she feels sorry for R14 and R15 (R25 roommates) because they had no way to cover themselves up when they are dressing. R25 stated she tried to close her eyes but it is so much better now that they have curtains. R14's Minimum Data Set (MDS) dated [DATE] documents R14 as severely cognitively impaired. This same MDS documents R14 as requiring supervision with toileting, bathing, dressing, bed mobility and transfers. This same MDS documents supervision is defined as Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.R15's Minimum Data Set (MDS) dated [DATE] documents R15 as moderately cognitively impaired. This same MDS documents, R15, requires supervision with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers. This same MDS documents supervision is defined as Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.R16's Minimum Data Set (MDS) dated [DATE] documents R16 as moderately cognitively impaired. This same MDS documents R16 as requiring supervision with eating, oral hygiene, personal hygiene, bed mobility, transfers and moderate assistance from staff for toileting, bathing and dressing.R17's Minimum Data Set (MDS) dated [DATE] documents R17 as severely cognitively impaired. This same MDS documents R17 is dependent on staff for complete assistance with oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.R18's Minimum Data Set (MDS) dated [DATE] documents R18 as moderately cognitively impaired. This same MDS documents R18 as requiring supervision with eating, oral hygiene, personal hygiene, bed mobility, moderate assistance from staff for bathing, dressing and maximum assistance from staff for toileting and dressing.R22's Minimum Data Set (MDS) dated [DATE] documents R22 as cognitively intact. R25's Minimum Data Set (MDS) dated [DATE] documents R25 as moderately cognitively impaired. The facility policy titled Resident Rooms revised 6/18/2026 documents all resident bedrooms will be equipped to assure full visual privacy for each resident. Including ceiling suspended curtains which extend around each bed in non-private bedrooms.

Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for residents by failing to remove hazardous extension cords and damaged electrical equipment from a resident room; maintain a clean community shower room; repair damaged walls and fixtures; and maintain common areas free of construction materials and disrepair. These deficient practices affected three residents (R11, R13, R18) out of seven residents reviewed for Physical Environment in a sample list of 35 residents. Findings include:R13's Minimum Data Set (MDS) dated [DATE] documented R13 as cognitively intact.On 6/18/26 at 12:25 PM, R13's room contained a power strip hanging from a metal holder directly against the side of her bed. The power strip had a power cord that had been neatly cut in half. The detached portion of the cut cord was coiled on the floor at the foot of the bed. In addition, R13's air mattress was plugged into an extension cord that was connected to the wall outlet.On 6/18/26 at 12:26 PM, R13 stated her room was a mess because of the broken power strip nailed to the wall and cords everywhere. R13 stated she had not cut any cords or plugged anything into the extension cords. She stated she understood conditions were chaotic following the severe storm but expected the room to have been cleaned up after nearly two weeks.On 6/18/26 at 12:35 PM, V15 Maintenance Director stated the facility lost power for three days due to severe weather on 6/11/26, 6/12/26, and 6/13/26. V15 stated extension cords were temporarily used to connect medical equipment to emergency power supplied by the generator. V15 acknowledged maintenance staff forgot to remove the extension cord from R13's room after commercial power was restored and stated extension cords should not have remained in use for resident medical equipment once power returned.R11's Minimum Data Set (MDS) dated [DATE] documented R11 as cognitively intact.On 6/16/26 at 10:25 AM, the South Building North Hall shower room contained a wet cigarette butt, loose tobacco, balls of dried brown material, multiple wet towels, dead insect carcasses, and live gnats. The room had a strong musty odor.On 6/16/26 at 10:26 AM, V2 Director of Nursing (DON) stated the shower room remained in use by residents because two of the facility's four shower rooms were out of service. V2 confirmed residents had been showered in that room earlier that morning and acknowledged the room needed to be cleaned before additional residents used it.On 6/18/26 at 10:05 AM, R11 stated only two community shower rooms were available for resident use because two shower rooms were out of service. R11 stated the shower room on his hall was not kept clean, described it as filthy, and stated it should be cleaned after each resident use.R18's Minimum Data Set (MDS) dated [DATE] documented R18 as moderately cognitively impaired.On 6/18/26 at 10:18 AM, the wall beneath the light switch in R18's room contained an area of missing paint measuring approximately two feet wide by four inches high.On 6/18/26 at 10:19 AM, R18 stated he expected the facility to patch and paint the damaged wall and remarked he would even help purchase the paint if necessary.Observations of the South Building on 6/16/26, 6/17/26, 6/18/26, and 6/23/26 consistently revealed numerous unrepaired environmental concerns, including:A small, attached dining room being used to store dozens of boxes of floor tile. On three survey days, the room also contained two resident beds and three mattresses.A large, previously patched section of drywall in the main dining area measuring approximately six feet long by six inches high that remained unpainted.A community sink cabinet with a missing front panel exposing the underside of the sink and plumbing.Multiple areas of chipped paint extending approximately four feet long by twelve inches high on the wall adjacent to the South Building nurses' station.On 6/23/26 at 10:15 AM, V15 Maintenance Director acknowledged there were numerous areas throughout the facility requiring repair or replacement. V15 stated he maintained a lengthy repair list and would eventually address all the items but was currently focused on higher-priority repairs.The facility's policy titled Resident Rights, revised 6/15/26, stated residents have the right to a safe, clean, comfortable, and homelike environment, including receiving treatment and support for daily living in a safe manner.The facility failed to maintain resident rooms, shower facilities, and common areas in a safe, clean, and homelike condition. Residents were exposed to damaged electrical equipment and extension cords remaining after an emergency, unsanitary shower conditions despite ongoing resident use, and multiple unrepaired environmental deficiencies that persisted over several days despite staff knowledge of the conditions.

Based on observation, interview and record review the facility failed to ensure fire system equipment was functioning properly and failed to complete a thorough fire watch for 10 (R5, R27-R35) residents residing in Zone 2 of the Dementia Unit out of 10 residents reviewed for Physical Environment in a sample list of 35 residents. Findings include:On 6/18/26 at 1:00 PM, the North Building fire alarm annunciator panel located behind the front nurses' station displayed the message, Trouble Fire - Zone 2 Open Fault.On 6/18/26 at 1:10 PM, V22 Medical Records Clerk was observed conducting a fire watch in the North Building. V22 stated the fire watch was being conducted because Zone 2 was offline and included rooms 4 through 17 of the Dementia Unit. During the fire watch, V22 did not inspect rooms 5 through 13.On 6/23/26 from 9:38 AM through 10:17 AM, continual observations were made of fire watch rounds on the Dementia Unit. V42 Certified Nurse Aide (CNA) walked the hallway and looked only into rooms with open doors. V42 did not touch closed resident room doors to assess for heat, did not open closed resident room doors to visually inspect the rooms, and did not proceed beyond the fire doors into the closed hallway to inspect rooms 5 through 13, despite those rooms being located within the affected Zone 2 fire alarm area.On 6/23/26 at 9:40 AM, V15 Maintenance Director stated water damage beginning on 6/6/26 resulted in a damaged fire sensor on 6/10/26. V15 further stated there was also a disconnected wire affecting the fire alarm panel. A temporary roof was installed on 6/12/26 to prevent additional water intrusion. V15 stated the damaged sensor served Zone 2 of the North Building Dementia Unit, which included rooms 4 through 17. V15 acknowledged fire watch rounds should include all rooms within Zone 2 and stated staff would be educated to ensure all affected rooms were inspected during future fire watch rounds.On 6/23/26 at 11:00 AM, V44 Fire System Service Coordinator stated the facility requested emergency service after a worker accidentally cut a wire while repairing storm-related water damage. V44 stated the fire alarm annunciator displayed Zone 2 Open Fault and the fire alarm control panel also had an internal ground fault. V44 stated the fire alarm control panel required replacement before additional troubleshooting could be completed. V44 stated an estimate for replacement was provided to the facility on 6/11/26 and no response had been received from the facility. V44 stated the facility should remain on continuous fire watch until the panel was replaced and all deficiencies corrected. V44 explained that because the sensor was faulty, the facility could not rely on it to detect an actual fire. Additionally, because of the panel malfunction, there was no assurance that the fire department would be notified if the system activated.On 6/23/26 at 11:50 AM, V1 Administrator stated the fire alarm system began malfunctioning during the afternoon of 6/10/26. V1 stated the fire alarm monitoring company responded on 6/11/26 and identified a faulty wire affecting the sensor. V1 stated the facility was awaiting insurance approval before proceeding with repairs.The facility Daily Census Report for 6/10/26 documented 10 residents (R5 and R27 through R35) resided within Zone 2 of the North Building Dementia Unit.The facility's General Inspection of Sprinkler System report, based on an onsite inspection completed on 6/11/26, documented the fire alarm panel displayed, Trouble Fire - Zone 2 Open Fault and Trouble in System Ground Fault. The report further documented, During the storm the building's roof presented leaks and caused trouble on the fire panel.The fire system company's job worksheet dated 6/11/26 documented, Water damage, believe someone might have cut a wire - currently on Fire Watch. Emergency Call Out. FACP showing open on Zone 2 even with resistor connected directly to Zone 2. Also showing ground fault with nothing connected to the panel. Internal issue with panel. Panel needs to be replaced before further troubleshooting can occur. Quoted panel replacement to the customer.The facility's Fire Watch Policy, revised 6/1/18, required that whenever a significant portion of the fire alarm or sprinkler system is not functioning, the fire watch team will observe and inspect every room.The facility failed to ensure staff completed fire watch rounds in accordance with facility policy after a significant portion of the fire alarm system became impaired. Staff repeatedly failed to inspect all resident rooms within the affected fire alarm zone despite knowing the fire detection system for Zone 2 was unreliable and that the fire alarm control panel was experiencing an internal fault. This deficient practice left 10 residents residing on the Dementia Unit without the full compensatory fire safety measures required while the fire alarm system remained impaired.

Based on observation, interview, and record review the facility failed to protect residents' right to be free from verbal and mental abuse by staff for two of three residents (R127, R138) reviewed for abuse in the sample list of 64. This failure resulted in psychosocial harm of R127. Findings include: The facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated April 2021 documents residents have the right to be free from verbal and mental abuse and the facility will establish and maintain a culture of compassion and caring for all residents. 1.) On 5/31/2026 at 9:33 AM R127 stated R127 received medical neglect waiting for three hours for her call light to be answered while needing to be changed and this past Friday R127 was left in a wet brief for five hours. The same Certified Nursing Assistant (CNA) then declined to bring R127 ice water and food from the fridge. R127 stated the CNA was (V20). R127 stated, We (R127/V20) have gotten into it for my (R127's) call light being on for five hours. R127 stated V20 was very defensive about it and brought two people back with V20 to provide R127's incontinence cares, 'who all stood there watching me get changed while talking about car crashes, someone dying, and cheating'. R127 stated V20 screamed at R127 from the hallway that V20 had more important people to take care of and R127 should have told V20 that R127 wanted R127's food from the fridge. R127 stated this was witnessed by V37 CNA this past Thursday. R127 stated R127 reported these concerns to the wound nurse V26 Registered Nurse (RN) as well as unidentified CNAs. R127 stated R127 told V20 to stay the f*** (expletive) away from R127. R127 stated R127 feels V20's actions are abusive and R127 has called her family in tears because of this. R138, R127's roommate, stated R138 was present for these interactions between R127 and V20. R127 and R138 were observed residing in the same room. R127's Minimum Data Set (MDS) dated [DATE] documents R127 as cognitively intact and R127 is dependent on staff for toileting hygiene. R127's Care Plan dated 2/13/26 documents R127 is at high risk for abuse related to medical and physical condition. R127's Care Plan dated R127 has a behavior problem/accusation toward staff related to Bipolar Disorder, Anxiety Disorder, Paranoid Personality Disorder, and borderline personality disorder. The facility's daily staffing dated 5/29/26 documents V20 worked on R127's hallway on evening shift. On 5/31/26 at 3:33 PM V47 CNA stated V47 works evening shift often on R127's/R138's hallway, and R127 calls when R127 is incontinent. V47 stated V47 found R127 soaking wet twice with R127's call light on and R127 said the call light had been on for a long time. V47 stated this was about two or three weeks ago. V47 stated about two or three months ago V47 reported V20 to the former Director of Nursing, because V20 likes to be on V20's cellular phone instead of answering call lights and doing incontinence rounds. V47 stated R127 and R138 do not have any behaviors. V47 confirmed R127 and R138 are cognitively intact and credible. On 6/01/2026 at 10:31 AM V26 RN stated on dayshift on Tuesday of last week or Thursday/Friday of the week prior R127 voiced concerns about a CNA, ice not being available, R127's call light being on, and that the CNA brought a bunch of staff in the room during R127's incontinence cares. V26 confirmed R127 also alleged that the CNA yelled at R127. On 6/2/26 at 3:12 PM V37 CNA stated while V37 passing out supper trays on R127's hallway on Tuesday or Thursday of the week prior, R127 told V20 CNA R127 wanted R127's food from the fridge but V20 did not report this to V37. R127 then told V37 R127 did not get dinner because V20 never brought R127's food. V37 stated V37 witnessed V20 yell at R127 from the hallway saying V20 got busy and forgot, then R127 said V20 does not like R127 from a prior incident. V37 stated R127 and V20 verbally went back and forth but does not recall exactly what was said. V37 stated V37 would consider this to be verbal abuse, R127 is of sound mind and was offended by V20's actions. V37 stated on the Wednesday prior R127 told V37 R127 waited a long time to be changed, and a CNA brought two other unidentified staff in to watch while R127 was naked and provided incontinence cares. V37 stated R127 reported R127 did not like the staff's tone of voice and R127 was going to report this. V37 stated R127 also said R127 was waiting on ice water from dayshift for a couple hours and her water pitcher was still at the desk when V37 came in at 3pm. V37 stated at times R127 waits until R127 is saturated because R127 does not want certain people who make R127 feel uncomfortable taking care of R127. On 6/2/26 at 4:22 PM V20 CNA stated V20 provides care for R127 and last worked on Friday, 5/29/26. V20 stated R127 does refuse cares from V20, R127 wanted R127's food, V20 was in the hallway and R127 told V20 to get out of R127's room. 2.) On 5/31/2026 at 9:43 AM R138 stated, (V21 CNA) treats (R138) like sh** (expletive), (V21) tells me (R138) how nasty I (R138) am, and mistreats me (R138). R127, R138's roommate stated this incident happened around December 2025/January 2026 and R127 witnessed this incident. R127 stated R127 reported this to unidentified staff while sobbing because the incident made R127 feel uncomfortable. R138's MDS dated [DATE] documents R138 as cognitively intact. R138's Care Plan dated 2/13/26 documents R138 is at risk for abuse vulnerability related to medical and physical condition. V21's employee file contained an Education/Disciplinary Notice dated 3/19/26 documenting verbal warning given for customer service complaints, signed by V28 Social Service Director. On 6/01/2026 at 3:22 PM V28 stated V21's disciplinary action form was regarding V21's tone and being rude when answering a call light.

Based on observation, interview, and record review the facility failed to maintain communication and collaboration with an offsite dialysis center, follow dialysis and physician's orders, complete assessments and monitoring for dialysis related complications, and report elevated blood pressures for one of two residents (R15) reviewed for dialysis in a sample list of 64. These failures resulted in R15 being hospitalized and admission to the intensive care unit. Findings include: The facility's Diet Manual dated 2025 documents the following: A Chronic Kidney Disease (CKD) Renal diet is for resident's with CKD and is appropriate for resident's on dialysis. This includes 75-85 grams (g) of protein, 2.5-3.5 g of Sodium, 1.8-2.5 g of potassium and 1.5 g or less of phosphorous per day. Whole Milk is limited to 1/2 cup per day. High sodium foods, citrus fruits/juices, bananas, potatoes, beans, and tomatoes may be limited. A regular diet with renal precautions can be used instead of the CKD Renal diet which includes avoiding salt packets, not citrus fruits/juices, no bananas, limiting milk to one cup per day, and limiting potatoes to one serving at lunch and/or supper. Renal precautions should be documented on the resident's meal card and care plan. Ham is listed as a high phosphorous and sodium food, and potatoes are listed as a high potassium food.The facility's Diet Spreadsheet Week 2 dated 3/2/26 documents the following: On Sunday (5/31/26) regular diet lunch included brown sugar glazed ham, candied yams, and buttered peas. The CKD renal diet lunch included pork patty, buttered noodles, and buttered peas.On 05/31/2026 at10:27 AM R15 stated R15 receives dialysis three times per week and R15 is supposed to be on a renal diet, but that isn't followed as R15 frequently gets served potatoes. R15 stated the nurses do not do any assessment/monitoring after returning from dialysis and paperwork is not sent with R15 to dialysis. R15's left upper arm was wrapped with a gauze bandage. At 12:00 PM R15's meal ticket showed regular, No Added Salt diet, fluid restriction. R15 ate all the ground ham with gravy and peas and did not eat the mashed potatoes. R15 stated R15 isn't supposed to have mashed potatoes but R15 is served mashed potatoes every day. R15's meal tray included an 8 ounce glass of grape flavored drink. There was a water pitcher half full of ice at R15's bedside. R15 stated R15 is supposed to be on a fluid restriction.On 6/3/26 at 8:23 AM R15's meal tray was on the hall cart on R15's hall. R15's meal ticket documented regular diet and did not identify renal diet/precautions. There was an empty 8 ounce carton of milk and a 4 ounce glass of apple juice. This was confirmed with V3 Certified Nursing Assistant (CNA). V3 stated R15 is not on a fluid restriction. On 6/3/26 at 8:25 AM R15 had two water pitchers at her bedside, one full and the other half full, confirmed with V44 CNA. V44 stated staff do not do any tracking of R15's fluid intake.R15's active care plan includes interventions for monitoring and assessing R15's dialysis access site every shift, 1500 milliliter daily fluid restriction, administering medications as ordered, monitoring weights, dietary consult to regulate potassium intake, monitoring and reporting abnormal vital signs to the physician, and follow diet as ordered. R15's active physician's orders did not include daily fluid restriction, withholding medications on dialysis days, dialysis center information or frequency of dialysis. R15's orders included liberalized renal diet, check bruit and thrill of dialysis fistula every shift (5/31/26), obtain vital signs pre and post dialysis (5/31/26), and weigh weekly.R15's April 2026 and May 2026 Medication Administration Records (MARs) document the following: Weigh weekly as of 5/20/26 but does not list any weights recorded. R15 was on a 1500 milliliter (ml) daily fluid restriction with fluid intakes recorded and 7 days in April intake was greater than 1500 ml. R15's fluid restriction was not resumed on 5/8/26 after returning from the hospital and R15's assessment/monitoring of bruit and thrill was not resumed until 6/1/26. R15's pre-dialysis blood pressure was 170/78 on 4/29/26. Hydralazine Hydrochloride 50 milligrams (mg) by mouth three times daily for hypertension with seven missed noon doses in April, eight in May, and one in June on dialysis days.R15's weight log documents on 4/8/26 140.2 pounds and R15's last documented weight of 156.4 pounds on 5/7/26. R15's electronic medical record did not contain any dialysis communication forms after December 2025. R15's April-June 2026 nursing notes document intermittent communication with the dialysis center, not three times weekly.R15's dialysis communication binder, provided by V2 Director of Nursing, included paper communication forms that were not uploaded into R15's electronic medical record and did not consistently document written communication to/from the dialysis center three times per week. R15's Dialysis Communication Form dated 4/15/26 documents the dialysis center recorded R15's post-dialysis weight as 70.3 kilograms (kg) (154.98 pounds). R15's dialysis center communication documents R15's post-dialysis weights as 69.9 kg (154.10 pounds) on 4/17/26 and 71.9 kg (158.51 pounds) on 4/27/26; and R15 has complained of ongoing right side pain for about a week. R15's Dialysis Communication Form dated 5/27/26 documents the facility recorded R15's pre-dialysis weight as 156.4 pounds, R15's diet as regular and fluid restriction as n/a (not applicable).R15's Nutrition Note dated 5/21/2026 at 10:52 AM documents: R15 was assessed for nutrition related to dialysis and R15 has CKD stage 4. R15's diet orders include liberalized renal diet and 1500 ml daily fluid restriction. R15 had significant weight gain of greater than 10% in one month, likely related to fluid retention, and to continue to monitor weights weekly. R15 is at risk for nutritional decline related to End Stage Renal Disease on dialysis and need for therapeutic diet.R15's blood pressure log documents R15's blood pressure ranged from 107/70-153/77 between 4/2/26 and 4/25/26. This log documents R15's blood pressure as:164/77 on 4/26/2026 at 11:23 AM170/78 on 4/29/26 at 9:00 AM167/66 on 4/29/26 at 11:06 PM 174/76 on 5/1/26 at 2:04 PM177/72 on 5/3/26 at 11:17 AM164/79 on 5/4/2026 at 10:26 AMThere is no documentation in R15's medical record that the facility reported R15's blood pressures to R15's physician/practitioner prior to being hospitalized on [DATE]. R15's Nursing Notes document the following: On 4/2/26 at 1:02 PM the dialysis center called to request R15's Metoprolol orders be reviewed with the physician due to bradycardia episodes during dialysis treatments. On 4/29/2026 at 12:21 PM the dialysis center called to report R15's general fatigue/malaise, R15's pulse fluctuated 40-50 beats per minute and current blood pressure of 157/80, R15's dialysis treatment will be reduced to 1.9 liters, and message was left for R15's physician. On 5/4/2026 at 10:44 AM R15 had vomited twice, R15 had elevated blood pressure, dialysis treatment was cut short, and R15 was sent to the local emergency room.R15's Hospital History and Physical dated 5/4/26 at 7:30 PM documents R15 presented with headache, nausea, vomiting, and abdominal pain that has been ongoing for four days and was admitted for hypertensive urgency. R15's assessment/plan included poorly controlled hypertension, presented with elevated systolic blood pressures 170s-180s, R15 did not get her home medications including Amlodipine 10 mg daily, Clonidine 0.3 mg per hour patch, Hydralazine 50 mg three times daily, Toprol Extended release 100 mg daily. This includes instructions to give these medications after dialysis. R15's weight on 5/5/26 was 159 pounds. R15 was given intravenous cardiac medications and admitted to the intensive care unit.On 6/3/26 at 8:27 AM V38 Licensed Practical Nurse stated R15 goes to (dialysis center) and the contact information would not need to be documented in R15's medical record, agency staff would be verbally informed of R15's dialysis center information. V38 stated vital signs are taken pre/post dialysis and there would be no need to contact the dialysis center with any changes in R15's condition except on dialysis days. V38 stated R15 is on a fluid restriction with guidelines to follow which should be documented in physician's orders and the MAR. V38 reviewed R15's MAR and verified no documented fluid restriction or dialysis center information and frequency. V38 stated weights are recorded on the weight log and MAR but typically weights are done at dialysis, so the facility does not record the weights. V38 stated there are no parameters for when to notify the physician for pre/post dialysis monitoring and vital signs. V38 stated R15 does miss noon doses of cardiac medications on dialysis days, including Hydralazine. V38 confirmed there are no orders regarding this. V38 stated R15 has a dialysis access site in left arm and bruit/thrill is assessed and documented on the MAR. At 8:56 AM V38 confirmed R15's orders for dialysis frequency and center contact information as well as fluid restrictions were not resumed after R15 readmitted from the hospital and should have been.On 6/3/26 at 9:09 AM V43 Dialysis Clinical Care Coordinator stated the center requires the facility to give a verbal report prior to each dialysis treatment and the facility sends a paper form to document communication and any changes in condition. V43 stated R15 should be on a 1500 ml daily fluid restriction, if this isn't followed it could increase hypertension and lead to fluid retention. V43 stated the facility should monitor R15's blood pressure and overall condition following dialysis and notify the primary physician for any changes in blood pressure. V43 stated R15 can have mashed potatoes but depends on how many other potassium foods she is routinely consuming.On 6/3/26 at 8:40 AM V42 Nurse Practitioner stated the facility should notify a provider if R15's systolic blood pressure is greater than 160 and the facility should contact dialysis with vital signs prior to sessions so dialysis can make determinations. V42 stated R15 has a long-standing history of hypertension and R15 should have weekly weights. At 9:28 AM V42 stated R15 was hospitalized on [DATE], R15 received dialysis and cardiology evaluation/treatment. V42 stated V42 was on vacation the week prior but if V42 was notified of R15's increased blood pressures V42 may have adjusted R15's Metoprolol since that was recommended by R15's nephrologist. V42 stated the facility should have contacted R15's primary physician or an alternate nurse practitioner regarding R15's elevated blood pressures.On 6/3/26 at 9:35 AM V2 Director of Nursing stated weights are often deferred to dialysis to document on the communication forms. V2 stated physician notification would be documented in the nursing notes, and if it isn't documented in the nursing notes then there would be no additional documentation to provide. On 6/3/26 at 3:18 PM V2 provided and reviewed R15's dialysis communication binder. V2 confirmed these forms are not completed three times weekly and these forms have not been uploaded into R15's electronic medical record. V2 stated the facility and dialysis are to complete these forms pre and post each dialysis session.On 6/3/26 at 9:44AM V15 Assistant Dietary Manager stated R15 is on a regular diet, not a renal diet and R15 should be on a fluid restriction. V15 stated renal diets would avoid high potassium foods such as tomatoes, baked potatoes, oranges/juice, and sweet potatoes. V15 stated R15 can have mashed potatoes, which was served on 5/31/26 at noon and R15 was served ground ham as well. V15 reviewed the facility's weekly menu and confirmed mashed potatoes served in place of the sweet potato and brown sugar ham were listed as the regular diet, and renal diet listed pork patty with buttered noodles.On 6/3/26 at 10:11 AM V41 Registered Dietitian stated R15 is on a liberalized renal diet and 1500 ml daily fluid restriction. V41 stated liberalized mimics regular diet but removes foods that are higher in potassium, sodium and phosphorous based on laboratory results. V41 stated the dietary staff should follow the renal diet on the menu for R15 and if the diet and fluid restriction aren't followed this could cause fluid retention, edema, and affect R15's laboratory results. The facility's Hemodialysis policy dated 9/1/24 documents: The facility will provide care and treatment, consistent with professional standards of practice, physician orders, the resident's care plan/goals/preferences to meet the needs of residents who receive hemodialysis. This includes ongoing assessment and monitoring of the resident's condition and complications before and after dialysis treatments, and ongoing communication and collaboration with the dialysis center. The nurse will communicate to the dialysis facility via telephone or written communication including treatment orders, medication administration, nutritional/fluid management, weights, and change in condition. The nurse will monitor and document the status of the resident's access site upon return from the dialysis center and every shift. Physician's orders for dialysis should include the type of access site, the dialysis center name and contact information, transportation arrangements, any medication administration or withholding prior to treatments, and fluid restrictions.The facility's Care Planning Special Needs- Dialysis policy dated 9/1/24 documents: The care plan will reflect the responsibilities and coordination of care with the facility and the dialysis center. Interventions include documentation and monitoring of complications, pre and post weights, monitoring of access sites, nutrition/hydration, laboratory tests, vital signs, provision of medications, and transportation arrangements. Changes in condition following dialysis treatments will be reported immediately to the physician.

Based on observation, interview, and record review the facility failed to ensure food items were stored, labeled, and maintained in a sanitary manner. These failures have the potential to affect all 145 residents residing in the facility.Findings include:On 5/31/26 at 8:25 AM the kitchen and food storage areas were toured Dietary Aide, V16.Upon entering the storage room there was a red rack on the floor with three loaves of bread and four packages of hot dog buns. V16 went through the bread and buns removing four items. V16 stated the facility has mice and they ate through the wrappers and ate the bread and buns. Holes were present in the packages of bread and buns.In the freezer, multiple containers of ice cream and ice cream cups were observed with no dates indicating when they were opened.In the storeroom, the floor was visibly dirty with debris along the wall and under shelving.On the dry storage shelves, three bags of brownie mix were found with no date.On the rotation shelf, several gallon cans were stored without any dates indicating when they were placed into use.In the freezer, an opened box of cinnamon strudels was found with no date.Several storage totes used for holding food items were observed to be in poor condition, with rips and sharp edges. The facility was storing instant mash potatoes in a tote and the items were not dated. On the dry storage shelf, multiple gelatin packages were found without dates.Also in dry storage, four drink mix packages were found with no dates.During an interview at the time of the observations, the Dietary Manager V14 confirmed the items were not dated and the totes should have been replaced and acknowledged these practices did not meet the facility's food storage and sanitation policies.Facility's food storage policy was requested but never received.The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 5/31/26 documents 145 residents reside in the buildings.

Based on observation, interview and record review the facility failed to ensure an effective pest control program was maintained to prevent rodent activity in the main kitchen dry storage area. This failure resulted in food items being contaminated by mice and created the potential for food borne illness for all 145 residents who reside in the facility. Findings include:On 5/31/26 at 8:25 AM, the kitchen dry storage area was observed with V16 Dietary Aide. A package of sliced bread was observed in a red crate sitting on the floor with holes chewed through the packaging. Portions of the bread were missing in the areas surrounding the holes, consistent with rodent activity.A package of hot dog buns on the same shelving unit was also observed with holes chewed into the packaging, and sections of the buns were missing where the holes were present.The presence of holes in the packaging and missing product is consistent with mice having accessed and eaten the food items.on 5/31/26 at 8:30 AM at the time of the observation, V16 confirmed the packaging damage and missing pieces of product were caused by mice and acknowledged the items will be discarded immediately. V14 Dietary Manager, confirmed the kitchen has mice in the storage area and they have a contract with the pest control vendor, and will notify V40, Maintenance Director, to contact the vendor.Review of the contract vendor's Service Report dated 5/26/26 has the following comments: I inspected the (mouse traps) in the kitchen, office and restrooms. I found mice activity in the south kitchen and replaced the glue boards as needed. The Service Report dated 5/11/26 states During today's service I inspected (mouse traps) in the kitchen area. I found mice in (mouse trap) that was placed in the south kitchen.The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 5/31/26 documents 145 residents reside in the buildings.

Failures at this level required more than one deficient practice statement. A. Based on interview and record review the facility failed to maintain infection control logs that identified infectious organisms to monitor for trends. This failure has the potential to affect all 145 residents in the facility. B. Based on observation, interview and record review the facility failed to develop and implement a Legionella water management plan that included identified risk areas and control measures. This failure has the potential to affect all 145 residents in the facility. C. Based on observation, interview, and record review the facility failed to follow and implement Enhanced Barrier Precautions and failed to perform proper hand hygiene when administering medications via gastrostomy tube (G-tube) for two of six residents (R124, R111) reviewed for infection control from a total sample of 64 residents.Findings include: a.1) The facility's Infection Surveillance policy dated as revised June 2026 documents the following: Infection surveillance is the core of the facility's infection prevention and control program and identifies infections and monitors infection control practices to reduce and prevent the spread of infections. The Infection Preventionist leads surveillance activities and maintains documentation. Pathogens are included as part of the surveillance and monitoring of infection control. The facility's January-March 2026 Infection Control Logs do not include any surveillance or monitoring of infectious organisms for urinary tract infections to identify trends or patterns. The facility's May 2026 Infection Control Log does not document any surveillance or monitoring of infectious organisms. The column listed to document the organism is either left blank or just lists the general infection, such as pneumonia or urinary tract infection. On 6/01/2026 at 2:22 PM V26 Registered Nurse stated V26 was the former IP (Infection Preventionist) and was on vacation for the latter half of April until V26 returned on 5/6/26 when V26 became the facility's wound nurse. V26 stated V26 did not complete any infection control logs during that time for tracking and monitoring of infections. V26 stated V26 did not identify any trends in infections. On 6/01/2026 at 3:29 PM V6 IP confirmed the facility's May 2026 infection control log does not document infectious organisms. V6 stated V6 does not have access to obtain culture results and has to wait for nurse management to provide this documentation. V6 stated V6's role as the IP is to track and identify any trends/patterns in infections. V6 confirmed this should include monitoring for any patterns or trends in infectious organisms. On 6/2/26 at 8:43 AM V25 Assistant Director of Nursing (ADON) stated V25, and the former DON were trying to keep up with the infection control logs January-March 2026. V25 reviewed these logs and confirmed they do not document surveillance and monitoring of infectious organisms for urinary tract infections. The facility's LONG-TERM CARE FACILITY APPLICATION FOR MEDICARE AND MEDICAID dated 5/31/26 documents a census of 145 residents. b.1.) The facility's undated Legionella Surveillance policy documents the following: Legionella (bacteria commonly found in water) poses a health risk when grown in numbers, aerosolized, and breathed in through small, contaminated water droplets. Legionella grows best in water temperatures of 77 degrees Fahrenheit (F.)-108 F, especially in water that is not moving or does not contain disinfectant to kill germs. Showers and fountains create aerosols. Physical control measures include maintaining potable water systems and non-potable water systems shall be routinely cleaned and disinfected. Temperature controls include storing hot water above 140 F. The facility's undated Water Management Plan documents cold water is heated to approximately 145 F. throughout the buildings by multiple hot water heaters (refer to facility map) and then tempered via thermostatic mixing valves to 100 F-110 F distributed to all resident and staff handwashing stations. This water management plan does not identify any other Legionella risk areas or control measures. The facility's undated Water Flow Guide and Risk Areas for both the North and South building identify sinks, showers, and water heaters as Legionella risk areas. The facility's undated floor plans for both the North and South buildings identify multiple hot water heaters located throughout the buildings including hallways and resident room closets. On 6/02/2026 at 10:48 AM V40 Maintenance Director stated V40 temps the water at the faucets in resident rooms. V40 stated hot water tanks should be around 135 F but will have to check for sure. V40 was unsure how many hot water heater tanks the facility has. V40 stated the facility has one shower room that is not used and V40 flushes the water once per week. V40 stated the facility has one water fountain which requires filter changes but V40 has not changed the filter since November 2025 when V40 became the maintenance director. V40 was requested to provide documentation of the facility's Legionella control measures implementation. On 6/3/26 at 10:20 AM V40 provided logs of water temperature checks for resident rooms and bathrooms. V40 stated V40 had no other documentation or logs to provide for implemented Legionella control measures. Random hot water heater tanks stored in resident room closets on the North and South halls of the South building and the south halls of the North building were viewed with V40 and V39 Regional Maintenance Director between 10:25 AM and 11:05 AM. These hot water heater tanks did not contain gauges or thermostats to identify the temperature of the water stored in the tank, and one gauge was set at approximately 130 F. This was verified with V39 and V40. V40 stated all the facility's hot water heater tanks are like this and these tanks supply the water to all resident rooms and bathing areas. V40 stated the prior maintenance director had a device that would test the temperature of the hot water heater tank water, but it broke. V40 stated V40 checks shower heads as needed and changes the filters but has no documentation of this. V39 stated shower head cleaning should be done quarterly as part of the Legionella plan. V40 stated the facility has three shower rooms in the South building with one not in use, and two shower rooms in the North building. The facility's water fountain near the nurse's station in the South building was viewed during this time, the fountain was available for use/functional and contained a red light. V40 stated the red light indicates the filter needs changed. V39 stated that typically the water fountains have been removed from the other buildings this corporation manages. On 6/3/26 at 11:13 AM V40 reviewed the facility's Legionella plan and confirmed it did not address all risk areas in the facility and control measures to address these areas. The facility's LONG-TERM CARE FACILITY APPLICATION FOR MEDICARE AND MEDICAID dated 5/31/26 documents a census of 145 residents. c. 1.) On 6/1/26 at 9:22 a.m., V12, Licensed Practical Nurse (LPN), was observed administering R124's medications via gastrostomy tube (G-tube). Enhanced barrier precautions (EBP) signage was posted on the R124's room door. V12 prepared medications at the medication cart, entered R124's room, and put on gloves. V12 entered the shared bathroom and filled disposable cups with water from the sink, then mixed the medications with the water. V12 proceeded to the resident's bedside, verified G-tube placement, administered the medications via the tube, and flushed the G-tube following administration. During the observation, no hand hygiene was performed and V12 did not put on a gown prior to or during administration of R124's medications. On 6/1/26 at 9:45 a.m., V12, LPN, stated R124 is on Enhanced Barrier Precautions (EBP) and stated he should have worn a gown and performed hand hygiene during medication administration. V12 further stated that he had not been following those practices when providing care to R124. R124's Electronic Health Record dated 5/7/26 documents R124 has several medical diagnoses including Gastrostomy Status, Dysphagia, and cancer of the left lung and mandible. R124's Care Plan dated 5/7/26 documents that R124 requires tube feedings related to Adenocarcinoma of the left lung, Cancer of the mandible, and Dysphagia. R124's Medication Administration Record dated June 2026 documents R124 has an active order and is receiving Famotidine 20 milligrams (mg), one tablet via G-Tube one time a day, Sertraline oral concentrate 20 mg per milliliter (ml), 2.5 ml via G-Tube daily, GlycoLax powder, 17 grams via G-Tube two times a day, and Lyrica 50 mg via G-Tube two times a day. On 6/3/26 at 1:10 p.m., V2, Director of Nursing (DON), stated that V12, Licensed Practical Nurse (LPN), should have performed hand hygiene before, during, and after administering medications via G-tube to R124 and should have worn a gown during medication administration in accordance with the facility's Enhanced Barrier Precautions policy. c2. An admission Record dated 3/17/26 documents R111 has diagnoses including but not limited to peripheral vascular disease, acquired absence of right leg below knee, bacteremia, and type two diabetes mellitus with foot ulcer. On 5/31/2026 at 8:50AM, R111 was sitting in his wheelchair with his left foot wrapped. R111's left knee had a scab about the size of a quarter surrounded with redness. His left middle finger had two pinkish-red scabs near the knuckle. Outside of R111's room there is no Enhanced Barrier Precautions (EBP) signage posted, and no gloves, gowns, or masks were available. On 5/31/2026 at 9:14 AM, V51 (Licensed Practical Nurse) stated she had never heard of EBP at the facility and does not know what it is. On 6/01/2026 at 12:48 PM V6 (Infection Preventionist) stated R111 should be on EBP due to his wound. R111's care plan initiated on 4/2/26 documents R111's has a diabetic foot ulcer to his left foot but does not address EBP. R111's Order Summary Report dated 05/31/2026 was reviewed and no physician orders were present for EBP. The facility's Enhanced Barrier Precaution policy, revised in 2026, documents an order for enhanced barrier precautions will be obtained and initiated for residents with wounds, including diabetic foot ulcers.

Based on observation, interview and record review the facility failed to follow up on resident grievances reported in the resident council meetings and document the outcome of any actions taken to resolve the concern for nine of nine (R1, R55, R89, R100, R102, R106, R109, R110 and R136) residents reviewed for resident council on the sample list of 64. This failure also has the potential to affect all 145 residents residing in the facility. On 6/1/2026 at 1:30 PM during the resident council meeting, R1, R55, R89, R100, R102, R106, R109, R110 and R136 stated they do not feel that the facility always gives them a response to their grievances and if they do it is not timely. The facility's Resident Council Meeting minutes for the South building dated 12/30/25 document a concern that medications are not given on time. The facility's Resident Council Meeting minutes for the South building dated 1/27/26 do not document a follow-up to the concern from 12/30/25 that medications were not given on time. These minutes document a concern that dietary likes and dislikes are not followed. The facility's Resident Council Meeting minutes for the South building dated 2/23/26 do not document a follow-up to the concern that dietary likes and dislikes are not followed. The facility's Resident Council Meeting minutes for the North building dated 2/24/26 document a concern that tray tables are warped, cheese is not melted, there are not enough condiments, the food is cold and dried out, there are not appropriate serving sizes or enough to drink and there are no snacks. The facility's Resident Council Meeting minutes for the North building dated 3/31/26 do not document a follow-up to the dietary concerns from the 2/24/26 meeting. The facility's Concern/Compliment form dated 4/4/2026 documents a concern that ice water or hydration is not routinely passed. The follow-up section on this form is blank, and the outcome section of this form does not document whether the actions taken resolved the issue. On 6/1/2026 at 3:06 PM, V28 Social Service Director stated she does not document her follow up to the facility's grievances. The facility's Policy labeled Resident and Family Grievances with a review date of 5/2026, states the Grievance Officer will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. On 6/3/2026 at 2:17 PM, V34 [NAME] President of Clinical Operations stated V28 should have residents or representatives sign off on the grievances when V28 follows up with the residents to show they were notified. The facility's Long Term Care Facility Application for Medicare and Medicaid dated 5/31/26 documents there are 145 residents residing in the facility.

Based on observation, interview, and record review the facility failed to ensure access to the state survey results for nine of nine (R1, R55, R89, R100, R102, R106, R109, R110 and R136) residents reviewed for resident council on the sample list of 64. This failure also has the potential to affect all 145 residents residing in the facility. Findings include: On 6/1/2026 at 1:30 PM, during the resident council meeting R1, R55, R89, R100, R102, R106, R109, R110 and R136 stated that they do not know what the survey binder is or where it was located. On 6/1/26 at 1:55 PM, a survey binder was not in any of the common areas in the north or south buildings. On 6/1/2026 at 2:02 PM, V2 Director of Nursing stated she would locate the survey binder. At 2:13 PM, V2 stated she was still looking for it. At 2:25 PM, V2 stated the survey binder for the south building was found in the human resource office and there is not a binder for the north building. On 6/3/3026 at 2:17 PM, V34 Director of Clinical Operations stated the survey binder should be readily available to the residents. The facility's Long Term Care Facility Application for Medicare and Medicaid dated 5/31/26 documents there are 145 residents residing in the facility.

Based on observation, interview and record review, the facility failed to maintain accurate accounting of resident trust fund accounts and provide quarterly statements for four of five residents (R15, R138, R92, R111) reviewed for personal funds in the sample list of 64. Findings include: 1.) On 5/31/26 at 10:27 AM R15 stated R15 receives social security income and requested the surveyor check to ensure R15 is receiving R15's money. R15 stated R15 has a resident trust fund account but was unsure of statements or account balance. R15's Resident Statement with date range of 3/4/26-6/1/26 documents an accounting of R15's personal funds account. This statement documents a debit of $300 on 3/27/26 and a debit of $200 on 5/5/26. The Resident Trust Petty Cash Withdraw Log dated 3/5/26-3/27/26 documents a cash withdrawal of $300 on 3/27/26 for R15, signed only by V27 Business Office Manager and not R15. The Resident Trust Petty Cash Withdraw Log dated 4/7/26-4/14/26 documents a cash withdrawal of $200 on 4/14/26, signed only by V27 and not R15. This debit is not included in R15's Resident Statement. The Resident Trust Petty Cash Withdraw Log dated 5/29/26-6/1/26 documents a cash withdrawal of $200 on 5/29/26, which has not yet been reflected on R15's Resident Statement. There is no documentation that R15 or R15's family are provided with quarterly resident trust fund statements. On 6/02/2026 at 9:45 AM V27 Business Office Manager stated R15's statements are provided monthly to V46, R15's Family. On 6/2/26 at 12:38 PM V46 stated V46 does not receive R15's trust fund statements but the facility should be giving them to R15. V46 is unsure if this is being done. On 6/02/2026 at 12:20 PM V27 and V48 [NAME] President of Business Development reviewed R15's trust fund accounting ledger/statement and the withdrawal logs. V27 stated R15 withdrew $300 on 3/27/26 and $200 on 4/14/26. V27 verified R15's trust fund accounting ledger/statement does not match these withdrawals noted on the log. V27 stated V27 did not have R15 sign for the cash withdrawals, V27 just makes a notation that R15's family was aware of the withdrawal. V48 confirmed the accounting ledger/statement and withdrawal logs should match. V48 confirmed cash withdrawals require resident signatures. On 06/02/2026 at 1:40 PM V27 stated V27 does not have any documentation that trust fund statements are given to R15 or R15's family. 2.) On 5/31/26 at 9:31 AM R138 stated R138 is supposed to receive social security income and R138 was admitted with cash. R138 believes it is set up in a trust fund account but the facility does not inform R138 of R138's trust fund balance. R138's Resident Statement with date range 3/27/26-6/1/26 documents R138 had debits of $60 on 3/27/26 and 5/5/26 for personal needs items. These debits do not reflect the entries on the facility's cash withdrawal logs. The facility's Resident Trust Petty Cash Withdrawal log dated 3/5/26 documents a cash withdrawal of $60 by R138. The facility's Resident Trust Petty Cash Withdrawal Log dated 4/7/26 documents a cash withdrawal of $60 by R138. There is no documentation that R138 is provided quarterly trust fund statements. On 06/02/2026 at 9:45 AM V27 stated trust fund statements are given to R138 as needed on request. R138 does refuse at times because it upsets R138, but V27 reapproaches R138 and R138 will then usually agree to receive the statement. At 1:40 PM V27 stated V27 does not have any documentation that trust fund statements are given to R138. 3. R92's face sheet documents R92 admitted to the facility on [DATE]. On 5/31/2026 at 1:55 PM, R92 stated she did not know for a long time she had money in an account at the facility, and she does not receive quarterly statements. R92's electronic medical record does not document that R92 receives quarterly statements for her resident trust account. On 6/02/2026 at 1:32 PM, V27 Business Office Manager stated V27 attempted to give R92 a statement one time and R92 got upset. V27 stated she did not document this. V27 stated V27 has never provided R92 with a statement since that time. On 6/3/2026 at 2:17 PM, V34, [NAME] President of Clinical Operations, stated V27 should be attempting to give R92 her statement in a sealed envelope and documenting if she gets upset. 4. A Minimum Data Set, dated [DATE] documents R111 has moderate cognitive impairment. On 5/31/2026 at 8:50 AM, R111 stated he has five hundred dollars he gave to the facility to be kept in a safe and he has been requesting it, but no one has given him it. On 6/2/2026 at 8:45 AM, V27 (Business Office Manager) stated R111 does have money locked in a safe in her office. V27 stated R111 has requested portions of his money and received it, but never the entire amount. V27 stated R111 has taken out two or three dollars and R111's family is called when money is removed, but there is no record kept of these transactions. V27 took an envelope out of the safe and it had R11's name written on it with a date of 3/14/26 and the amount of $507.00. On 6/2/2026 at 9:15 AM, V27 counted R111's money in the envelope and $507.00 was in it. V27 stated R111 may not have taken out dollars but may have taken change (cents) from it. V27 stated R111's money is his own personal money and not a trust fund, so accounting does not need to be completed for it. V27 confirmed there is no accounting record for R111's $507.00. V27 and V1 (Administrator) are the only ones who have access to the safe. R111's medical record did not document a personal funds accounting sheet for R111's $507.00. The facility's Resident Personal Funds policy dated May 2026 documents if the resident chooses to deposit personal funds with the facility, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds. This policy documents resident personal funds in excess of $100 will be deposited in an interest-bearing account and will credit all interest earned for that account. This policy documents the facility will establish and maintain an accounting system according to generally accepted accounting principles of each resident's personal funds managed by the facility, and individual financial records must be available to the resident through quarterly statements and upon request.

Based on interview and record review the facility failed to follow their abuse prevention policy by failing to obtain employee background checks upon hire. This failure affects four of four residents (R127, R138, R15, and R2) reviewed for administration in the sample list of 64. Findings include: The facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated April 2021 documents the facility conducts employee background checks and will not knowingly employ individuals who have been found guilty of abuse and neglect by a court of law or had abuse/neglect findings or concerns entered into the state nurse aide registry. On 5/31/2026 at 9:33 AM R127 voiced allegations of abuse involving V20 Certified Nursing Assistant (CNA). R138, R127's roommate, stated R138 witnessed the incidents between V20 and R127.R127's Minimum Data Set (MDS) dated [DATE] documents R127 as cognitively intact and R127 is dependent on staff for toileting hygiene. R127's Care Plan dated 2/13/26 documents R127 is at high risk for abuse related to medical and physical condition. R127's Care Plan documents R127 has a behavior problem/accusation toward staff related to Bipolar Disorder, Anxiety Disorder, Paranoid Personality Disorder, and borderline personality disorder.V20's employee file does not contain any background checks. V20's (payroll form) documents V20's date of hire as 7/31/25. The facility's daily staffing dated 5/29/26 documents V20 worked evening shift on the North Hall of the South building. The facility's Midnight Census Report dated 5/31/26 documents R127, R138, R15, and R2 all reside on the North Hall of the South building. On 6/2/26 at 1:14 PM V1 Administrator provided V20's background checks dated 6/2/26 via electronic mail. On 6/2/26 at 3:40 PM V1 stated background checks should be done upon hire. V1 confirmed this would be part of the facility's abuse policy. On 6/2/26 3:05 PM V45 Human Resources was unable to locate V20's background checks so V45 ran them today. V45 confirmed V20's hire date. On 6/2/26 at 4:22 PM V20 CNA stated V20 provides care for R127 and last worked on 5/29/26 on the North Hall of the facility (where R127, R138, R15, and R2 reside).

Based on observation, interview, and record review the facility failed to ensure medications were appropriately stored and labeled for five (R16, R29, R57, R82, R125) of ten residents reviewed for labeling and storage of medications from a total sample of 64 residents.Findings: 1.) On 6/2/26 at 8:57 a.m., the facility's North Wing Medication Cart contained a medicine cup that held seven medications and were labeled with R16's name. V19, Licensed Practical Nurse (LPN) stated she prepared those medications to give to R16 and was not sure why she didn't give them when she pulled them from the cards, but she should have given them to R16 right away. V19, LPN went through each medication and identified/ confirmed the following medications were in the cup Haldol 5 milligrams (mg), Viread 300 mg, Levetiracetam 750 mg, Zonisamide 100 mg, and Multivitamin. R16's Medication Administration Record (MAR) dated June 2026 documents that R16 has an active order and is receiving Haldol 5 mg, 1 tablet by mouth twice a day, Viread 300 mg, 1 tablet by mouth daily, levetiracetam 750 mg, 2 tablets by mouth twice a day, Zonisamide 100 mg, 2 capsules by mouth twice a day and Multivitamin, by mouth once a day. On 6/3/26 at 11:08 a.m., the South Hall medication cart was reviewed with V35, Licensed Practical Nurse (LPN). During the review, an insulin lispro pen was observed with the label removed and no open date documented. V35 identified the pen as being used for R57 and stated it should have contained a label. V35 further stated that R57 had refused insulin that morning and that if she had noticed the pen was unlabeled, she would have disposed of it and obtained a properly labeled pen. R57's Electronic Health Record (EHR) documents that R57 has a diagnosis of Type 2 Diabetes Mellitus. R57's MAR dated June 2026 documents that R57 has an active order for Insulin Lispro 100 units per milliliter, with instructions for nurses to inject five units subcutaneously after meals. On 6/3/26 at 11:18 a.m., the East Hall medication cart was reviewed with V36, Licensed Practical Nurse (LPN). During the review, opened Insulin Glargine and Insulin Aspart pens labeled for R29 were observed without an opened date documented. The cart also contained a second Insulin Glargine pen with the pharmacy label removed and a small yellow label with R29's name; however, no open date was documented. R29's EHR documents a Medical Diagnosis of Diabetes mellitus due to an underlying condition with Chronic Diabetic Kidney Disease. R29's MAR dated June 2026 documents that R29 has an active physician's order and is receiving Insulin Aspart 100 units per milliliter with instructions for nurses to inject eight units subcutaneously before meals. This MAR also documents an order for Insulin Glargine 100 units per milliliter with instructions for nurses to inject 10 units subcutaneously in the morning. On 6/3/26 at 9:08 a.m., the North Building medication storage room was reviewed with V18, Registered Nurse (RN). During this review there was no thermometer found in the refrigerator and there was a Temperature Log dated June 2026 for North Building which does not contain any documentation. On 6/3/26 at 1:23 p.m., V2, Director of Nursing (DON), stated that insulin pens stored in a refrigerator prior to opening may become moist, causing labels to tear. V2 stated when this occurs, the pen should be discarded immediately and replaced with a properly labeled pen. V2 stated nurses should document when insulin pens are opened, calculate the 28-day discard date, and label the pens accordingly. V2 also stated that medication refrigerators should have a thermometer and that night shift nurses are responsible for documenting refrigerator temperatures each night. 2.) On 5/31/2026 at 9:29 AM R82 had a tube of menthol 5% on R82's overbed table. R82 stated the nurses apply the menthol to R82's arms, R82 does not apply the cream herself. R82's active physician's orders as of 5/31/26 do not include orders for menthol 5% or to keep this medication at the bedside. On 5/31/26 at 10:07 AM V5 Licensed Practical Nurse stated R82 does not have an order for to keep medications at the bedside or an order for Menthol topical gel. V5 entered R82's room and confirmed the menthol was on R82's overbed table. On 6/1/26 at 2:31 PM V2 Director of Nursing stated medications should be kept in the medication carts. V2 stated depending on the medication, the facility provides a lock box and key for the resident to keep in their room. V2 stated there should be a physician's order for the medication to be kept in the resident's room and an order for the medication. 3. On 5/31/2026 at 9:30 AM, two white tablets in a clear medication cup were sitting on R125's bedside table. No staff were present in the room. On 5/31/2026 at 9:33 AM, V30 Licensed Practical Nurse stated the tablets were Tylenol. V30 stated V30 did not administer the Tylenol to R125 and left them in the room for R125's family member V50 to give to R125. R15's electronic medical record did not contain an assessment for self-administration of medications or for medications to be administered by V50 On 6/3/2026 at 2:07 PM, V2 Director of Nursing verified that there was no order or assessment for self-administration or for V50 to administer his medications and staff should not be giving medications to V50.

Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to address a tripping hazard for two residents (R89, R100) of 18 residents reviewed for safety in a sample list of 64. B. Based on observation, interview, and record review the facility failed to provide supervision to prevent a fall, failed to implement post fall interventions, and failed to complete post fall neurological assessments for two of three residents (R17, R2) reviewed for falls in the sample list of 64. C. Based on observation, interview, and record review, the facility failed to provide required supervision during smoking for residents assessed as needing supervision while smoking for four (R64, R128, R130, R79) of four residents reviewed for smoking on of a sample list of 64.Findings included: a.1.) On 06/01/2026 at 2:50 PM Outside the door to R89 and R100's room a section of missing floor laminate approximately 6 feet in length and 2 feet wide was observed where the floor is uneven preventing R89 and/or R100 from entering or exiting without passing over this tripping hazard. R100's MDS dated [DATE] documents R100 uses a walker for ambulation and is unsteady on her feet. This MDS also documents R100 requires supervision or touching assistance for ambulation. On 6/1/26 at 2:10PM R100 was observed using the walker without assistance to walk over 50 feet unassisted from R100's room to the therapy area and back. R89 was observed on 6/1/26 at 2:10PM ambulating in her wheelchair with both her prosthetic legs in place to and from the therapy room. R89's MDS 3/26/26 documents R89 does not have any Prosthetics. On 6/2/26 at 11:00AM V1, Administrator verified the missing laminate causes a tripping hazard especially for the residents who reside in that room. b.1.) R17's Minimum Data Set assessment dated [DATE] documents R17 has moderate cognitive impairment. R17's Quarterly assessment dated [DATE] documents R17 is at high risk for falls. R17's undated Care Plan documents R17 is at a high risk for falls and should have anti-rollbacks on her wheelchair to aid in the prevention of falls with an initiation date of 1/08/2024. R17's care plan documents R17 has impaired cognitive function. On 5/31/2026 at 10:19 AM, R17 was sitting in her wheelchair in the dining room. No anti-rollback device was present on her wheelchair. R17 stated she fell a few days ago and had prior falls where she hurt her knee and couldn't hardly walk for a while after that. R17 stated It was a few months ago. On 6/03/2026 at 12:12 PM, V52 (Licensed Practical Nurse) recalled R17's fall on 5/26/2026. V52 was coming back from lunch when he saw R17 coming down the ramp and saw her fall. R17 slipped out of her chair. V52 stated there were other residents outside, but not staff. V52 did see multiple people inside the lobby. Normally R17 stays inside the building. On 6/03/2026 at 12:30 PM, V49 (Registered Nurse) recalled R17's fall on 05/26/2026. He reported R17 fell forward out of her chair outside of the facility on the ramp. There was an orientating receptionist that did not have a trainer with them at the time. The orientee let R17 out of the building. V49 does not believe the orientee was familiar with R17 and did not know to not let R17 go outside by herself. R17 was assessed and sent to the hospital for evaluation and treatment. On 6/03/2026 at 2:00PM, V2 (Director of Nursing) stated if a resident wants to go outside of the facility by themselves, they have to be cognitively intact and have a community survival skills assessment completed. If the resident is not cognitively intact then a staff or family member should be monitoring the resident outside. V2 confirmed R17 should not have been outside on 05/26/2026 by herself. R17's nurse's note dated 5/26/2026 at 7:00 PM documents R17 was observed outside near the facility ramp area following witnessed fall from wheelchair. R17 was assessed and her left knee was swollen and R17 reported pain in it. R17 was sent to the hospital for evaluation and treatment. b.2.) R2's Minimum Data Set, dated [DATE] documents R2 has moderate cognitive impairment. R2's Care Plan dated 12/10/25 documents R2 is high risk for falls related to weakness. This care plan includes fall interventions for orthostatic vital signs (5/1/26) and new lighter shoes for ambulation (5/13/26). R2's May 2026 Medication Administration Record documents R2 received Plavix (antiplatelet) 75 milligrams by mouth daily. R2's Nursing Note dated 5/1/2026 at 10:57 AM documents R2 exited his room requesting assistance and reported R2 had fallen in his bathroom and hit R2's head. This note documents R2 independently got himself up after the fall and complained R2's head was exploding. This note documents initial vital signs, provider notification and orders to send to the emergency room. Emergency services arrived but R2 refused to go to the hospital and was evaluated in R2's room by emergency medical personnel. Provider was notified of refusal, and neurological checks were initiated as ordered. There are no documented neurological assessments in R2's medical record following this fall. R2's Care Plan Summary note dated 5/15/2026 at 4:13 PM documents the following: The interdisciplinary team reviewed R2's 5/13/26 fall. R2 is alert and oriented to person, place and time and uses a four wheeled walker for ambulation. Nursing staff were in the rotunda when resident was walking towards the nurse's station. R2 tripped on his shoe due to heaviness and sustained a witnessed fall. Nursing staff immediately assessed resident, with no complaints of pain or reported injury. R2 assisted back to his feet and sat down on his four-wheeled walker. After 5-10 minutes passed, R2 complained of pain and requested to go to the emergency room. Physician was notified and R2 was transferred to the hospital and returned with a referral for orthopedics for right knee and ankle pain. R2 was placed in an immobilizer and stirrup. The root cause of the fall was unsafe footwear, and new intervention was to purchase new, lighter footwear. R2's Orthopedic After Visit Summary dated 5/21/26 documents fracture of the right leg. On 05/31/2026 at 8:31 AM R2 was in bed with a brace on his right leg. R2 stated he had a fall last week while walking in the hall by himself. R2 stated R2's wheeled walker got too far ahead of R2 and R2 went down. On 6/3/26 at 12:50 PM R2 had a brace on his right leg. R2 stated the orthopedist said R2 has a fractured tibia from the fall. R2 had white tennis shoes at his bedside. R2 stated those are the shoes R2 was wearing when R2 fell, and no one has provided different shoes following the fall. On 6/3/26 at 12:53 PM V2 Director of Nursing confirmed R2's post fall interventions for orthostatic blood pressures and new shoes. V2 reviewed R2's blood pressure log and confirmed there were no documented orthostatic blood pressures documented. V2 stated V28 Social Services Director was supposed to purchase new shoes for R2 that were lighter, following R2's fall. V2 confirmed there were no documented neurological assessments after R2's fall on 5/1/26. V2 stated that is something V2 is working on. On 6/3/26 at 1:00 PM V28 stated V28 had asked R2 about getting different shoes that were lighter but V28 was waiting to see what shoes R2 wanted V28 to purchase. V28 stated V28 had not yet purchased new shoes for R2. c.1). On 6/01/2026 at 1:20 PM, R64 and R128 were seated in two chairs and smoking approximately 6 feet from the entrance doors of the front building with a No Smoking sign posted. There was no staff present outside with R64 and R128 at this time. R130 and R79 were smoking by themselves in the designated smoking area. Upon entrance into the doorways, V23 (Activity Aide) was approaching the entrance doors. V23 confirmed residents are not supposed to smoke in the non-smoking area. V23 statedThe residents are technically supposed to be past the fencing on the sidewalk (which is approximately 15 feet away from the building), but don't always do that. V23 usually supervises the residents who smoke by walking back and forth outside of the building to each smoking area or she will sit in the activity room and look back and forth through the windows. On 06/01/2026 at approximately 4:40 PM, V1 (Administrator) confirmed residents should not be smoking within 15 feet of the facility entrance and that a staff member should be outside with and supervising the residents smoking at all times. R64's Care Plan documents R64 is a smoker and requires supervision while smoking with an initiation date of 05/30/2024. R79's Care Plan documents R79 is a smoker and will be supervised while smoking with an initiation date of 02/27/2025. R128's Care Plan documents R128 requires supervision while smoking with an initiation date of 03/27/2026. R130's Care Plan documents R130 is a smoker and requires observation while smoking with an initiation date of 06/19/2023. The facility's Smoking Policy, revised in August of 2022, documents smoking is only permitted in designated resident smoking areas and that any resident with smoking privileges that require monitoring has to have direct supervision at all times while smoking.

Based on observation, interview, and record review the facility failed develop and implement comprehensive care plans for discharge planning for four residents (R92, R127, R138, R154) of four residents reviewed for discharge planning in a sample list of 64. Findings include: 1.) R154's progress note documents R154 was admitted [DATE] and was alert and oriented. R154's Minimum Data Set (MDS) dated [DATE] documents R154 is cognitively intact. R154's Care Plan updated 3/24/26 documents R154 is taking part in the following restorative nursing programs: Passive Range of Motion, Active Assisted Range of Motion, Bathing, and Grooming. This Care Plan further documents (R154) wishes to return/be discharged to community/prior living arrangements after she completes therapy and medically ready.On 5/31/26 at 10:00AM R154 was observed lying in bed on an alternating pressure air mattress on her back. R154 stated, I was supposed to be here for rehab and to go home. I'm not getting any therapy. They tell me if I can't go to the therapy room, I can just lay here. They leave me here in my bed soaked in urine and poop. I ring the bell. They say they need help and don't come back. Nobody has talked to me about a plan to go home. I'm just stuck here. R1 stated, I'm really sensitive about my size (587pounds) and the staff here think I don't want to try but I do. R154 sniffed and tears welled up in her eyes. On 6/2/26 at 2:00PM V28 (Social Service Director) and V29 (Care Plan Coordinator) were in the therapy room. When surveyor inquired about viewing therapy notes, V28 stated, (R154) hasn't had any therapy because (R154) won't get out of the bed and even though she is continent She urinates and defecates in her bed. I haven't done anything to find a place for her out of the facility. I just assumed she'd work with her family to find a place. (R154) won't do anything for herself. 2. On 5/31/2026 at 1:55 PM, R92 stated she wants to go home, and staff have not asked her about discharge planning. R92 was tearful and stated she wanted to be closer to her daughter so she could see her. R92's Progress Note dated 5/3/2026 where documentation was present for R92 declining to want to go home did not include an evaluation of discharge needs or a discharge plan. R92's Discharge Care Plan dated 2/18/25 documents that this care plan has not been revised since 2/18/2025. On 6/01/2026 at 3:06 PM, V28 Social Service Director stated R92 stated she has not attempted to contact outside agencies to help R92 be able to be discharged to the community. V28 referenced a discharge planning review from 10/14/2024 and social services progress note dated 5/3/2026 as documentation for R92 not wanting to be discharged . On 6/3/30206 at 2:07 PM, V2 Director of Nursing and V34 [NAME] President of Clinical Operations stated V28 should be discussing discharge planning with R92 quarterly and documenting appropriately. 3.) On 5/31/2026 at 9:43 AM R138 stated no one has helped R138 with discharge planning and R138 has spoken to V28 Social Services Director (SSD) about this. V28 told R138 that R138 could not discharge because R138 could not wash R138's feet. R138 stated three months ago R138 also discussed discharging with the former SSD. R138 stated the staff have this attitude that R138 is going to be in this facility forever, R138 does not want to be in this facility and R138 does not require a lot of care. R138 stated R138 would like therapy services to get stronger and be able to discharge. R138's admission MDS dated [DATE] documents there was no active discharge planning and R138 did not wish to discharge from the facility. R138's MDS dated [DATE] documents R138 as cognitively intact. R138 requires supervision/touch staff assist for Activities of Daily Living, except for bathing which requires partial/moderate assistance (helper does less than half the effort.) This MDS documents R138 did not receive therapy services and there was no discharge planning. R138's active care plan does not include a problem, goals or interventions for discharge planning. R138's electronic medical record does not contain documentation regarding discharge planning. R138's Physical Therapy Discharge summary dated [DATE] documents R138 discharged from therapy services. On 6/1/26 at 10:24 AM V28 stated V28 asks about discharge planning quarterly as part of the MDS review and discharge planning is documented in the social services progress notes. V28 stated R138 wants to discharge to an assisted living apartment but R138 is unable to bathe R138's self. V28 stated R138 is currently on a wait list for (assisted living facility). At 1:48 PM V28 stated V28 did not have documentation to provide for R138's discharge planning. V28 stated about a year ago V28 had electronic mail documentation with (assisted living facility) regarding R138, that facility does their own assessment to determine if the resident is appropriate for admission. V28 stated R138 received therapy when R138 first admitted but R138 hasn't mentioned anything further about therapy. V28 stated V28 usually coordinates therapy services with V55 Director of Rehabilitation. On 06/01/2026 at 2:08 PM V55 stated nursing staff notifies the therapy department of resident requests for therapy so a screening or evaluation can be completed. V55 stated R138 received occupational therapy from 5/22/25-6/16/25 and physical therapy from 6/20/25-7/16/25. V55 stated R138 was able to walk 37 feet with a wheeled walker and minimal staff assist upon discharge. 4.) On 05/31/2026 at 9:33 AM R127 stated R127 is wanting to discharge to R127's own place with home care, but no one is helping R127 facilitate this. R127 stated R127 talked to R127's insurance company, the local Department of Rehabilitation for home services, as well as V28 and the former SSD. R127 stated R127 last requested discharge planning about two months ago and has asked about getting therapy services to help R127 get stronger to discharge but R127 has not received any therapy services. R127's MDS dated [DATE] documents R127 is cognitively intact, R127 did not receive therapy services and there was no discharge planning. R127's Care Plan documents a problem dated 2/12/25 R127 desires to discharge home. R127 will set and achieve discharge goals that R127 has set. This care plan documents R127 and R127's responsible party have discussed remaining in the facility per physician recommendations. This care plan includes an intervention that social services will address discharge planning at R127's request. This care plan has not been updated since 2/12/25. R127's Social Service Progress Note dated 12/28/25 documents R127's goal is to discharge home within the next year, R127 is currently working with R127's family to make this possible, and SSD will continue to monitor and assist R127 with discharge planning when R127 is ready. There are no documented discharge planning notes after this in R127's medical record. R127's Physical Therapy Discharge summary dated [DATE]-[DATE] documents R127 discharged from therapy on 8/11/25. On 6/01/2026 at 10:24 AM V28 stated R127 wants to go home but requires extensive assistance and 24 hour care, and R127's family are unable to take care of R127. V28 stated V28 has reached out to local services to inquire about getting home health care services for R127. At 1:48 PM V28 stated V28 could not locate any other documentation for R127's discharge planning. V28 stated R127 would set up home health services if R127 had a discharge date and plan but there are none. V28 stated this is not something that is brought up all the time. V28 stated R127 received therapy and was able to sit up on the side of the bed, but now R127 refuses. V28 stated it is news to V28 that R127 requested therapy services and V28 coordinates with V55 for therapy services.On 06/01/2026 at 2:08 PM V55 stated R127 received physical therapy 7/16/25-8/11/25 and was supposed to go home with family but R127's family changed their mind as they didn't think they could take care of R127. V55 stated R127 requires extensive care, at the time of therapy discharge R127 was able to sit on the edge of the bed, R127 did not walk, and R127 used a full mechanical lift for transfers. The Discharge Planning Policy, revised 5/2026, states the evaluation of the discharge needs and plan will be completely documented on a timely basis in the clinical record. This policy documents that a resident discharge plan will be evaluated quarterly, and the assessment information and discharge goals will be reflected in the care plan.

Based on observation, interview and record review the facility failed to report allegations of abuse to the administrator and state survey agency for three of three residents (R127, R138, R79) reviewed for abuse in the sample list of 64. Findings include: 1.) On 5/31/2026 at 9:33 AM R127 stated R127 received medical neglect waiting for three hours for her call light to be answered while needing to be changed and this past Friday R127 was left in a wet brief for five hours. The same Certified Nursing Assistant (CNA) then declined to bring R127 ice water and food from the fridge. R127 stated the CNA was (V20). R127 stated, We (R127/V20) have gotten into it for my (R127's) call light being on for five hours. R127 stated V20 was very defensive about it and brought two people back with V20 to provide R127's incontinence cares, who all stood there watching me get changed while talking about car crashes, someone dying, and cheating. R127 stated V20 also screamed at R127 from the hallway that V20 had more important people to take care of and R127 should have told V20 that R127 wanted R127's food from the fridge, witnessed by V37 CNA this past Thursday. R127 stated R127 reported these concerns to the wound nurse V26 Registered Nurse (RN) as well as unidentified CNAs. R127 stated R127 told V20 to stay the f*** (expletive) away from R127. R127 stated R127 feels V20's actions are abusive and R127 has called her family in tears because of this. R138, R127's roommate, stated R138 was present for these interactions between R127 and V20. R127 and R138 were observed residing in the same room. R127's Minimum Data Set (MDS) dated [DATE] documents R127 as cognitively intact. The facility's abuse log March-May 2026 does not document any allegations of abuse involving R127/V20. On 5/31/26 at 3:20 PM V1 Administrator and V2 Director of Nursing both stated they had not received any complaints or abuse allegations involving R127. On 6/01/2026 at 10:31 AM V26 RN stated on dayshift on Tuesday of last week or Thursday/Friday of the week prior R127 voiced concerns about a CNA, ice not being available, R127's call light being on, and that the CNA brought a bunch of staff in the room during R127's incontinence cares. V26 confirmed R127 also alleged that the CNA yelled at R127. V26 stated V26 filled out a grievance forming documenting R127's concerns and gave the form to V1 Administrator immediately after R127 voiced the concerns. At 2:22 PM V26 stated V26 did not physically hand V1 this grievance, V26 left it on V1's desk. On 6/2/26 at 3:12 PM V37 CNA stated while V37 passed supper trays on R127's hallway on Tuesday or Thursday of the week prior, R127 told V20 CNA R127 wanted R127's food from the fridge but V20 did not report this to V37. R127 then told V37 R127 did not get dinner because V20 never brought R127's food. V37 stated V37 witnessed V20 yell at R127 from the hallway saying V20 got busy and forgot, then R127 said V20 does not like R127 from a prior incident. V37 stated R127 and V20 verbally went back and forth but does not recall exactly what was said. V37 stated V37 would consider this to be verbal abuse, R127 is of sound mind and was offended by V20's actions. V37 stated on the Wednesday prior R127 told V37 that R127 waited a long time to be changed and a CNA brought two other unidentified staff in to watch while R127 was naked and provided incontinence cares. V37 stated R127 reported R127 did not like the staff's tone of voice and R127 was going to report this. V37 stated R127 also said R127 was waiting on ice water from dayshift for a couple hours and her water pitcher was still at the desk when V37 came in at 3pm. V37 stated at times R127 waits until R127 is saturated because R127 does not want certain people who make R127 feel uncomfortable taking care of R127. V37 stated V37 did not report this to anyone and V37 was unsure who the facility's abuse coordinator was. On 6/1/26 at 12:26 PM V1 stated V1 doesn't have a grievance, and nothing was reported to V1 from V26. V1 stated V1 would want to be notified of these things right away. On 6/2/26 at 3:40 PM V1 Administrator confirmed abuse allegations are to be immediately reported to V1. 2.) On 5/31/2026 at 9:43 AM R138 stated, (V21 CNA) treats (R138) like sh** (expletive), (V21) tells me (R138) how nasty I (R138) am, and mistreats me (R138). R127, R138's roommate stated this incident happened around December 2025/January 2026 and R127 witnessed this incident. R127 stated R127 reported this to unidentified staff while sobbing because the incident made R127 feel uncomfortable. R138's MDS dated [DATE] documents R138 as cognitively intact. On 5/31/26 at 3:20 PM V1 Administrator and V2 Director of Nursing both stated they had not received any complaints or abuse allegations involving R138. At this time R138's allegation involving V21 CNA was reported. On 6/2/26 at 3:40 PM V1 stated V1 was unable to locate any documentation that R138 reported these concerns to any staff and V1 checked the December 2025 and January 2026 grievances. V1 stated R138 did not voice any concerns while V1 and V2 discussed R127's allegation with R127. V1 confirmed V1 did not report R138's allegation involving V21 CNA to the state survey agency and confirmed abuse allegations should be reported to the state survey agency. 3. A Minimum Data Set, dated [DATE] documents R79's is cognitively intact. An admission Record dated 05/31/2026 documents R79 diagnoses include but are not limited to Schizoaffective Disorder, Generalized Anxiety Disorder, Borderline Personality Disorder, Paranoid Personality Disorder, Bipolar Disorder, Attention-Deficit Hyperactivity Disorder, Delusional Disorders, and Suicidal Ideations. On 05/31/2026 at 9:55 AM, R79 was sitting in his room. R79 reported recently a catastrophe happened here (the facility). R79 stated he got into a fight with V12 Licensed Practical Nurse. R79 stated R79 was in his room playing his guitar and V12 came in and slammed the door. R79 stated R79 came out of his room and told V12 that R79 would kick his (V12) a** if V12 slammed his door again. R79 stated V12 then called R79 a [NAME] and chased R79, so R79 threw a chair at V12 and V12 called the cops on R79. R79 had to go to the local hospital. R79 stated V12 is very triggering to R79 now and R79 hears V12 saying things like suicide outside of R79's room to taunt R79. R79 stated R79 has tried to talk with the nurses about it. R79 stated this (the facility) is his home and he feels V12 is trying to destroy R79's life. R79 reported he just sits in his room with his headphones on. On 05/31/2026 at 3:23 PM, V1 (Administrator) stated V1 was unaware of R79's reports of V12 triggering and taunting R79 by saying things like suicide outside of his room after the incident on 5/21/26. V1 reported he will investigate R79's reports of taunting by V12. On 06/03/2026 at 9:30 AM, V1 (Administrator) stated he has not reported the allegation of abuse he received on 5/31/26 regarding R79 and V12 to the state agency. The facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated April 2021 documents residents have the right to be free from verbal and mental abuse and the facility will establish and maintain a culture of compassion and caring for all residents. This policy documents the facility will identify all possible incidents of abuse and report any allegations within the timeframes required by federal requirements.

Based on interview and record review the facility failed to ensure the surety bond exceeds the total resident trust fund balance. This failure affects three of five residents (R15, R92, R138) reviewed for resident trust funds in the sample list of 64. Findings include: The facility's Resident Personal Funds policy dated May 2026 documents The facility will purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. The facility's Bond Continuation Certificate dated 5/2/25 and ending 7/31/26 documents an insured sum of $117,000. The facility's Commercial Interest Checking statement dated 4/1/26-4/30/26 documents the total resident trust fund beginning balance of $126,776.99 and ending balance of $150,821.17. The minimum balance was $128,100 and average balance was $150,582. R15 and R138 are listed in this statement. The Trial Balance dated 6/2/26 documents a total resident trust fund balance of $157,677.38. R15, R138 and R92 are included in the resident trust fund balance. On 6/02/2026 at 10:37 AM V27 Business Office Manager verified the total resident trust fund balance for April 2026 exceeded the facility's surety bond. At 1:40 PM V27 provided the current resident trust fund balance and confirmed it exceeds the surety bond. V27 stated V27 requested a surety bond increase today.

Based on observation, interview, and record review, the facility failed to ensure residents are treated with dignity and respect for four of 29 residents (R2, R15, R10, R143) reviewed for resident rights in the sample list of 64. Findings include: 1.) On 5/31/2026 at 11:57 AM R2 was in R2's room using a plastic spoon to eat. There were no other utensils on R2's meal tray. R2 had no upper or lower teeth. R2's meal included a ham slice, baked potatoes and peas. R2 stated the plastic spoon was the only utensil provided with R2's meal and it was difficult to cut the ham. R2's roommate, R10, was also using a plastic spoon to eat and there were no other utensils on R10's meal tray. R10's meal included a ham slice cut into pieces and baked potato. On 5/31/26 at 12:00 PM R15 was eating in R15's room using a plastic spoon to eat. R15's meal tray did not include any other utensils. R15 stated the plastic spoon was the only silverware provided with R15's meal. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has moderate cognitive impairment, has no natural teeth, and R2 had significant weight loss in one or six months. R10's MDS dated [DATE] documents R10 has severe cognitive impairment. On 5/31/2026 at V3 Certified Nursing Assistant confirmed some residents were served regular silverware and some served plastic for the North Hall room trays. V3 stated the kitchen staff told V3 the kitchen ran out of regular silverware, so plastic silverware was used. V3 confirmed only plastic spoons were served on these trays. On 6/01/2026 at 11:15 AM V15 Assistant Dietary Manager stated, I (V15) don't know why they (staff) would serve plastic silverware to the residents for lunch. V15 stated V15 orders metal silverware, all three utensils, twice a week, which comes in packages of 24 for each utensil. V15 stated silverware goes missing but the facility has plenty of knives. V15 confirmed it would not be acceptable to provide only a plastic spoon for meals and would not be appropriate to eat sliced ham with a plastic spoon. 2. R143's Minimum Data Set assessment dated [DATE] documents R143 is cognitively intact. An admission Record dated 6/03/2026 documents R143's diagnoses include, but are not limited to Cerebral Infarction, Major Depressive Disorder, and anxiety disorder. On 6/01/2026 at 3:00 PM, V53 (Licensed Clinical Social Worker) was speaking very loudly down the hallway stating, That was inappropriate! I don't appreciate being talked to that way!. At approximately 3:05 PM, V53 stated V53 didn't like R143's tone of voice and that is why she said that to R143. On 6/01/2026 at 3:20 PM, R143 stated that she was talking to V53 about her concerns with needing more assistance at times and frustrations with staff and V53 said, You're just going to have to put up with it. R143 reports her interaction with V53 just makes her feel like she is not being treated with respect. R143's Social Services Trauma Informed Care assessment dated [DATE] documents loud noises are a trigger for R143 that causes her alarm or distress.

Based on interview and record review the facility failed to accurately transcribe an opioid analgesic medication order and failed to ensure nursing staff questioned and verified a large dose of a high-risk medication (Morphine 500 mg) before administration. This failure resulted in R5 experiencing drowsiness, respiratory depression, and memory loss. R5 was treated with Narcan (opioid antagonist) and later sent to the emergency room. These failures affected one of three residents (R5) reviewed for Pharmaceutical Services on the sample list of ten. The Immediate Jeopardy began on 3/10/26 when R5 was given an overdose of Morphine Sulfate (500 milligrams). V1 Administrator was notified of the Immediate Jeopardy on 3/31/26 at 2:50 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 3/10/26 and the deficient practice corrected on 3/11/26 prior to the start of the survey and was therefore Past Noncompliance. No POC or Revisit will be required. Findings Include: The facility's Medication Administration policy dated 3/10/26 documents medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Nurses are to ensure that the six rights of medication administration are followed: right resident, right drug, right dose, right route, right time, and right documentation. Nurses are to review the Medication Administration Record (MAR) to identify the medication to be administered. Nurses are supposed to compare the medication source with the MAR to verify resident name, medication name, form, dose, route, and time, Nurses are to refer to drug reference material if unfamiliar with the medication. All medications are to be signed off when given in the MAR. If the medication is a controlled substance, nurses are to fill out and sign the corresponding narcotic book. The facility's Controlled substance Administration and Accountability policy dated 10/1/25 documents the facility will have safeguards in place to prevent loss, diversion, or accidental exposure. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. In all cases the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form. The Controlled Drug Record served the dual purpose of recording both narcotic disposition and patient information. R5's Hospice Orders dated 3/5/26 document an order for Morphine Sulfate (Concentrate) Oral Solution 100 milligrams per 5 milliliters- give 0.25 milliliters by mouth every two hours as needed for moderate pain/air hunger. R5's Physician Order Sheet dated March 2026 documents and order for Morphine Sulfate (Concentrate) Oral Solution 100 milligrams per 5 milliliters- give 30 milliliters by mouth every two hours as needed for moderate pain/air hunger. R5's Medication Administration Record (MAR) dated March 2026, documents on 3/10/26 V9 Registered Nurse (RN) administered approximately 30 milliliters of Morphine Sulfate orally to R5. On 3/25/26 at 2:03 PM V9 Registered Nurse (RN) stated on 3/10/25 at 7:50 AM, she administered approximately 25 milliliters (500 milligrams) of Morphine Sulfate orally to R5 which is 100 times the prescribed dose for R5. V9 stated the order was transcribed incorrectly into R5's Physician Orders and Medication Administration Record. V9 stated she should have verified the order. V9 confirmed she neglected to document the dose she administered on the corresponding narcotic count sheet. V9 stated R5 went about her normal routine most of the morning. V9 stated, about 12:30 PM, when V10 Hospice Certified Nurse Assistant (CNA) came to V9 to inquire about R5's pain medicine, is when she realized she had given R5 an overdose of the Morphine earlier that morning. V9 stated she notified V1 Administrator and V2 Director of Nurses (DON) of her mistake. V9 stated all three of them (V1, V2, V9) went into R5's room right away. R5 was very difficult to arouse. V9 stated V1 asked her to get an order for Narcan (opioid antagonist) and administer the medication to R5. V9 stated she got the order, administered one dose of Narcan and within about 30 seconds R5 began to wake up and was confused as to why there were so many staff in her room. On 3/26/26 at 2:20 PM V10 Hospice Certified Nurse Assistant (CNA) stated she arrived at the facility to provide care for R5 on 3/10/26 at approximately 12:30 PM. V10 stated when she arrived R5 was sleeping. V10 stated when she asked R5 if she was in pain, R5 responded with a very quiet whisper, yes. V10 stated she left R5's room to talk to R5's nurse (V9 Registered Nurse). V10 stated she told V9 that R5 was in pain and asked if she could have more pain medicine. V9 went to check and came back stating she believed there was a mistake, and she had administered the wrong dose earlier that morning and therefore did not have any more morphine to give R5. V9 told V10 that R5 was given approximately 30 milliliters of Morphine Sulfate. V10 stated she called her Hospice Nurse (V21) and Hospice Director of Nurses (DON V19) to report the overdose. V10 stated she went back into R5's room and took her vital signs. V10 stated R5 was difficult to arouse, her eyes were fluttering open and closed, and she could not visually see R5 breathing so she had to place her hand on R5's chest to take her respiratory rate, which was very slow. On 3/27/26 at 10:39 AM V19 Hospice Director of Nurses (DON) stated she was called on 3/10/26 by V10 Hospice CNA who was concerned for R5's wellbeing. V10 told V19 that the facility had given R5 an overdose of Morphine and R5 was very drowsy and was very hard to wake up. V19 stated she had instructed V10 to take R5's vital signs while she was on the phone with her and V10 said it was hard to get R5's respiratory rate because her breaths were so shallow and slow. V10 had to place her hand on R5's chest to count any breaths. At that time R5's respiratory rate was decreased. On 3/26/26 at 2:06 PM V21 Hospice Registered Nurse stated V10 Hospice CNA called her to report R5 had received a significant overdose of Morphine that morning (3/10/26). V21 RN stated she went straight to the facility. She arrived at the facility at about 1:50 PM. R5 had just received one dose of Narcan. V21 stated V1 Administrator, V2 DON, and V9 RN as well as V10 CNA were in R5's room. V9 was taking R5's vital signs. V21 stated she remembers R5's respiratory rate was an eight (Breaths per Minute) at the time. R5 was very confused at the time and was not quite sure why everyone was in her room. On 3/26/26 at 12:21 PM V22 Hospice Licensed Practical Nurse stated she arrived at the facility on 3/10/26 at about 10:00 PM for a bedtime visit with R5. V22 stated she found R5 in her room in bed. R5 asked her for a drink of water but when V22 gave her the cup, R5 took a sip and then started to fall asleep while holding the water. V22 stated she took R5's vital signs and R5 had periods of apnea, and her respiratory rate was ten (Breaths per Minute). V22 stated R5's eyes rolled back in her head, and she wouldn't respond for a minute. V22 stated she consulted V21 Hospice DON and V29 R5's family who all agreed she should be sent to the emergency room. R5 was transferred to the emergency room for assessment after morphine overdose. On 3/27/26 at 11:47 AM R5 stated she remembered the morphine dose on the morning of 3/10/26 was a lot larger than normal. V9 RN put the Morphine in a medicine cup, and she usually got it in a little dropper under her tongue. R5 stated she wasn't sure maybe if the dose or medication changed but she took the medicine. R5 stated she remembers eating her breakfast that morning but doesn't remember anything after until V22 Hospice Nurse was telling her was going to the hospital, and she was confused as to why. R5 stated she knows they said she had a morphine overdose, and she knows she wasn't herself that day. R5 stated she can remember everything during and after the emergency room visit and everything before breakfast, but everything in between is just blank. R5 stated she is glad she is still alive. R5 stated she would not have wanted to die from someone's mistake. On 3/27/26 at 12:15 PM V25 Pharmacist stated an overdose of concentrated oral Morphine could results in shallow breathing, decreased respirations, impaired cognitions, and other effects up to or including death. On 3/27/26 at 3:44 PM V30 Hospice Medical Doctor confirmed a dose of 500 mg of oral Morphine is a high dose of Morphine and potential ramifications of this dose could be severe respiratory depression or death. On 3/20/26 at 1:05 PM V2 Director of Nurses confirmed V9 did not verify the inaccurate dose of Morphine or question the abnormally large dose of Morphine which led to V9 administering approximately 25 milliliters (500 milligrams) of oral Morphine Sulfate, which was an overdose Morphine for R5. R5's Hospital Transfer Form dated 3/10/26 documents R5 was transferred to the emergency room at 10:30 PM for periods of apnea and low respiratory rate. R5's Hospital Documentation dated 3/10/26 at approximately 11:00 PM, R5 arrived in the emergency room for evaluation related to the morphine overdose. R5's Medication Error Report dated 3/10/26 documents there was a transcription error with R5's Morphine sulfate order. The dose was supposed to be 0.25 milliliters orally every two hours as needed however the order was transcribed as 30 milliliters orally every two hours as needed. The administering nurse (V9 RN) did not question order and administered 30 milliliters of Morphine Sulfate to R5. The report documents the error could have endangered R5 and had a high potential for adverse reactions up to and including death. The Immediate Jeopardy that began on 3/10/26 was removed on 3/10/26 when the facility had established R5 was clinically stable, administered Narcan (opioid analgesic) to R5, sent R5 to the emergency room for evaluation, and verified and corrected R5's medication order. The deficient practice was corrected on 3/11/26 after the facility took the following actions: 1.R5 was assessed clinically stable by V2 Director of Nurses. Completed 3/10/26. 2. V28 Medical Director was notified of the incident by V4 Assistant Director of Nurses. Completed 3/10/26. 3. R5 was given Narcan (opioid analgesic) and later sent to the local emergency room for evaluation on 3/10/26 at 10:30 PM. 4. V9 Registered Nurse was suspended pending a comprehensive investigation of the incident. Completed 3/11/26. 5. All licensed nursing staff were educated on proper protocol for medication order transcription, verifying order accuracy, double-check protocols, controlled medication administration documentation, medication error protocol, and who to notify for any medication discrepancy either in person or by phone by V2 Director of Nurses (DON) and V4 Assistant Director of Nurses (ADON). Completed 3/11/26. 6. The Medication Administration and Reconciliation Guidelines, Medication Administration Policy and the Controlled Substance Administration and Accountability Policy were reviewed and revised by V1 Administrator and V2 Director of Nurses. Completed 3/10/26. 7. A facility-wide audit of all controlled substance orders was completed by V2 Director of Nurses. Completed 3/10/26. 8.A facility wide audit of all high-risk medication transcription accuracy was completed by V2 Director of Nurses and V4 ADON. Completed 3/10/26. 9. A facility-wide audit was completed by the facility's pharmacy of all controlled substances in the building. Completed 3/13/26. 10. Ongoing Quality Assurance measures of random competency evaluations for nursing staff regarding high-alert medication administration for thirty days post incident completed by V2 Director of Nurses and V4 ADON. Started 3/11/26 and ongoing. 11. Ongoing Quality Assurance measures of random audits of medication administration techniques completed weekly for four weeks by V2 Director of Nurses and V4 ADON. Started 3/11/26 and ongoing, 12. Ongoing Quality Assurance measures of audits of controlled substance count sheets completed weekly for four weeks by V2 Director of Nurses and V4 ADON. Started 3/11/26 and ongoing. 13. Monthly review of medication error logs and follow up with the Quality Assurance Committee completed by V2 Director of Nurses and V4 ADON. Started 3/11/26. The facility presented an abatement plan to remove the immediacy on 3/31/26 and the survey team accepted the abatement plan on 4/1/26.

Based on interview, and record review, the facility failed to separate a resident (R5) from contact with other residents after an allegation of sexual abuse to prevent further sexual abuse and assault. This failure affects one resident (R6) out of six reviewed for sexual abuse on the sample list of fourteen. This failure resulted in immediate jeopardy. The immediate jeopardy began on 2/2/26 at approximately 10:30 am when R5 was left unsupervised after an allegation of sexual abuse towards R4, and sexually assaulted R6 while unsupervised. V1, Facility Administrator, was notified of the immediate jeopardy on 2/13/26 at 11:15 am.The surveyor confirmed by interview and record review, the Immediate Jeopardy was removed on 2/16/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Based on interview, and record review, the facility failed to separate a resident (R5) from contact with other residents after an allegation of sexual abuse to prevent further sexual abuse and assault. This failure affects one resident (R6) out of six reviewed for sexual abuse on the sample list of fourteen. This failure resulted in immediate jeopardy. The immediate jeopardy began on 2/2/26 at approximately 10:30 am when R5 was left unsupervised after an allegation of sexual abuse towards R4, and sexually assaulted R6 while unsupervised. V1, Facility Administrator, was notified of the immediate jeopardy on 2/13/26 at 11:15 am.Findings include:On 2/11/26 at 8:55 AM, V21 (family member of R11) stated she witnessed R5 poking his finger into the private area of R4. V21 stated she had to move R5's wheelchair to prevent further inappropriate contact with R4. She reported informing Certified Nursing Assistant V13 when V13 arrived in the dining room. V21 stated both R5 and R4 were in wheelchairs, so the action could not have been accidental, such as one slipping or falling into the other. V21 stated she believed R5's action was intentional.On 2/6/26 at 3:22 PM, V13 (Certified Nursing Assistant) stated a family member (V21) of another resident (R11) informed her that R5 had grabbed R4 in her private area in the dining room. V13 stated that at the time of the report she had just returned inside after supervising residents who were smoking outside. V13 stated she directed R5 to go down the hall to his room and then went to remove her coat. She stated that while she was hanging up her coat, R5 proceeded down the hall to R6's room, where the second sexual incident occurred. V13 stated when she returned to the dining room after removing her coat, she received a report from V11 (Housekeeper) that R5 was touching R6 in her diaper area. V13 stated that when she arrived at R6's room after V11's report, V12 (Licensed Practical Nurse) was already removing R5 from R6's room. V13 further stated R6's bed sheet was pulled to the side, R6's incontinent undergarment was unfastened exposing her genital area, and R6 was tearful.On 2/6/26 at 10:24 AM, V11 (Housekeeper) stated that on 2/2/26 she observed R6 lying on the bed while R5 was touching R6 in her diaper area. V11 clarified that R6 was not wearing her diaper. V11 stated she reported what she saw to Certified Nursing Assistant V13 and Nurse V12.On 2/6/26 at 1:10 PM, V12 (Licensed Practical Nurse) stated she had been the nurse on duty on 2/2/26 when V11 reported seeing R5 touching R6 in her diaper area. V12 stated she responded to R6's room to remove R5 and observed R6's bed sheet pulled to the side, R6's incontinent undergarment unfastened, and R5's finger inside R6's vagina.The facility policy Abuse, Neglect and Exploitation dated 10/1/25 documents that the facility will implement policies to prevent all types of abuse and will make efforts to ensure residents are protected from psychosocial harm and additional abuse, including room and staffing changes to protect residents from an alleged perpetrator. The policy states staff must respond immediately to protect alleged victims.The facility's staff in-service training for Abuse Prevention and Reporting dated 8/29/25 documents, by signature, that V11, V12, and V13 received abuse prevention training.On 2/11/26 at 4:24 PM, V1 (Administrator) stated he expects staff to take steps to prevent further abuse. V1 stated staff should immediately remove the resident from the incident and not call him until the situation is under control. V1 stated it is part of facility policy for staff to remove the perpetrator from the incident. V1 stated he needed to have a conversation with V13 that would include education that removing her coat in that type of situation is not a priority. V1 stated V13 could have taken multiple actions to prevent further abuse but described this as Monday morning quarterbacking, and stated he would discuss what she could do differently in the future, such as moving the perpetrator to the far side of a table and asking other staff to monitor while she reported the incident.Surveyor confirmed onsite that the facility took the following measures to remove the immediacy on 2/16/26:R5 was placed on one-to-one continuous supervision pending full investigation on 2/3/26 at approximately 9:45 AM.R5 was assessed by an emergency room physician on 2/2/26.R5 was assessed by Social Services V4 on 2/3/26.A psychiatric evaluation was requested on 2/3/26 by Assistant Director of Nursing V3 and completed on 2/5/26 by Psychotherapist V49.R6 was assessed for injury, trauma, and psychosocial needs by Registered Nurse V22 and Social Services V4 on 2/3/26.R4 was assessed for injury, trauma, and psychosocial needs by Registered Nurse V22 on 2/3/26 and Social Services V4 on 2/5/26.Families and responsible parties of R5 and R6 were notified on 2/3/26 by Social Services V4.R4's family/responsible party was notified on 2/5/26 by Social Services V4.Law enforcement and required state agencies were notified per mandatory reporting requirements on 2/3/26 and 2/5/26 by Administrator V1.A room change was completed on 2/2/26 to ensure separation of R5 and R6, and R6 was later moved to the south building upon return from emergency room evaluation on 2/4/26.All-staff in-service training for abuse prevention was conducted on 2/3/26 by Administrator V1, Director of Nursing V2, and Assistant Director of Nursing V3.Administrator V1, Director of Nursing V2, and [NAME] President of Clinical Operations V33 reviewed the Abuse Prevention Policy on 2/3/26 to ensure inclusion of a clear step-by-step response protocol following any allegation, mandatory immediate separation of the alleged perpetrator, and immediate notification of the Administrator and Director of Nursing.A facility-wide risk assessment for abuse involving Social Services V15, Care Plan Coordinator V37, Director of Nursing V2, and Assistant Director of Nursing V3 was completed on 2/16/26.

Based on observation, interview, and record review, the facility failed to protect residents' right to be free from sexual abuse and assault perpetrated by another resident (R5) with known sexual behaviors. This failure affects two residents (R4 and R6) on the sample list of fourteen. This failure resulted in immediate jeopardy. The immediate jeopardy began on 2/2/26 at approximately 10:30 am when R5 made sexual contact with R4 and R6. V1, Facility Administrator, was notified of the immediate jeopardy on 2/13/26 at 11:15 am. The surveyor confirmed by interview and record review, the Immediate Jeopardy was removed on 2/16/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include:R4's Census Detail and Medical Diagnoses List, both dated 2/10/26, document R4 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, transient ischemic attacks (mini strokes), altered mental status, muscle weakness, difficulty walking, and need for assistance with personal care.On 2/6/26 at 10:33 AM, R4 was seated in a wheelchair in the hallway next to the nurses' station. R4 could not formulate a response relevant to questions being asked. R4 continuously pointed her right index finger in different directions and spoke in a mumbling manner, occasionally uttering sensible words about brother or cooking.R4's Care Plan dated 1/9/26 documents R4 is at risk of abuse. A prior Care Plan dated 4/3/24 documented R4 was at low risk of abuse and was revised on 5/8/25 to reflect R4 was the alleged victim of abuse from another resident on 5/7/25.The facility's Serious Injury Initial Report dated 5/7/25 documents an allegation R5 had touched the breasts of R4.The facility's Center for Medicare and Medicaid Services Form 2567 (Statement of Deficiencies) and associated Resident Numerical Reference dated 4/17/24 document a cited incident involving R5 (then R205) as the perpetrator of sexual abuse toward R4 (then R206), in which R5 touched R4's breasts.R6's Census Detail and Medical Diagnoses List, both dated 2/10/26, document R6 was admitted to the facility on [DATE] with diagnoses including dementia, depression, pseudobulbar affect, reduced mobility, anxiety, lack of coordination, and bipolar disorder. The same list documents an additional diagnosis of confirmed adult sexual abuse dated 2/4/26.On 2/6/26 at 10:55 AM, R6 was seated in a wheelchair in her room. R6 made no verbal responses to questions and only produced intermittent humming noises. R6 wheeled herself through her room, into the hallway, and back into her room without any apparent direction or intended destination.R6's Care Plan dated 2/5/26 documents R6 experienced sexual assault by another resident, placing her at risk for emotional distress, physical harm, and a compromised sense of safety. A prior Care Plan dated 6/2/25 documents R6 is at risk of abuse.R5's Census Detail and Medical Diagnoses List, both dated 2/10/26, document R5 was originally admitted to the facility on [DATE] with diagnoses including cerebral infarction, anxiety, mood disorder, high-risk heterosexual behavior (7/30/24), schizoaffective disorder bipolar type, and moderate vascular dementia with agitation.R5's Care Plan initiated 1/6/25 documents R5 wanders aimlessly throughout the facility. The same Care Plan documents R5 inappropriately touches other residents and staff and makes inappropriate comments. A Care Plan dated 1/6/25 further documents R5 is an identified offender with a criminal history including domestic battery (2003), battery and resisting a peace officer (1986), contempt of court (1983), and thefts and burglaries (1983, 1995, and 2006).On 2/6/26 at 10:24 AM, V11 (Housekeeper) stated on 2/2/26 she noticed two wheelchairs in R6's room. Knowing R6 resided alone, she entered to determine why there was a second wheelchair present. V11 stated R6 was lying on the bed and R5 had his hand in R6's diaper area. V11 clarified R6 was not wearing her diaper. V11 reported she informed Certified Nursing Assistant V13 and Nurse V12 about what she saw.On 2/6/26 at 10:40 AM, R5 was seated in a wheelchair in the main dining room engaged in an occupational therapy activity. R5 had a small quart-sized bucket of clothespins colored green, red, blue, and yellow, along with a stack of colored and numbered cards. R5 drew a card from the deck (observed as a green 6), selected and counted six green clothespins, and clipped them to the card-three with his right hand and three with his left. He received no instructions while performing the activity. A stack of completed cards was in front of him, with a yellow number one card on top holding one yellow clothespin.During the observation, R5 stated he did not have any girlfriends at the facility because every time he picked one, she would pick another man. R5 stated there were a few women he would like to talk to, but they did not want to talk to him. R5 stated he had touched one woman down below, then clarified on her pu*s (vagina) and stated it occurred in her room. R5 added he thought the woman wanted him to touch her but couldn't prove it.On 2/6/26 at 1:10 PM, V12 (Licensed Practical Nurse) stated she had been the nurse on duty on 2/2/26 when V11 reported seeing R5 touching R6 in her diaper area. V12 stated she responded to R6's room to remove R5 and observed R6's bed sheet pulled to the side, R6's incontinent undergarment unfastened, and R5's finger inside R6's vagina.On 2/6/26 at 1:50 PM, V3 (Assistant Director of Nursing) confirmed the incident involving R5 touching R6 occurred on 2/2/26. V3 stated R6 went to the emergency room for evaluation on 2/3/26 because initial reports indicated R5 had been touching R6 in her diaper and thigh area, which was why the Nurse Practitioner (V9) initially conducted only a brief visual examination. V3 further stated after administrative investigation began, witnessing staff reported actual vaginal touching and penetration had occurred.On 2/6/26 at 3:22 PM, V13 (Certified Nursing Assistant) stated she had received V11's report about R5 touching R6 in her diaper area. V13 stated she had provided care for R6 approximately 15-20 minutes prior and R6 was in bed with her undergarment fastened and covered with a sheet at time. When V13 arrived after the report, R6's sheet was pulled aside, her undergarment was unfastened exposing her genital area, and R6 was tearful. V13 stated this was the second report she had received about R5 day. She reported a family member (V21) of another resident (R11) informed her R5 had grabbed R4 in her private area in the dining room.On 2/11/26 at 8:55 AM, V21 (family member of R11) stated she witnessed R5 poking his finger into the private area of R4. V21 stated she moved R5's wheelchair to prevent further contact and informed Certified Nursing Assistant V13 when she arrived. V21 stated both residents were in wheelchairs, so the action could not have been accidental, and she believed R5's actions were intentional.On 2/11/26 at 3:24 PM, V2 (Director of Nursing) stated neither R4 nor R6 had the cognitive capacity to consent to sexual activity.On 2/11/26 at 4:20 PM, V1 (Administrator) confirmed neither R4 nor R6 had the cognitive capacity to consent.The facility's Investigative Report (partially completed) dated 2/3/26 documents an initial interview with V12 conducted by V1 and V2, during which V12 reported receiving V11's report R5 had his hand in R6's diaper area. V1 documented V12 appeared uncomfortable being interviewed by two males and noted V3 would conduct a follow-up interview. During interview, V12 demonstrated what she saw and stated when she entered R6's room, R5 had his finger inside R6's vagina.R5's Nursing Progress Note dated 2/2/26 documents R5 was evaluated by Nurse Practitioner V9 at 11:18 AM due to sexually inappropriate touching of another resident. A note dated 2/3/26 documents R5 was placed on one-to-one supervision at 11:59 AM.R6's Nursing Progress Note dated 2/2/26 at 11:38 AM documents she was evaluated by Nurse Practitioner V9 after being touched sexually in an inappropriate manner.The facility policy Identifying Types of Abuse dated September 2022 defines sexual abuse as any nonconsensual sexual contact of any kind with a resident, including unwanted touching, especially of the breasts or perineal area, and all types of sexual assault. The facility policy Abuse, Neglect, and Exploitation dated 10/1/25 documents the facility will implement policies to prevent all types of abuse.Surveyor confirmed onsite the facility took the following measures to remove the immediacy on 2/16/26:R5 was placed on one-to-one continuous supervision on 2/3/26 at approximately 9:45 AM.R5 was assessed by an emergency room provider on 2/2/26, Social Services V4 on 2/2/26, and a psychotherapy provider on 2/3/26.R4 received a head-to-toe nursing assessment on 2/3/26 by Registered Nurse V22.R6 received physician notification and medical evaluation on 2/2/26 by Nurse Practitioner V9.R5 received physician notification and medical evaluation on 2/2/26 by Nurse Practitioner V9.R5 received a psychosocial assessment and emotional support on 2/3/26 by Social Services V4.R4 received a psychosocial assessment and emotional support on 2/5/26 by Social Services V4.R6 received a psychosocial assessment and emotional support on 2/5/26 by Social Services V4.Families/responsible parties for R5 and R6 were notified on 2/3/26 by Social Services V4.R4's family/responsible party was notified on 2/5/26 by Social Services V4.Law enforcement and state reporting requirements were completed for R5 and R6 on 2/3/26 by Administrator V1.Law enforcement and state reporting requirements were completed for R4 and R5 on 2/5/26 by Administrator V1.R6 was transferred to the hospital for evaluation and relocated to the south building upon return on 2/4/26.A facility-wide resident assessment for abuse risk was conducted by Social Services V15, Care Plan Coordinator V37, Director of Nursing V2, and Assistant Director of Nursing V3, completed 2/16/26.All-staff in-service training for abuse prevention was conducted on 2/3/26 by Administrator V1, Director of Nursing V2, Assistant Director of Nursing V3, and Social Services V4.The Abuse Prevention Policy was reviewed on 2/5/26 by Administrator V1, Director of Nursing V2, and [NAME] President of Clinical Operations V33 to ensure inclusion of defined staff response steps and immediate Director of Nursing and Administrator notification.

Based on observation, interview and record review the facility failed to ensure the safety of one (R1) resident by not implementing resident centered fall interventions and failed to thoroughly investigate one (R1) resident fall with injury out of four residents reviewed for falls in a sample list of four residents. R1 experienced pain and bleeding after her fall thus was transported to and evaluated at the emergency room , where she received three sutures to her forehead because of the fall. Findings include: R1's Electronic Medical Record (EMR) documents medical diagnoses of Intracapsular Fracture of Left Femur, Left Artificial Hip Joint, Forehead Laceration, Protein Calorie Malnutrition, Diabetes Mellitus Type II, Morbid Obesity, Cerebral Infarction, Trans Ischemic Attack (TIA), History of Falling, Abnormalities of Gait and Mobility and Dementia. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 requires supervision with toileting, bathing, dressing, personal hygiene, bed mobility and transfers. R1's Fall Risk assessment dated [DATE] documents R1 as a fall risk. R1's Care plan intervention dated 10/10/2024 documents R1 is to wear non-skid socks while in bed. This same care plan documents an intervention dated 5/16/24 which instructs staff to ensure R1's Activities of Daily Living (ADL) are met and to provide a safe and secure environment. R1's Change of Condition Evaluation dated 1/18/25 documents R1's bed was in low position prior to her fall. R1's SBAR dated 1/19/25 documents R1 had an injury to her forehead with sutures in place. R1's Nurse Progress Note dated: -1/18/25 at 1:20 AM documents, Observed (R1) in a pool of blood in a sitting position on the floor facing the door with her Left foot under her bottom. Evidence suggest (R1) may have hit her head on the nightstand. Cleaned blood off wound bed with Normal Saline and sterile gauze. Applied cold compress. Called 911 due to the amount of blood (R1) had lost. - 1/18/25 at 10:42 AM documents, (R1) came back to the facility from hospital at approximately 8:55 AM. (R1) has a stitch to forehead laceration, area has dried blood. (R1) has no complaints of pain to other parts of the body. -1/18/25 at 10:49 PM documents, Hematoma on (R1's) forehead with a one inch laceration. Pain scale 10 out of 10. Sutures intact. -1/19/25 at 12:03 AM documents R1's emergency room nurse reported to the facility that R1 has three stitches and needs them removed in 5-7 days and needs to be seen by Physician in the next seven days. -1/20/25 at 1:22 PM documents the facility interdisciplinary team reviewed R1's fall from 1/18/25. This same note documents, Staff observed (R1) seated on floor of room by bed, facing door. Right leg extended; Left leg bent with Left foot under buttocks. Blood noted on floor. Laceration noted to (R1's) forehead. Bleeding controlled with clean dry dressing. No other injuries noted. Pain reported at laceration, no other complaints of pain/discomfort. (R1) reported that she rolled out of bed which is likely as prior to fall event resident was noted to be in bed. (R1) transported to emergency room . (R1) returned with three staples to forehead. Root Cause Analysis: (R1) rolled while sleeping and fell off the bed. IDT intervention: (R1's) bed to be in low position while she is in bed. R1's Hospital Record dated 1/18/25 documents R1's chief complaint as Laceration, Head Injury and Fall. This same report documents R1 had a fall from her bed resulting in a forehead laceration. R1's Final Report to the State Agency dated 1/22/25 documents R1 fell from her bed on 1/18/25 at 1:20 AM resulting in a 1.5 centimeter (cm) laceration that required treatment in the emergency room where three sutures were placed. This same report documents R1's care plan was updated with a new intervention of ensuring R1's bed is to be in low position. On 3/1/25 at 9:30 AM, 1:15 PM and 3:20 PM R1 was lying in her bed. R1's bed was positioned up against the wall with the window approximately four feet from the ground. R1 had five pillows surrounding her head and torso on the wall side of her (her Left side). R1 was positioned on the right side of the bed closest to the room door. R1 did not have call light in reach. R1 was not wearing no skid socks. On 3/2/25 at 10:00 AM R1 was lying in her bed with her call light laying over her bedside dresser, not within R1's reach or visual field. On 3/1/25 at 9:40 AM V4 Agency Licensed Practical Nurse (LPN) stated V4 is R1's nurse. V4 Agency LPN stated she is unaware of how to find a resident care plan or how to find a residents fall interventions. V4 LPN stated she does not have any residents on her hallway that are considered being at risk for falls. V4 Agency LPN stated, I just walk down the hall and if a resident has a floor mat in front of their bed, then I know that resident might have fallen before. If they (facility) don't put the mat down, that resident is not considered a fall risk. On 3/1/25 at 9:55 AM V8 Certified Nurse Aide (CNA) stated she is R1's CNA. V8 CNA stated R1 is not considered a fall risk. V8 CNA stated the facility has a binder that tells you all the basic information including fall risk and interventions. On 3/2/25 at 9:20 AM V21 Assistant Director of Nursing (ADON)/Registered Nurse (RN) stated he is the manager of the North building where R1 resided when she fell on [DATE]. V21 ADON/RN stated R1 has fallen out of bed prior to 1/18/25. V21 ADON stated R1's sleeping patterns should have been included on her care plan. V21 ADON stated, All of those pillows would have crowded (R1) out of her bed. It forced (R1) to sleep close to the edge of bed which wasn't safe. The staff should have answered (R1's) call light as soon as it was activated and not waited until they (staff) got to (R1) during rounds. (R1) has Dementia. (R1) didn't know what she was doing. That is why we (staff) are here is to help these residents. We (staff) all knew how she slept. I don't know why it wasn't on (R1's) care plan but it should have been. Then the agency staff would know to not put so many pillows in her bed. On 3/2/25 at 3:30 PM V17 Certified Nurse Aide (CNA) stated she was the CNA on duty on 1/18/25 when R1 fell obtaining a forehead laceration. V17 CNA stated R1 was known to be a 'wild sleeper' who tosses and turns all night. V17 CNA stated R1 is incontinent but also was able to use the bathroom. V17 CNA stated when she started her shift, she checks on all her residents and saw R1 lying in bed with her bed positioned up against the wall with the window. V17 stated R1 had five large pillows surrounding her head and torso on the wall side of her (her Left side). V17 stated R1 was positioned on the Right side of the bed closest to the room door. V17 CNA stated she was doing her rounds and heard R1 screaming. V17 CNA stated when she went to check on R1, R1 was laying on her stomach on the floor in between the bedside dresser and bed with her head facing the door. V17 CNA stated R1 was looking at me when I walked into her room with a very scared, panicked look on her face. V17 stated she could tell that R1 was scared. V17 CNA stated there was no one around, so she had to leave R1 to get V18 Agency Licensed Practical Nurse (LPN). V17 stated when they (V17, V18) both returned to R1's room, she was sitting on the floor with her back leaning against her bed. V17 stated R1 was wearing one sock, and the other foot was bare. V17 CNA stated R1's bed was already in low position. V17 CNA stated the staff on the previous shift had placed R1's five pillows on her bed. V17 CNA stated she was aware of R1's position in bed and decided to wait until time for rounds to reposition R1. V17 stated, I should have taken those pillows out. I knew better. But really, that should have been on (R1's) care plan so the agency staff will know better. We (staff) that work here all know that. It is the agency staff that put them there. I just should have taken them out as soon as I saw them. That was an awful night for (R1) and all of us (staff). On 3/2/25 at 3:50 PM V18 Agency Licensed Practical Nurse (LPN) stated R1 was a 'wild sleeper'. V18 LPN stated she was notified by V17 CNA that R1 had fallen. V18 LPN stated when V18 arrived at R1's room, R1 was sitting on the floor with her right leg extended and her left leg bent as R1 was sitting her Left foot. V18 LPN stated R1's sheets were still on her bed, but her facility blanket, and her personal comforter were blood soaked and twisted up in her legs. V18 LPN stated R1 had a large pool of blood on the floor next to her and her head was bleeding profusely. V18 LPN stated she provided first aid and called emergency services. V18 LPN stated R1 was complaining of pain to her forehead. V18 LPN stated R1 had one sock on, and the other foot was bare. V18 LPN stated she believes R1 was trying to get up to use the bathroom when she got tangled in the blankets and fell . V18 LPN stated R1's call light had been activated. V18 LPN stated R1 would not have had a safe position in her bed due to all the pillows. V18 LPN stated, I work agency, so I really do not know these residents that well. I rely on the facility staff. I have worked with (R1) before and know she should not have had all those pillows and also the staff should have answered her call light so she wouldn't have tried to get up on her own. On 3/2/25 at 2:40 PM V16 Nurse Practitioner (NP) stated R1's fall on 1/18/25 resulted in a trip to the emergency room for assessment and treatment of her forehead laceration which required three sutures. V16 NP stated R1's fall could have been prevented if the fall interventions were in place. V16 NP stated the staff should know where to find fall interventions for all residents, know who is at risk for falls and be able to follow the fall care plan interventions to prevent falls with major injury like R1's 1/18/25 fall. V16 NP stated R1 could have sustained neurological deficits from her head injury she sustained at the facility. V16 stated residents who are assessed to be a fall risk should have care plan interventions initiated and in place that are consistent with each residents patterns, behaviors and capabilities. V16 NP stated the staff should assess every resident at risk for falls to create individual care plans that are centered around the individual's needs. V16 NP stated R1's fall could have been prevented if the facility would have created an accurate care plan and followed fall interventions that were specific to R1. The facility policy titled Falls Clinical Protocol revised March 2018 documents the staff and Physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable.

Based on observation, interview, and record review the facility failed to provide adequate supervision for a cognitively impaired resident, known to exit seek, and with a prior elopement history, to prevent an elopement. The facility also failed to complete a full body post-elopement assessment to determine injury, failed to develop an elopement care plan with interventions in a timely manner, and failed to ensure functional exit door alarms. These failures resulted in R1, a severely cognitively impaired resident at risk of falls and receiving anticoagulation therapy, exiting the facility without staff knowledge or supervision, walking approximately 0.4 miles in extreme cold weather down a busy street. R1's likely path included steep ditches and large rocks. These failures affect one of three residents (R1) reviewed for elopement on the sample list of 14. The Immediate Jeopardy began on 01/01/25 at approximately 4:30 PM, when R1 exited the facility by a deactivated alarmed exit door. Staff were unaware R1 was missing for approximately one-half to one hour. During this time R1 walked in the street during rush hour traffic, in below freezing temperature, without a coat until a passerby alerted the facility staff of R1's location. Staff confirmed R1 was not assessed for possible injury, or hypothermia after being brought back to the facility. V1 Administrator was notified of the Immediate Jeopardy on 1/16/25 at 3:00 pm. The surveyor confirmed by observation, interview and record review the Immediate Jeopardy was removed on 01/23/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's Census record documents R1's initial admission to the facility was on 12/27/24. R1's Diagnoses sheet dated 12/27/24 documents the following: Dementia in Other Diseases Classified Elsewhere, Severe, With Mood Disturbance, Delirium Due to Known Physiological Condition, Restlessness and Agitation, Hypertension, Paroxysmal Atrial Fibrillation, Muscle Weakness (Generalized), Unspecified Abnormalities of Gait and Mobility, and Other Lack of Coordination. R1's Physician Order Sheet (POS) dated 12/27/24 - 1/9/25 documents the following: Eliquis (anticoagulant) Oral Tablet 5 (five) milligram (mg), Give 5 mg by mouth two times a day for Atrial Fibrillation, Metoprolol Succinate ER, Oral Tablet Extended Release 24 Hour, 50 MG every day for Hypertension and Spironolactone Tablet 25 MG, Give 1 tablet by mouth one time a day for Hypertension. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired and R1 has a history of falls before and after admitting to the facility. R1's Admission Assessment (Baseline Care Plan) dated 12/27/24 documents R1 has had falls prior to admission, R1 has an unsteady gait and sitting balance, and R1 is at high risk of falls. R1's Elopement Evaluation dated 12/30/24 documents R1 that has the ability to leave the building, R1 is not considered independent for outside pass privileges, and R1 has been noted at exit doors or wandering. R1's Care Plan was not updated to include a concern for elopement until 1/1/24. R1's Nurse's Note dated 12/30/2024 at 04:13 am documents, Resident still up and not staying seated. Resident wandering and exit seeking. Resident pushing on exit doors. Redirected but continues. R1's 72 hour Charting Follow-Up Late Entry Note dated 1/1/25 at 10:42 AM (fall 12/30/25) documents (R1) Follow-up assessment post-fall. Resident is alert and disoriented per usual baseline. No new injuries noted on assessment. No pain. No changes noted in ROM (range of motion). Bed in lowest position. Monitoring for behaviors. Call light in reach. Non-skid socks/ footwear in place, increase monitoring, (departure alert device), and 1:1 (one on one). No skin issues noted. No bruising noted. No s/s (signs or symptoms) of infection noted to site. No swelling noted. Fall Follow up assessment post-fall. R1's Nurses Notes dated 12/30/24 at 11:40 pm document, Resident alert but confuse(d) and disoriented. Respiration even and non-labored. Speech clear. Appetite good and drink fluids well. Needs assist with ADLs (Activities of Daily Living). Can be combative when agitated. Uses wheelchair for mobility. No complaints made from fall. Continue(s) to get out of bed or chair by himself and at times cannot be dissuade. Very unstable when on his feet. High risk for falls. Concern for a need for one on one monitoring made known to DON (V2, Director of Nursing) and Administrator (V1). R1's Behavior Note dated 12/31/2024 at 12:21 am documents, Resident noted to be combative and aggressive with CNA (unidentified Certified Nursing Assistant) when attempting to assist resident. Resident grabbed CNA in collar while she was attempting to help resident back in his wheelchair. Shortly after resident attempted to elope via south hall exit. Resident was able to open the door and step outside before the nurse (unidentified) on duty was able to catch him. Resident began to resist staff attempting to re-direct him from the exit. Resident ask this writer if she had called the police for him, he was being held against his will and needed the police to rescue him. Resident was informed he was placed in the facility for assistance with his care by his family and he was not being held hostage but receiving health care. Resident was assisted back to the nursing station where he is currently sitting. R1's Admission assessment dated [DATE], signed by V3, Nurse Practitioner documents R1 has a baseline altered mental status and is non decisional and R1 had a fall over the weekend without any noted injury. V3's Assessment documents, (R1) has a history of impulsivity since admission (12/27/24) to the facility, crawling in his room, and requiring frequent observation with fall mats at bedside. He has also been wandering and exit-seeking, with potential placement on a (departure alert device bracelet) per (V2, Director of Nursing) DON and clinical staff. The same assessment directs staff to provide Frequent observation. R1's COMMUNICATION- with Family/NOK/POA (Power of Attorney) dated 12/31/2024 at 1:48 am, signed by V3, Licensed Practical Nurse (LPN), documents, Resident sent to ER (emergency room ) for evaluation and treatment as needed due to resident falling, hit his head against wall resulting in him biting his tongue. Resident tongue purple in color. Resident states his tongue is painful 10/10 (on a scale of one to ten equals extreme pain). (V6, Assistant Director of Nursing) ADON was made aware of resident incident and state(d) send resident to ER due to being on anticoagulant (blood thinner). MD (V7, Medical Director) made aware of incident at 1:07 am. Call attempted to POA (V13, R1's Family Member) 01:13 am at (private number), voicemail not set up unable to leave message. Nurse to nurse report given to (V4, Registered Nurse) at (local Hospital). Emergency service contacted at 1:20 am, arrived at 01:30 am. Resident noted to be confused in regard to the details of the incident. Nurse (unidentified) on duty, who was at the nursing station where the incident took place, states the resident was standing up adjusting his jacket and fell back hitting his head against the wall. This writer (V30, LPN) had just walked off from the resident assisting him back into his chair. R1's Nurse's Note dated 12/31/24 at 3:35 pm documents, Resident POA (V13, Power of Attorney) here, and made aware of resident being sent to (local hospital). Resident has been anxious this shift. Resident has been up ambulating this shift. Resident (V13, Family Member) here most of shift. Resident reminded most of shift to sit in w/c (wheelchair). Resident became agitated with writer after (V13, Family Member) left. Resident has been confused. Resident took all meds (medications) whole without difficulty. R1's Incident Note dated 01/01/25 at 5:30 pm, signed by V8, Registered Nurse (RN), documents Resident was observed ambulating outside the facility. CNA (V15, Certified Nursing Assistant) went to get resident to come back inside the building. No distress noted. No injury noted. POA (V13, Family Member), MD (V7, Medical Director), DON (V2, Director of Nursing) and Administrator (V1) notified. Resident placed on one on one monitoring (alarm bracelet) placed to left ankle. Will continue to monitor. R1's one on one supervision sheet is dated as initiated 01/01/25 at 5:30 pm. On 1/9/25 at 7:15 am V8, Registered Nurse (RN) stated, The evening (R1) got out and walked down (Street Name) Avenue, I think it was the 01/01/25. A passerby called the facility and said we had a confused resident walking in the middle of the street, over by the apartments. The passerby said he (R1) did not have on a coat. It was pretty cold day. I can't remember if it snowed yet, but I think it may have. There was snow when I left my shift. (Street Name) Avenue traffic gets very busy during evening rush hour. The CNA (V15, Certified Nursing Assistant) went right away to go find him (R1). (R1) was always trying to go somewhere. He was consistently exit-seeking. He would shake the exit doors whenever I worked. He had never gotten far out of the building when I had him (was R1's nurse). I had not seen (R1) for a quite a while that evening. I am not sure how long he was gone. Nobody had seen him for about an hour. I asked everyone. I figured it was probably (R1) the passerby saw. None of us working heard an alarm go off. We had no idea how he got out of the building, or how long he had been gone. I ended up telling (V12, Maintenance Director) to look at the cameras to find out which door (R1) went out because nothing triggered an alarm when he (R1) left. I admitted (12/27/24) him (R1) and did not know he was an elopement risk at time. He was admitted with A-Fib (abnormal fast heartbeat) and had a history of falls. It was evident within a day or two of admission he was an elopement risk. He was not a one-on-one until 1/1/25 after he was found outside walking in the street. We put a (departure alert device) on him at time too. When (V15, CNA) brought him (R1) back to the facility, he (V15, CNA) said he did not see any injuries. (V15, CNA) said (R1) was very cold and warmed up in (V15, CNA's) car. V8, RN stated I did not complete a full body assessment, vital signs or neurological assessment when (R1) returned to the building. I did not complete an accident report, or risk management report. The incident note you have is all I had time to do. I was working a hall and a half (of residents) and training a new nurse. Now I think about it, he (R1) had several falls in the facility. He came to us with a history of falls. He could have had a fall outside when he eloped evening (1/1/25). He used a wheelchair, and we were constantly reminding him not to stand up. He had a very unstable gait. I should have completed a thorough assessment, just like we do when a resident has an unwitnessed fall. On 1/9/25 at 8:55 am V13, R1's Family Member stated, (The facility) has called me (V13) four times about (R1) exiting the building. Three times, I was told he was just outside the doors. Once he walked right out the front door. The other times he went out the side doors. One time they reported he was found walking down (Street Name) Avenue. I was not thrilled about. It was 20 degrees (Fahrenheit) outside. I did not understand how could happen if he was adequately supervised. He can't walk steady and is in a wheelchair. How could he get all the way to (Street Name) Avenue and have been walking. He has had a couple falls before and after being at (the facility) trying to walk. On 01/9/25 at 4:45 pm R6 stated R6's room and R1's room, share a bathroom. R6 stated R1 was confused and repeatedly came in to R6's room and yelled for R6 to get out of R1's house. Staff were supposed to be watching him. Half the time the staff were visiting with each other down the hall, nowhere near his (R1) room. I saw with my own eyes several times. They did nothing to keep him out of my room. I finally put a chair against the bathroom door so he would stop coming in. He was supposed to have a sitter with him all the time. They obviously were not keeping a good eye on him. On 1/9/25 at 1:35 pm V12, Maintenance Director stated he had reviewed the cameras to determine which doors R1 left from on each elopement attempt. V12 stated, The first time he went out on 1/1/25, he went out the west door. He had a heavy coat and shoes on. He left his wheelchair at the door. A CNA (unidentified) saw (R1's) chair (wheelchair) at the exit. The CNA was talking to (V8, Registered Nurse). They (unidentified CNA and V8, RN) saw out the window, as (R1) was walking past the window. They both ran out the west hall door and brought him back. The second time, the same day (1/1/25), he had sweat pants and a tee shirt on, and no coat. (R1) went out the smoking door and pushed open the emergency gate off the patio (this fall R1 walked down (Street Name) Avenue). On 1/6/25 he went out the west wing exit door. (V8, RN) and a CNA (unidentified) went out immediately and brought him back in. His next elopement on 1/7/24, he could be seen fighting with staff at the west door. Five staff exited the building and stayed with him until the police came. I will give you a timeline from the cameras. On 1/9/25 at 3:10 pm V12, Maintenance Director provide the timeline of R1's four elopements from the facility, which confirmed V12's interview account of the elopement incidents noted above. On 1/1/25 R1 was dressed in heavy coat, blue jeans, and shoes at 8:58 am when R1 exited the facility via the west wing door, leaving his wheelchair at the exit. * At 8:59 R1 could be seen on the facility camera walking northbound on the sidewalk. * At 9:02 am R14 sees R1's wheelchair and looks at the exit door. * At 9:03 am (unidentified receptionist) shuts off the alarm. * At 9:04 am R14 alerts staff (unidentified) to the wheelchair. * At 9:05 am R14 talks to V8, Registered Nurse (RN). * At 9:06 am R1 walks south, past the windows. (unidentified CNA) and V8, RN rush out [NAME] door. * At 9:07 am (unidentified CNA) brings R1 back into the facility. V27, CNA moves a spare hospice bed in the hallway, over to the entrance, for R1 to sit down on while the unidentified CNA goes to get R1's wheelchair. R1 taken to his room. On the same day 1/1/25 R1 had a second elopement timeline documents: * At 4:35 pm R1 was in the west wing dining area. * At 4:42 pm R1 went out the smokers door, to the patio and rolls to the north gate. * At 4:44 pm R1 pushed the emergency north side gate open. R1 went out of the gate wearing sweatpants and tee-shirt. * At 4:47 pm Unidentified male CNA possibly shut alarm off. V12 stated the male CNA walked in the direction of the key pad to shut off the alarm but could not actually be seen entering the code. * At 4:50 pm (eight minutes after R1 exited the building, by this timeline) V53, Receptionist takes a phone call and alerts an unidentified staff member. * At 4:59 pm V15, CNA grabs his own coat. * At 5:02 pm V15 and V38, CNAs go out the front door. * At 5:06 pm R1 is brought back via front door by V15 and V38. * At 5:08 pm V15, CNA and V8, RN were trying to determine R1's exit door location. V6 Assistant Director confirmed there is no progress note or assessment documentation of R1's elopement in R1's medical record correlate to the first elopement 1/1/25 on above time line. On 1/9/25 at 4:05 pm V15, Certified Nursing Assistant stated, I was the person went to get (R1), I think it was on the first (January 1, 2025). Supper trays had not been delivered yet. A woman (unidentified) called the facility. The woman said she saw a guy walking in the middle of the street, on (Street Name) Avenue. She said the guy was down by the (Name) apartments. The (Name) apartments are about a half mile down the road. (Street Name) is a busy street. It happened during rush hour traffic too. I could have guessed it was (R1), but we didn't know for sure, yet. I had not seen him for a while because he goes all over the place in his wheelchair. It was around 4:30 pm the last time I saw him. He was notorious for shaking the exit doors and trying to leave. He was an exit seeker for sure before. Everybody knew it. I should say, I knew it. I can't speak for what other people knew. They should have known it, is what I will say. He would rush the door and say he needed to leave. He has done since he was admitted (12/27/24). We usually hear the door alarms sound and get to him before he gets too far out the door. That evening, no door alarm sounded. We had no idea what door he went out, or how long he was gone. I left (the facility) and drove down (Street Name). Traffic was heavy. I got down by the apartments. He (R1) was walking down the north bound lane. He was not in the center of the street. He was in the center of the north bound lanes. He was about four feet from the curb when I saw him. Traffic was going around him. I stopped in the street, so all the traffic went around my car, instead of him (R1). I got out of my car and went to get him. I don't know what the temperature was, but I was cold just getting out of my car. (R1's) arms were red and he (R1) said his hands were getting numb they were so cold. He was just in a short sleeved tee-shirt and had no coat on. He was really, cold. The lady that called was parked in the apartment drive. She said she talked to him, and noticed he seemed very confused that it was why she called. She thought it could be a resident from (the facility). I had my heat turned up as high as it could go. (R1) thanked me for picking him up and wanted me to take him to some address in Danville. I worked with him a lot and know he has dementia. I told him I would like him to come with me and warm up first. He did not have any behaviors for me, then or ever. I have heard he has been aggressive with other staff. Never for me. I have a lot of experience working with dementia residents. Most often they can be distracted with an activity or food. I found both worked for (R1). We got back to the facility and sat in the car for a couple more minutes, so he was good and warm. He (R1) was cooperative when I turned him over to (R8, Registered Nurse/RN). (V8, RN) asked if he was hurt. I told her (V8, RN), he (R1) was cold, but I didn't notice if he had any injuries. (R8, RN) took it (assumed R1's care) from there. I don't know if she did vitals or anything. I went on to get supper trays served. It was close to 5:30 pm which is normal time for supper trays to come up. V15, CNA stated, I later heard (R1) went out the smoking area doors. That door alarm has not worked right for a while. You just push on the bar for a couple of seconds, and it opens without the alarm sounding. Somebody is usually at the nurse's station and can see door if people go out to smoke. After this elopement they put a (departure alert bracelet) on (R1's) ankle and made him (provided R1) a one on one (constantly supervised by one staff). I was his one on one several times since, and never had a problem distracting him if he started exit seeking. V15, CNA agreed to show this surveyor the area R1 would have likely traveled, to where V15, CNA found R1 in the street 1/1/25. On 1/9/25 at 4:14 pm V1, Administrator confirmed R1 exited the building through the smoking area doors. On 1/9/25 at 4:18 pm V15, CNA and this surveyor went to the interior and exterior doors that exit the facility to the patio and courtyard smoking area, at the back of the building, north side of the building. The first, interior door does not alarm. The exterior door has a horizontal push bar lever across the center of the door. V15 directed the surveyor to push the bar for a few seconds and it will open. The door did not open. There is a green button to the left of the door. When pushed, the door opens and the alarm sounds. V1 was just inside the interior door and responded to the alarm. V15 stated, They must have already fixed it. This door alarm has not functioned properly for a long time. Once V15, CNA and this surveyor were out on a smoking patio, at the back of the south building, there were two gates. One single-wide gate was to the left, down a sidewalk off the patio approximately 50 feet. A double-wide second gate was straight ahead off the patio, approximately 50 feet. V15 stated the single-wide gate was likely not the gate R1 used, because it opens inward and would be difficult to maneuver R1's wheelchair. V15, CNA and this surveyor walked the approximately 50 feet forward to a double-wide gate, which opens outward. The patio gate has an emergency exit required pushing the button and holding it. No alarm sounded. Together V15 and this surveyor walked approximately 150 feet around the fenced patio to winding sidewalk. The sidewalk sloped downward past two wings of the facility building, as we headed towards the front of the building on the south side. V15, CNA stopped at the edge of the building outside the therapy room. V15, CNA stated, This is where (R1's) left his wheelchair that night. V15 stated, In order for (R1) to get to (Street Name) Avenue he would have had to walk from his wheelchair across all this grass and head north again to where I found him. V15, CNA and this surveyor walked down a 50-foot uneven hill, from the sidewalk where R1's wheelchair had been found. At the base of the uneven hill, we continued to walk through the grass another approximately 150 feet straight towards (Street Name) Avenue. The ground was rough with divots throughout. V15, CNA and this surveyor were approximately 10 feet from the street. There were approximately over one hundred, extra-large scattered rocks stacked haphazardly from the ground. The large rocks extended up an eight-foot steep incline. At the ground level the extra-large rocks spanned six feet wide at the base and extended upward to a three-foot-wide easement at the street. V15, CNA stated each rock weighed approximately 20 or 25 pounds. The street curb, on each side of the three-foot-wide easement, was eight inches tall. As this surveyor and V15, CNA decided we could not safely balance ourselves on the rocks, we turned to walk in the uneven grass, at the bottom of the eight-foot steep incline. V15 stated, (R1) may have climbed the rocks, but most likely walked in the grass. He (R1) had a very unstable gait. That is why he used a wheelchair. He had a couple falls in the facility from trying to stand up from his wheelchair. He was not safe to walk on his own. I can't imagine how (R1) was able to walk this area. You (surveyor) and I (V15, CNA) are having a hard time maintaining our balance. As we continued to walk, this surveyor and V15, CNA had on coats. V15 stated, It was about this cold when I found (R1) (Confirmed on Accu-Weather website, temperature was 23 degrees Fahrenheit, at this time). There was some wind, but no snow. As we continued to walk on the uneven grass next to the steep incline, which was running parallel to the street, the incline gradually level out with the street eight inch curb. We walked past both the North and South facility buildings. We walked across one parking lot entrance road to the facility. The parking lot entrance to the North building junction with the street was crowded with a steady flow of vehicles. The speed limit posted was 35 miles per hour. V15 stated this steady flow of traffic is the normal for rush hour traffic on the and is about the same time R1 would have been out walking in the traffic. After crossing the parking lot entrance, there was a grassy area approximately 200 feet, next to an apartment complex. Before reaching the apartment parking lot entrance road off the street, there was an approximately 15 feet by 20 feet concrete slab in the grassy area. There was an electrical site warning sign. There were four steel electrical utility transformer boxes on the concrete slab. One of the electrical utility transformer boxes was four foot wide by approximately eight foot long and eight-foot tall. The other three steel electrical utility transformer boxes were approximately three foot tall, by three foot wide and two foot long. The electrical boxes had multiple access doors with pad lock. At the opposite end of the same 200-foot grassy area there was a gas line warning sign. The gas line warning sign was outside of four concrete, two and a half feet tall pillars. The four pillars sat in a square pattern approximately eight feet apart. Inside the four concrete pillars there were multiple metal gas pipes. The gas pipes varied in sizes of approximately two- and three-inch diameters. The metal pipes looked like a play structure for children. The metal gas pipes crossed each other in jungle gym fashion at different heights. The metal gas pipes structure stood approximately eight feet high at its tallest. The gas pipe structure was approximately six feet wide and four feet long at the base. The metal pipes had locks on several of the bar junctions. V15 pointed to the area V15 found R1 on the. R1 was found across the grassy area from the gas pipe structure, in front of the drive to the apartment complex parking lane entrance, in the middle of the north bound lane. This surveyor measured the mileage by car. R1 traveled on foot on 1/1/25. The distance one way by car, from the facility to where R1 was found, measured four tenths of a mile. This does not include the facility sidewalk distances from the back of the south building to the front of the south building, where R1 had left his wheelchair. The National Oceanic and Atmospheric Administration ([NAME]) website documents on 01/01/25 at 4:35 pm, in this city it was 30 degrees Fahrenheit with 10 mile per hour winds, equal to real feel temperature on the skin of 21 degrees Fahrenheit. On 1/15/25 at 7:20 am V7, Medical Director stated he was informed of several of R1's elopements. None of R1's elopements or attempts reported to V7 by the facility included (R1) that exited the building and was walking down street unassisted. V7 stated V7 did not know R1 was off the facility grounds. V7, stated R1 has Dementia, has been sent to the emergency room post-falls because he is on a blood thinner and had hit his head. V7 stated is his standard protocol to have a resident on blood thinners evaluated at the hospital post unwitnessed falls and witnessed to have hit their head during a fall. V7 stated, I had not heard a door alarm malfunctioned either. Alarms in the ER (emergency room ) go off all the time. I even had a patient go hypoxic. No one initially responded to the alarm. It is the same in nursing homes. I think the staff are immune to the sounds of the alarms. They hear them often. (R1) should have been closely supervised to prevent this from happening. His (R1's) Dementia alone put him at risk of elopement. Having had falls, the short time he was in the facility, also put him at risk serious of injury. To hear he was out walking in the street, in cold temperatures, adds to the potential for serious harm. Knowing he had not been assessed by the nurse when he returned to the facility, is even more concerning. A full assessment should have been completed immediately, to have gotten a full picture of any harm after the incident. Adequate supervision may have changed all. Yes, he was at great risk of serious injury. On 1/22/25 at 1:30 pm V38, CNA stated no one had seen (R1) for about an hour. V38 stated V8, Registered Nurse asked everyone night after the facility got a call that R1 was outside the facility. R1's Care Plan dated 12/31/24 does not document an elopement care area until 01/01/25. R1's care Plan documents the following: (R1) is an elopement risk/wanderer related to restlessness and agitation. (R1) cut off his (departure alert) bracelet. Date Initiated: 01/01/2025. He will not leave facility unattended through the review date. Date Initiated: 01/01/2025. His safety will be maintained through the review date. Date Initiated: 01/01/2025. Assess for fall risk Date Initiated: 01/01/2025, Enhanced supervision: 1:1 (one on one) within line of sight. Date Initiated: 01/01/2025 (Departure Alert Device) in place on left ankle. Monitor device is functioning properly, daily. The facility presented an abatement plan to remove the immediacy on 1/16/25. The survey team reviewed the abatement plan and accepted the abatement plan on 1/21/25. The Immediate Jeopardy began on 1/01/25 was removed on 1//23/24 when the facility took the following actions to remove the immediacy: 1. Confirmed the facility identified residents affected or likely to be affected by completing resident elopement assessments and reassessments and updating care plans. Completed by V1, Administrator V2, DON, V6, ADON/ QA Nurse, V10 Social Service Director (SSD) South, V11, SSD North, V28, ADON Evening shift on 1/2/2025. 2. Confirmed elopement binder was updated and at the nurses' stations, and the reception desk. Completed by V10 on 1/2/25. 3. Confirmed Accidents and Incidents- Investigating and Reporting Policies including documentation of the condition of the affected person, including vital signs was revised and updated. Completed by V9, [NAME] president of Clinical Services on 1/2/25. 4. Staff training was initiated and is ongoing as of 1/23/25. In-service training on elopement protocol and retention quiz were not provide prior to start of shift for several staff. The surveyor confirmed a sample of staff not in-serviced, which included: V36, Housekeeper, V40 Housekeeper, V41, CNA, V43, LPN, V45 CNA, and V50 Laundry, and Agency staff included: V34, CNA, V44, LPN, V47 LPN, V48, LPN, and V49, CNA. All staff identified stated they have been working in the facility throughout the month of January. V1, Administrator acknowledged all staff have not been educated as planned, as of this exit date 1/23/25. 5. Confirmed V1, V2 and V28 Assistant Director of Nurses initiated education relating to immediate head to toe assessments following unusual occurrences. Completed on 1/2/2025. 6. Confirmed V12, Maintenance Director assessed all doors, exit alarms, and the departure alert system to ensure proper working order and observed during survey. Ad-Hoc QAPI (Quality Assurance Performance Improvement) meeting was completed on 1/2/2025 discussing event and evaluating the current elopement program including conducting daily assessments of exits, and routinely scheduled elopement drills to be ongoing. One mock drill was completed during survey. Completed 1/2/25 and ongoing. 7. Confirmed V1, provided training to the IDT (Interdisciplinary team) regarding development of care plans to address residents who are newly identified with exit-seeking /wandering behaviors and elopement risk. Completed 1/2/25 and is ongoing. 8. Confirmed Ad-Hoc QAPI meeting, including the Medical Director by phone, to discuss the incident and the corrective actions to prevent similar events. Completed 1/2/25 and ongoing. 9. Confirmed in interviews, Daily IDT meetings were conducted to discuss new or worsening wandering/exit-seeking behaviors. Any new and/or worsening behaviors will be addressed by ensuring appropriate clinical interventions are implemented to prevent an incident of elopement. 1/2/25 and ongoing. 10. Confirmed QAPI team will review results of the audits, posttests, door and window checks. The QAPI team will determine if additional monitoring or corrective actions are necessary based on the review of monitoring activities. Completed 1/2/25 and ongoing.

Based on observation, interview and record review the facility failed to complete wound dressing changes as ordered by the wound care physician. This failure affects one resident (R1) out of three residents reviewed for wound care on a sample list of nine. This failure resulted in R1's wounds becoming repetitively infested with parasitic fly larvae (maggots) requiring sanitation, causing pain and causing the wound to deteriorate. Findings include: R1's medical record documents admission to the facility on [DATE] with diagnoses of Acute Kidney Failure, Type II Diabetes Mellitus, Morbid Obesity, Benign Prostatic Hypertrophy, Lymphedema, Dementia, Falls, Wounds, Weakness, Malaise, and Anxiety. R1's Minimum Data Set, dated dated dated [DATE] documents R1 is cognitively intact. R1's Wound Evaluation and Management Summary dated 8/7/24 by V16 Wound Physician documents wounds of the right, anterior, medial leg size 8 centimeters by 5 centimeters by 0.1 centimeter (cm); the right lateral leg size 17 cm by 6cm by 0.01cm; the left calf size 18cm by 10cm by 0.05cm and the left anterior leg size 20cm by 16cm by 0.05cm. The wound care order includes the application of 0.1% Triamcinolone cream to both legs with 4-layer compression wraps from ankle to knee, twice a week. On 8/19/24 at 12:18PM, V10 Wound Nurse said on the evening of 8/12/24, V14 Licensed Practical Nurse notified her she found maggots in R1's leg dressing and in his wheel chair. V10 Wound Nurse said she notified V16 Wound Physician and he ordered R1's legs to be washed with Betadine (antiseptic), and an abdominal dressing pad with gauze wrap followed by a pressure wrap every other day for 30 days. R1's Wound Evaluation and Management Summary dated 8/13/24 by V16 Wound Physician documents the right, anterior, medial leg wound measured 16cm by 14cm by 0.1cm and has declined. The wound evaluation completed on 8/20/24 documents the wound has continued to decline. The evaluation documents the right, lateral leg wound measured 18cm by 10cm by 0.01cm and a new wound was evaluated on the right lateral foot measuring 4cm by 6cm by 0.1cm. V16 Wound Physician documented on 8/20/24 R1's right leg wounds continue to decline. On 8/15/24, V10 Wound Nurse documented she completed the prescribed dressing changes on R1's wounds. However, no documentation of the appearance, size, drainage or condition of the wounds was found in R1's medical record on date. On 8/17/24, V22 Registered Nurse (RN) documented she completed the prescribed dressing changes on R1's wounds. However, no documentation of the appearance, size, drainage or condition of the wounds was found in R1's medical record on date. On 8/19/24 at 9:00AM, R1 was sitting near the nurse's station in a wheel chair with R1's legs wrapped. R1 said he had terrible pain in his legs and feet and behind his eye. R1 said the pain in his legs had been worse recently, but he didn't know why, and he needed someone to address it. On 8/19/24 at 9:25AM, R1's resident room, consisting of four residents, smelled strongly of urine and had two fly strips hanging in the room. One fly strip had six flies on it. On 8/19/24 at 9:30AM, R1's bilateral leg and foot dressings were saturated with thick yellow drainage and with urine. V2 Director of Nursing (DON) removed R1's right lateral and medial leg wound dressings and the dressing pulled away from the wound contained 7 adult size (length of a diameter of a dime) live maggots. At this time, V2 DON said this is the second time R1 has gotten maggots in the facility, as he was notified R1 had maggots in his wounds last Monday. V2 DON said this is unacceptable care. R1 was complaining of pain as the dressing was removed and asking V2 DON to please re-wrap his legs. On 8/19/24 at 4:00PM, V22 RN confirmed she did not perform a dressing change on 8/17/24 and R1 did not refuse, but rather we only had three Certified Nursing Assistants (CNAs) and the nurses were having to help pass trays and feed and I just got busy and forgot to do it after I charted it. On 8/19/24 at 10:10AM, V13 Nurse Practitioner (NP) stated, This has to be dealt with immediately. It could have been prevented and it could certainly have made the wound worse causing infection. This is unacceptable care. On 8/19/24 at 2:48PM, V16 Wound Physician said based on the size of the maggot, he questioned whether the dressings were being changed as ordered. V16 said maggots cause concern for infection, and he told the staff to move the resident to a private room and deep clean the room. On 8/20/24 at 9:30AM, V1 Administrator confirmed had the dressing changes been completed as ordered, maggot infestation could have potentially been prevented or at least caught sooner. On 8/20/24 at 11:00AM, V10 Wound Nurse stated she had suggested alternative pain control to V13 NP because of R1's pain with dressing changes, including Gabapentin and R1's wounds weren't getting better.

Based on interview and record review, the facility failed to ensure a resident was free from physical abuse for two of three residents (R1, R2) reviewed for abuse on the sample list of nine. This failure resulted in R2 experiencing discomfort and swelling to the face as well as being fearful of R1 after R1 hit R2. Findings Include: The facility's undated Preliminary 24 Hour Abuse Investigation Report documents on 6/3/24 at approximately 11:45 pm, V1 Administrator received an allegation that R1 struck R2 on the side of the face. R1 and R2's Physical Abuse Investigation Folder contained the following staff witness statements: V9 CNA's (Certified Nursing Assistant) statement documents R1 became very aggressive on Monday night (6/3/24). It started when R1 came back to the facility and just progressed. A little after 11:00 pm, another CNA came and got V9 stating that R1 had hit R2, R1's roommate, in the face and they needed separated. V4 Agency LPN (Licensed Practical Nurse) reported that the police were called to diffuse the situation and for V9 and the other staff to wait on the police. Before the police officer arrived, R1 came out of the room and started cursing the staff out. When the police officer arrived, R1 was still yelling at everyone while we were trying to calm him down. R1 said that since staff didn't see R1 hit R2, it didn't happen. After the police officer left the facility, staff asked R1 to switch rooms and R1 cursed staff out again and accused staff of being racist against R1 so R2 agreed to switch rooms instead. V10 CNA's statement documents, at the beginning of V10's shift (3rd shift) on 6/3/24, R1 was yelling out profanity. As V10 started walking to R1's room, R1 came out into the hallway and started yelling at the nursing staff. Upon arrival to R1's room, R2 was telling the nurse that R1 hit R2 in the side of the head with R1's fist. R1 returned to the room still yelling at the staff and R2. The police were called, and the officer suggested we separate the residents for the night. R2 was moved into a different room. V11 CNA's statement documents on 6/3/24 during 3rd shift, R1 and R2's call light was on and upon entry to the room, R2 yelled out that R1 needed to get out of the room because R1 came over to R2's side of the room and hit R2 in the face. V11 asked them both to stay quiet until I (V11) got back with a nurse. Once the nurse arrived, the situation further escalated. R1 was saying racial and rude remarks to the staff. R2 was moved to a different room. R2's Other Skin Condition Report dated 6/4/24 at 12:06 am by V4 Agency LPN (Licensed Practical Nurse) documents R2 has slight swelling to the left side of the face, near the eye. On 6/10/24 at 11:00 am, R2 stated R2 had loaned R1, former roommate, some money. R2 stated R1 never paid R2 back so R2 asked R1 for the money and R1 hauled off and hit me (R2) in the face. R2 stated the police were called and R2 was moved into a different room. R2 explained R2 was happy to move because R2 was fearful of what R1 would do to R2 since R2 reported R1 to the police. R2 also stated that after being hit in the face, R2's face was initially sore and swollen. On 6/11/24 at 8:15 am, V5 SSD (Social Service Director) confirmed R1 hit R2. The facility's Abuse Prevention and Reporting Police dated October 2022 documents this facility prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Abuse is defined as any physical or mental injury inflicted upon a resident other than by accidental means.

Based on interview and record review, the facility failed to ensure the safety of residents by failing to accurately screen and assess a new resident upon admission and implement necessary safety interventions for two of three residents (R1, R2) reviewed for abuse on the sample of nine. This failure resulted in a newly admitted resident (R1) residing in a room with R2 and R1 being physically aggressive with R2, hitting R2 in the face with a closed fist. As a result of the physical abuse, R2 experienced facial discomfort and swelling along with psychosocial harm. Findings Include: The facility's Identified Offender-Admission Guidelines Policy dated May 2024 documents, Criminal History Record Information will be requested, the facility must review screenings and all supporting documentation to determine if the placement is appropriate, the facility must develop a plan of care appropriate to the needs of the offender. Upon admission of an identified offender, the facility, in consultation with the medical doctor and law enforcement, must specifically address the resident's needs in an individualized plan of care that reflects the risk assessment of the individual. In conducting a risk assessment of an identified offender and developing a plan of care, the facility shall consider the following: the care and supervision needs, if any, specific to the individual's criminal offense, the results of the screening conducted pursuant to the act, the amount of supervision required by the individual to ensure the safety of all residents, staff, and visitors in the facility. The physical and mental abilities of the individual, the current medical assessments of the individual, approaches to resident care that are proactive and are appropriate and effective in dealing with any behaviors specific to the identified offense, and the number and qualifications of staff needed to meet the needs of the individual and the required level of supervision at all times. The care planning of identified offenders shall include a description of the security measures necessary to protect facility residents from the identified offender, including whether the identified offender should be segregated from other residents, if the facility's risk assessment determines that an identified offender must have his or her own room. R1's Admission Referral Pack dated 5/10/24 contained a plan of care dated 2/6/24 that documents R1 has been identified as an Offender of a felony offense as listed in Section 25 of Healthcare Worker Background Check Act and has been assessed as a Moderate Risk towards other residents, staff or visitors. The nature of resident's offense was criminal trespass, burglary, false alarm complaints, DUI, retail theft, criminal damage to state property, resisting a peace officer, aggravated battery. He has a criminal history of being incarcerated most of his life from 1983-2021. R1's ongoing Census documents R1 was admitted to the facility on [DATE]. R1's Medical Record contained two different Illinois State Police Background Checks for R1, each with a different date of birth. The first one dated 5/10/24 documents, no record on file. The second one dated 5/22/24 documents, multiple hits and documents the following arrests and convictions: criminal trespass to land, false alarm/complaint to 911, burglary, DUI (Driving Under the Influence)/Alcohol, retail theft, criminal damage to state property, resisting a peace officer, possession of cannabis, attempted theft, and aggravated battery. R1's MDS (Minimum Data Set) dated 5/17/24 documents R1 is alert and oriented, has verbal behaviors, and requires supervision with ambulation and transfers. R1's Care Plan dated 5/31/24 does not document any Identified Offender Information. R1's Progress Notes dated 6/4/24 at 12:00 am by V4 Agency LPN (Licensed Practical Nurse) documents R1 was placed on 15 minute checks and R2 (R1's roommate) was removed from the room due to R2's allegations of R1 striking R2 in the face. R2's Progress Note dated 6/4/24 does not document the allegation of R1 hitting R2 however it does document a new skin concern of slight swelling on left cheek near the eye with no bruising at this time. On 6/10/24 at 11:00 am, R2 confirmed that R2 was struck in the face by R1. R2 stated R2 chose not to pressure charges on R1 but did report R1 to the police and was fearful of what R1 would do to R2 because of that, so R2 was happy that the facility moved R2 into a different room. R2 also stated that after being hit in the face, R2's face was initially sore and swollen. R1's Medical Record did not contain an Abuse Risk Assessment until 6/4/24 {25 days after admission to the facility and the day of the incident}. This assessment documents R1 is at high risk. On 6/11/24 at 8:15 am, V5 SSD (Social Service Director) stated the Corporate Office completes background checks, prior to admission, for all new admissions and if it comes back with a hit, then they give it to V5 to schedule finger prints. V5 stated V5 noticed the original background check had the wrong birthday input into the system so a new background was completed and that is when R1's hits showed up. V5 reviewed R1's ongoing census that documents upon admission (5/10/24), R1 was admitted into a four bed ward then was moved into a private room on 5/12/24, but V5 is unsure what happened to cause that room move. V5 explained that R1 remained in the private room until 5/22/24 when R1 was moved into a semi-private room with R2, due to another resident needing the private room R1 was in. V5 explained that after R1 hit R2 on 6/4/24, R2 was moved into a different room because R1 refused to move rooms. When asked about any safety precautions that were in place due to R1's background report, V5 stated V5 was aware of R1's background information however R1 was not displaying any behaviors until R1 was placed with a roommate, therefore no safety precautions were in place or care planned. V5 also stated, It has surprised us all because when (R1) was first admitted , (R1) was very pleasant but something happened and (R1) just turned left. V5 explained, R1 has not been physical with anyone since the incident with R2 however R1 continues to harass and torment, to the point where the staff are fearful of R1. V5 stated the next day when V5 checked on R2, R2 was still talking about the incident and wanted the police called again. The police came back out but R2 again did not press charges. On 6/11/24 at 10:12 am, V15 Freedom of Information Officer with the Danville Police Department confirmed that on 6/3/24 a couple minutes before midnight, the Danville Police Department received a call regarding R1 hitting R2, then was called back the following day regarding the same incident. On 6/11/24 at 10:42 am, V13 Regional Director of Operations, with V1 Administrator present, stated R1's background was run prior to R1's admission and as soon as the facility figured out it was run with the wrong date of birth, another background check was run. When asked about interventions to keep facility residents safe from R1 based off R1's background check, V13 did not provide any and stated V13 was not aware that R1 had an aggravated battery conviction on R1's record. On 6/11/24 at 10:50 am, R1 stated when R1 was admitted to the facility and placed into a room with other residents, a four bed ward, that R1 told both V1 Administrator and V5 SSD that the other two facilities R1 had been at in the past had R1 in a private room due to R1's background check and recommendations from the police but that this facility told R1 they could not do that. R1 explained after being in the four bed ward, another resident complained about R1, so the facility moved R1, then moved R1 in with just one other resident. R1 stated R1 thought R1 could handle it with just one other resident but I (R1) couldn't. (R2) accused me (R1) of hitting (R2) so now I (R1) have to defend myself. Had they {facility} had me (R1) in a room by myself to start like I (R1) told them {V1 and V5} I (R1) needed; this never would have happened. On 6/11/24 at 11:07 am, V1 stated R1 never told V1 that R1 needed to be in a private room based on R1's background check however R1 did ask V1 about being in a private room but the facility couldn't accommodate that.

Based on observation, interview, and record review the facility failed to identify significant weight loss, timely report significant weight loss to the dietitian and physician, ensure weight loss was assessed/evaluated by a physician, notify the resident representative of weight loss, implement nutritional recommendations, and obtain weekly weights for five (R70, R39, R62, R60, R97) of nine residents reviewed for nutrition in the sample list of 54. These failures resulted in R70 experiencing a significant one month weight loss of 5.52% after experiencing a 10.77% weight loss the month prior, and a total weight loss of 24.25% in six months. Findings include: The facility's Significant Weight Gain or Loss Policy revised February 2024 documents: 1. Dietary/Nursing team will obtain weights from nursing. a. After review a request for reweighs will be determined. 2. Dietician/Nursing will determine significant weight changes 1. Gain or loss of 5% in the last month b. Gain or loss of 7.5% in the last three months c. Gain or loss of 10% in the last six months 3. Dietician will review these clients and document the change 4. If recommendations are indicated will be communicated to nursing to notify the provider of the significant weight changes and recommendation. If weight loss noted: family and resident will be notified in addition to physician. IDT (Interdisciplinary Team) will review monthly to assure appropriate plan of care and interventions for those with significant weight gain or loss. 1.) R70's undated weight log documents the following weights: 158 pounds (lbs.) on 5/22/23. 159.3 on 6/7/23. 154.2 on 8/1/23. 137.6 (10.77% loss in one month) on 9/4/23. 130 (5.52 % loss in one month) on 1/0/1/23. 136.8 on 11/1/23. 136.2 on 12/12/23. 136 on 1/8/24. 120.8 on 2/1/24. 116.8 (24.25% loss in six months) on 2/19/24. 119.8 on 2/19/24. 115.2 on 3/4/24. There are no documented weights after 10/1/23 until 11/1/23 or between 2/19/24 and 3/4/24 to verify the accuracy of the weights. R70's Minimum Data Set (MDS) dated [DATE] documents R70 has cognitive impairment and R70 weighs 136 lbs. This MDS incorrectly documents R70 has not had a significant weight loss within the last six months. R70's Care Plan dated 9/21/23 documents R70 has unplanned and unexpected weight loss and includes interventions to notify the physician and dietitian immediately if weight decline persists. This care plan does not document any new interventions to address R70's weight loss after 1/12/24. R70's Diet Order dated 2/27/24 documents double portions at breakfast, lunch and supper. R70's Physician Order dated 12/20/23 documents give nutritional supplement 120 milliliters (ml) twice daily. There are no other documented nutritional supplements in R70's medical record. R70's March 2024 Medication Administration Record (MAR) documents administration of the nutritional supplement but does not document how much of the supplement is consumed. There is no documentation in R70's medical record that R70's September 2023 significant weight loss was reported and evaluated by a dietitian and physician, or that R70's February 2024 significant weight loss was reported to or evaluated by a physician prior to 2/20/24 and reported/evaluated by the dietitian prior to 2/26/24. There is no documentation that V40 (R70's Family) was notified of R70's significant weight loss in September 2023 or continued weight loss noted in February and March 2024. R70's Dietary Note dated 2/26/24 at 6:32 PM and recorded by V19 Dietitian documents R70's diagnoses include Alzheimer's Disease, Type 1 Diabetes Mellitus, Protein Calorie Malnutrition, Hypertension, Dysphagia, Iron Deficiency Anemia, Anxiety, Muscle Weakness and Encephalopathy. This note documents R70 is 68 inches tall, 119.8 lbs., and Body Mass Index is 18.2, underweight. R70's diet includes double portions at breakfast and dinner, and a nutritional supplement twice daily. This note documents significant weight loss for one, three, and six months, weight is down 16 lbs. from last month, R70 eats well, and unclear etiology of this weight loss. V19 recommended to increase double portions for all meals to prevent further weight loss. On 3/3/24 at 12:10 PM V39 Certified Nursing Assistant (CNA) fed R70 the noon meal that consisted of puree barbecue sandwich, vegetables, mashed potatoes, chocolate nutritional shake, and lemonade. R70's meal ticket did not document double portions. At 12:30 PM R70 ate all the noon meal. V39 stated R70 eats well and ate all the noon meal today. On 3/4/24 at 11:44 AM R70's meal ticket did not document double portions for the noon meal. At 12:18 PM R70 ate all R70's noon meal. On 3/5/24 at 8:42 AM R70 ate all R70's breakfast and R70's meal ticket documents double portions for the breakfast meal. On 3/4/24 at 4:11 PM V40 (R70's Family) stated V40 was not sure if R70 has had any weight loss, nobody has told V40 what R70 currently weighs, and V40 had planned to ask the facility about that. On 3/4/24 at 11:20 AM V38 Memory Care Director stated the nurses would know if a resident had a weight loss and V38 assists the CNAs in obtaining weights. V38 stated V38 reports weight loss to V41 Care Plan Coordinator and V5 MDS Coordinator during the weekly weight meetings. V38 stated V38 attends the meetings if the dementia unit (where R70 resides) has residents with weight loss. V38 last attended a weight meeting about a month ago. V38 stated R113 is the only resident on this unit with weight loss. On 3/4/24 at 12:53 PM V18 Licensed Practical Nurse (LPN) stated V18 gave R70's morning nutritional supplement and R70 only drank about 60 of the 120 ml given. V18 stated usually V18 tries to give R70 the remaining amount later, but V18 did not do that today. On 3/5/24 at 8:38 AM V25 Dietary Aide/Cook stated dietary staff look at the meal tickets to determine which residents should have double portions at meals. V25 stated double portions is listed on R70's dinner meal ticket, but not on R70's noon meal ticket. On 3/5/24 at 10:14 AM V21 Assistant Administrator stated weights are only documented in the resident's electronic medical record. V21 stated the Assistant Director of Nursing (ADON) is responsible for notifying the resident's family of weight loss, but we didn't have an ADON recently until a few weeks ago. V21 stated the ADON is also responsible for leading the weight program and V21 was unsure who was leading the weight program in the ADON's absence. V21 stated the dietitian's assessments are documented in the progress notes and V21 did not see a dietitian note/assessment for R70 in September. V21 stated double portions should be on the resident's meal tickets. On 3/5/24 at 11:51 AM V8 stated R70 had atelectasis found on R70's chest x-ray in September 2023, and V40 did not want any follow up x-rays, appointments, or anything invasive done. V8 stated V8 evaluated R70 today and the staff report R70 eats well. V8 stated V8 was unsure of the direct cause of R70's weight loss since V40 refused invasive testing. V8 stated V8 does not evaluate for weight loss and refers to the dietitian to address weight loss. V8 stated this is a large building, there is a lot of weight loss. V8 relies on the facility to report significant weight loss. V8 does not have time to evaluate each resident for weight loss, and V8 records the resident's weight in V8's Progress Notes. V8 stated the staff should absolutely follow the dietitian's recommendations and if those recommendations are not followed it can contribute to weight loss. V8 stated on 2/20/24 V8 noted in V8's notes that R70 had a slight weight gain. V8 reviewed R70's weights, and stated V8 believes R70's weight of 119.8 on 2/19/24 was inaccurate as it was obtained by a mechanical lift and the other weights were in a wheelchair. On 3/5/24 at 12:16 PM V20, Interim [NAME] President of Clinical Operations, stated V20 requested that V8 evaluate R70 today, and confirmed V40 was not notified of R70's significant weight loss in February. At this time documentation was requested that the physician was notified and evaluated R70's weight loss in September and February. The facility failed to provide this requested documentation. On 3/5/24 at 12:55 PM V19 Dietitian stated V19 conducts V19's nutritional assessments off site and runs a weight report during the first week of each month to identify significant weight loss. V19 stated V19 then places those identified residents on the Nutrition at Risk form, gives recommendations and the form to the facility, and if the facility identifies weight loss or nutrition concerns then they contact V19 by electronic mail. V19 stated it is difficult to stay up on the weights and nutritional assessments due to this being a large facility. V19's contract is for 36 hours per month at the facility, and it is difficult to complete all of it in that time frame. V19 stated V19 would have identified R70's significant weight loss during the first week of February when V19 ran the weight report, and V19 requested a reweigh on 2/16/24 to verify the accuracy of the 2/1/24 weight. V19 believes the weight was accurate based on R70's following weights. V19 stated the facility should implement V19's recommendations within a week and confirmed that waiting a week could also result in additional weight loss during that time. V19 stated V19 determines if residents are consuming supplements by communicating through electronic mail to the facility and reviewing progress notes. V19 stated if the resident isn't consuming the supplements, then V19 would try adding additional dietary supplementation such as fortified cereal, nutritional shakes, double portions, and whole milk with meals. V19 stated V19 did not give any nutritional recommendations for R70 in February until 2/26/24 when V19 recommended adding double portions to all meals, and V19 would have given that recommendation sooner once R70's weight loss was verified. V19 stated ideally the facility should reweigh to verify weights and should be completed by the 10th of each month. V19 stated V19 did not see any documentation that R70's significant weight loss and nutrition was evaluated in September by a dietitian, and double portions would have been recommended at that time. V19 confirmed adding the double portions prior to October could have helped stabilize R70's weight and if R70 is not receiving the recommended nutritional interventions it can contribute to weight loss. V19 stated R70's weight loss is a tough one. V19 was not sure what is causing R70's weight loss. 2.) R39's MDS dated [DATE] documents R39 has cognitive impairment and R39 has had a significant weight loss within the last month or six months. R39's undated weight log includes the following weights: 141.4 lbs. on admission 8/8/23. 137 on 10/1/23. 143 on 11/16/23. 120.2 on 11/29/23 and 12/3/23. 114.8 on 12/20/23. 119.0 on 1/3/24. 117.6 on 2/1/24 and 2/7/24. 122.2 on 3/4/24. There are no documented weights between 11/16/23 and 11/29/23. R39's March 2023 MAR documents to administer nutritional supplement 120 ml three times daily with breakfast, lunch, and dinner. R39's Dietary Note, recorded by V19, dated 12/23/2023 at 4:46 PM documents R39 is 63 inches tall, weighs 114.8 lbs. a 19.7% one month loss, and Body Mass Index is 20.3, underweight. R39's diagnoses include Vascular Leukoencephalopathy, Protein Calorie Malnutrition, Hypertension, Anemia, Malignant Neoplasm of breast, Gastritis, and Vascular Dementia. This note documents R39 has had ongoing weight loss since admission with recent hospitalization for COVID-19 (Human Coronavirus Infection) Pneumonia which likely contributed to weight loss. V19 recommended a nutritional supplement to be given daily. R39's Dietary Note, recorded by V19, dated 1/23/24 at 7:37 PM documents R39 has a 13% weight loss in three months, and R39 receives a nutritional supplement three times daily. This note documents that R39's weight is similar to R39's November weight and is showing some slight improvements. This note documents to continue nutritional supplement and recommend weekly weights. There is no documentation in R39's medical record that R39's physician and family were notified of R39's November 2023 significant weight loss, or that a dietitian evaluated this weight loss prior to 12/23/23. On 3/3/24 at 12:10 PM R39 was eating lunch. At 12:28 PM R39 ate half of a barbecue sandwich, and all the vegetables, mashed potatoes, and dessert. R39 drank all the lemonade and nutritional supplement. On 3/4/24 between 12:10 PM and 12:29 R39 ate lunch and R39 was not served a nutritional supplement. On 3/4/24 at 1:02 PM V18 LPN stated V18 is unsure if R39 gets a nutritional supplement but V18 will check. V18 reviewed R39's MAR which documented V18 had signed out R39's nutritional supplement as administered as scheduled for morning and noon. V18 stated V18 signed the MAR, but V18 had not given R39's supplement. On 3/5/24 at 12:16 PM V20 was asked to provide documentation that R39's family and physician were notified of R39's November significant weight loss. The facility failed to provide this requested documentation. On 3/5/24 at 12:55 PM V19 stated V19 did not evaluate R39's November weight loss until December when V19 recommended adding the nutritional supplement, and this supplement was increased to three times daily in January 2024. V19 stated V19 identified R39's significant weight loss mid-December and probably would have recommended the house supplement sooner if V19 was notified of the weight loss prior. V19 stated V19 questions the accuracy of R39's 11/16/23 weight and ideally the facility should reweigh to verify weights. 42702 3.) On 3/03/24 at 11:20AM, V45, R97's family member said R97 has lost weight since being at this facility. On 3/3/24 at 11:21 AM, R97's continuous tube feeding was running onto the floor as it was disconnected from port. On 3/5/24 at 11:30AM, R97's continuous tube feeding was turned off. R97's 12/18/23 dietician note documents a weight review and tube feeding review for R97 indicating that R97 is underweight. R97's weight sheet documents that on 12/20/23, R97's weight is 149.4 pounds. R97's weight sheet documents that on 12/27/23, R97's weight is 135.6 pounds, a ten percent weight loss in one week. R97's medical record does not document notification of the physician for this significant weight loss. R97's physician orders dated 12/18/23 document that R97 is to be weighted weekly. R97's medical record does not document that R97 received weekly weights from 12/18/23 through March 6, 2024. On 3/6/24 at 11:47 AM, V2 Director of Nursing confirmed that the Physician should be notified of any significant weight loss in residents. 37813 4.) R62's Care Plan revised 2/16/24 documents, (R62) has unplanned/unexpected weight loss. Date Initiated: 09/21/2023 No new nutritional or weight loss interventions have been documented since 9/21/23. On 09/02/2023, the R62 weighed 212 lbs. On 02/28/2024, the R62 weighed 167.2 pounds which is a -21.13 % Loss. There is no documentation in R62's medical record that the physician was notified of R62's significant weight loss. On 3/5/24 at 2:26PM V8 Nurse Practitioner stated, If the facility did not notify me of a weight loss for (R62) I would not have known to address it when I visit. 32853 5.) R60's Order Summary Report dated 3/4/24 documents diagnoses including Vitamin D Deficiency, Anemia, Abnormal Weight Loss, Type 2 Diabetes, Chronic Kidney Disease and Moderate Protein-Calorie Malnutrition. R60's electronic medical record contains a weight log which documents R60's weight on 10/11/23 as 229.18 pounds. This weight record then documents R60's weight on 11/8/23 as 168.6 pounds and on 11/10/23 as 168.8 pounds. R60's Nurse Progress notes do not document notification of the Physician or of the Registered Dietician of this weight loss, therefore there was nothing done to assess or treat this weight loss. On 3/6/24 at 11:47 AM, V2 Director of Nursing confirmed that the Physician and the Registered Dietician should be notified of any significant weight loss in residents.

Based on interview and record review the facility failed to properly monitor a door alarm and failed to ensure a resident did not exit the facility unnoticed (elopement). This failure resulted in R4 leaving the facility alone and unsupervised for over 1 hour and 16 minutes. This failure affects one (R4) of three residents reviewed for elopement in the sample of 5. R4 had potential for serious injury and/or death due to the inclement winter weather and residents' poor safety awareness of walking in the street. R4's hands and face were exposed to dangerously cold temperatures increasing potential of frostbite. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 1/15/24 at 6:41pm when R4 left the facility unnoticed by staff. R4 walked eight tenths of a mile from the facility and was found by police walking in the street at night with an outside temperature of 6 degrees F. (Fahrenheit). R4 was located by the local police department, identified, and brought back to the facility at 9:03pm. V1 Administrator was notified of the Immediate Jeopardy on 1/18/24 at 11:14am. The surveyor confirmed by observation, record review, interview that the Immediate Jeopardy was removed on 1/18/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R4's Facility Census documents R4 was admitted to the facility on [DATE] and has the following medical diagnoses; Schizophrenia, COPD, Malignant Neoplasm of Bladder, Epilepsy, Solitary Pulmonary Nodule, Hypertensive Urgency, Peripheral Vascular Disease, GERD, Dry Eye Syndrome, Hydronephrosis, Hyperlipidemia, Vitamin Deficiency, Constipation, Pain, and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. R4's Minimum Data Set (MDS) dated [DATE] documents R4's Brief Interview for Mental Status (BIMS) score 9, moderate cognitive impairment. TheWeatherChannel.com documented the temperature in (city) at 6:53 pm was 6 degrees Fahrenheit. Facilities Video Camera still photo's document R4 left the faciity on [DATE] at 6:41.22 pm and returned at 9:03.39 pm. R4's Police Report#2024-00000349 documents on 1/15/24 at 7:06 pm V17 Police Officer was dispatched to (local address) avenue (local High School), (city) and arrived at 7:06 pm. Upon arrival, V17 located R4 just west of (local address) street walking westbound in the middle of the westbound lane. V17 had R4 get into V17's squad after R4 stated R4 was freezing. R4 stated R4 was looking for R4's residence (local address) Avenue but could not find it. R4 then explained that it was a glass house. V17 drove to (local address) Avenue and pointed it out to R4. R4 stated that wasn't the house and the house is on the Northside of (local address) Avenue. R4 was explained at the even addresses were on the Southside of the roadway. R4 appeared confused asking V17 if they nuked the area because R4 didn't recognize it. R4 also notified V17 that R4 was told to 'walk off' and that was why R4 was outside walking. V17 drove R4 up and down (local address) Avenue for about 15 minutes it was decided to take R4 to the emergency department at (local address). Prior to going to the ER dispatch attempted to locate an address for R4 but was unsuccessful. While in the ER the staff at the front desk notified V17 that R4's last known address was (local address) Avenue. V17 recognized that to be nursing home. ER staff provided V17 with the nursing homes phone number. After about a 5-minute conversation the staff initially stated R4 did not reside there then they recanted and found R4 lived in the North building. Staff at the south building put V17 on hold while they transferred V17's call to the North building. The staff at the North building answered and hung up almost immediately. V17 called back and was hung up again then had dispatch make the phone call to confirm R4 was residing at a local residential address. V17 transported R4 back to the nursing home. Outside in the parking lot was V19 off duty supervisor, who was on scene to pick up son. V19 escorted R4 back inside to the staff on scene working. R4's Nursing Note dated 1/15/23 at 8:30 pm documents at 8:08 pm, call received from V8 Licensed Practical Nurse (LPN) regarding a call from the local police department that R4 was picked up. Call placed to V1 Administrator and Regional nurse consultant, Medical Doctor (MD) and R4's Power of Attorney (POA) made aware. Upon review of the camera footage, determined R4 left the facility at 6:41pm and shut alarm off. R4 was wearing street clothes, shoes, and winter coat. Call placed to police department to verify. Officer notes first call placed at 7:06 pm, second 7:07pm. Police contacted R4 and at that point was placed in police car. R4 stated R4 lived at (local address) Avenue and officer drove R4 up and down the block a few times before going to a particular house where R4 believes R4's dad lives. R4 was brought back to the facility. Called placed to the hospital and noted R4 had not been taken to the emergency room . On arrival to facility, head to toe assessment unremarkable. R4 confused and slightly agitated. R4 denies pain. Placed on 15-minute checks upon arrival. On 1/16/24 at 11:15am R4 said, last night (1/15/23) after dinner R4 left the facility to go to R4's dad's house in (city). R4 said, R4 was wearing shoes, socks, blue jeans, a sweatshirt, and a winter jacket with a hood. R4 said, it was a little cold out. R4 said, it was dark out and R4 couldn't find the address on the building and kept looking. R4 said, a police officer picked R4 up and brought back to the facility. On 1/17/24 at 9:35 am V9 Certified Nursing Assistant (CNA) said, V9 worked on 1/15/24 from 7:00 pm to 7:00 am in the North Building Psychiatric Unit. V9 said, when V9 got to work there were no residents outside smoking. V9 said, when V9 reports to work, V9 goes to the nurses' station and gets report from the prior shift, on resident behaviors, residents out of the facility and any other pertinent information regarding residents. V9 said, V9 then walked the halls, checking V9's residents to make sure they were all accounted for. V9 said, V9 is not sure if V9 saw R4 in the building that evening. V9 said, at around 8:00 pm V8 Licensed Practical Nurse (LPN) informed V9 that R4 was picked up by the police walking down (local address) Avenue and was bringing R4 back to the facility. V9 said, when R4 returned to the building R4 went back to R4's room and V8 assessed R4. V9 said, when the door alarm sounds, staff should go to the door and check to make sure no resident has left the facility. V9 said, there is a camera located at the nurses' station that captures the front door, and staff usually looks at it and check to make sure no one has left the building. On 1/17/23 at 10:12 am V8 Licensed Practical Nurse (LPN) said, on 1/15/24 V8 was working the 7:00 am to 7:00 pm shift in the North Building Psychiatric Unit. V8 said, V8 got report from the previous shift and did not know that R4 was not in the building. V8 said, the Certified Nursing Assistant (CNA) should check to see if all their residents are accounted for, and report back to V8 is any were not accounted for. V8 said, around 8:00pm, V8 received a call from the local police department and was given R4's name and date of birth to check to see if R4 resided in the facility. V8 informed them R4 did reside in the facility. V8 said, the police informed V8 they had R4 at the hospital after several calls of R4 walking around the street. V8 said, they brought R4 to the hospital in an attempt to identify and find out where R4 lives. V8 said, the police brought R4 back to the facility a short time later. V8 said, when R4 came back to the facility, V8 asked if R4 was in any pain, and R4 said no R4 was fine. R4 just wanted to go to R4's room. V8 said, R4 would only let V8 assess R4's hands. R4 is always reluctant to get a body assessment. V8 said, R4's hands and face did not have frostbite. V8 said, V8 and V9 later went back to R4's room and were able to check R4's feet which were ok. V8 said, V8 notified V1 Administrator, V2 Director of Nursing and R4's Power of Attorney. On 1/18/23 at 9:50 am V2 Director of Nursing said, on 1/15/23 at around 8:10pm, V2 received a call from V8 Licensed Practical Nurse (LPN) that R4 has exited the facility and was pick up by the local police department. V2 said, V8 informed V2 the police were bringing R4 back to the facility. V2 said, upon review of the camera footage, R4 left the facility at 6:41 pm and shut the audible alarm off at the front door. V2 said, R4 was wearing street clothes, shoes, and winter coat. V2 said, the alarm panel at the nurses' station was still ringing and flashing. V2 said, staff should have gone to the front door to determine what set the alarm off. V2 said, at this time the 7:00 pm shift was arriving to work, and the dietary workers were leaving to the main building. V2 said, V2 called the police department to verify. V2 said, police dispatch informed V2 they received the first call at 7:06 pm and second at 7:07 pm. V2 said, police made contact with R4 and R4 was placed in police car. V2 said, R4 informed the police officer that R4 lived at (local address) Avenue and the officer drove R4 up and down the block a few times before going to a particular house where R4 believes R4's dad lives. V2 said, the police officer brought R4 to the emergency room to see if they could assist in identifying where R4 lived. V2 said, staff were able to identify a last known address and the officer recognized it as the nursing home. V2 said, contact was made with the facility, and it was verified that R4 was a resident at the facility. V2 said R4 was brought back to the facility at 9:03pm. On 1/19/24 at 11:40 am V1 Administrator said, on 1/15/23 V1 was notified by V2 Director of Nursing (DON) that R4 had left the North Psychiatric building and was brought back to the facility by the police. V1 said, as soon as it was learned that V4 was located outside of the facility by the police a head count was conducted, and all residents were accounted for. V1 said, R4 has been a resident at the facility since 7/1/13 and has never attempted to elope. V1 said, R4 has never been an elopement risk. V1 said after the incident V15 Maintenance went to the facility and reviewed the video footage of the North Psychiatric building front door. The video showed on 1/15/23 at 6:41 pm R4 leaving the building wearing gym shoes, blue jeans, winter jacket and maybe gloves, and returning to the facility at 9:03 pm. V1 said, V1's expectations of staff when a door alarm goes off, staff should verify by going to the site of the alarm and verifying that no resident has left the building. V1 said, if staff is unable to verify who has left the building should have performed a head count, which was not done on 1/15/24. The Immediate Jeopardy that began on 1/15/24 was removed on 1/18/24 when the facility took the following actions to remove the immediacy: 1. Upon return to the facility1/15/24, R4 was assessed per V8 Licensed Practical Nurse with no skin or pain issues. 2. 1/16/24: R4 reassessed for risk of elopement and community survival skills. Plan of care updated to reflect current risk of elopement and associated behavioral needs per V23 Social Service Director. 3. Quality and Assurance meeting held on 1/16/24 at 11:30am with V1 Administrator, V23 Social Service Director, V24 Psychiatrist, V21 Psychiatric Mental Health Nurse Practitioner and V20 Regional Social Service and Activities Director. 4. On 1/15/24 after the incident V15 Maintenance Supervisor came to facility to review the incident and confirmed door alarm/system functional status. 5. Outside button control allowing the silencing of the door alarm was disabled on 1/16/24, by V15 Maintenance Supervisor. 6. R4 was put on 15-minute status checks. 15-minute checks are being documented on 24 hour/15-minute monitoring log. Certified Nursing Assistants are responsible for documenting the 15-minute checks, Completed by V8 Licensed Practical Nurse (LPN), V9 Certified Nursing Assistant (CNA) and V10 Certified Nursing Assistant (CNA) on 1/15/24. 7. Facility head count completed and continuous every shift, by staff. Completed by V8 Licensed Practical Nurse (LPN), V9 Certified Nursing Assistant (CNA) and V10 Certified Nursing Assistant (CNA) on 1/15/24 and continued every shift by Certified Nursing Assistants. 8. Code Pink Drill completed 1/18/24 for both buildings and premises, by V11 Memory Care Coordinator and V2 Director of Nursing (DON) for both buildings on the premises. 9. Between 1/16/24 and 1/17/24 all residents were reassessed by V23 Social Service Director, V11 Memory Care Coordinator, V28 Licensed Practical Nurse (LPN) and V22 Minimum Data Set Registered Nurse. Elopement/unauthorized Leave Risk Assessment. 10. Newly admitted residents or residents that display a new behavior related to elopement will be assessed or reassessed. This will be on-going, by V12 Psychiatric Rehabilitation Services Director, V11 Memory Care Coordinator and V23 Social Service Director started this responsibility on 1/17/24. 11. Facility all staff were reeducated to the elopement risk and Code Pink Policy, by V15 Maintenance Director, V22 Minimum Data Set Registered Nurse V29 Regional [NAME] President of operations and V26 Staffing Coordinator the education was conducted from 1/16/24 to 1/18/24. 12. Interdisciplinary Team educated on person centered interventions, reporting changes and behavior tracking, by V19 Director of Clinical Quality and Education, completed on 1/18/24. 13. The facility has an established policy regarding Code Pink Policy regarding responding to door alarms. On 1/17/24 all facility staff were in-serviced by V15 Maintenance Director, as to the existence and appropriate usage and response to facility alarm. Any agency staff or new staff will be educated prior to working on the floor. This will be on-going. The facility contacted agency staffing agencies with regard, etc. V15 Maintenance Director and V30 Human Resources Director. 14. V25 Director of Clinical and Education for Arcadia Care reviewed the establish policy on 1/18/24 and reviewed policy is being maintained. 15. Code Pink Drill was carried out on 1/18/24, by V11 Memory Care Coordinator and V2 Director of Nursing (DON) for both buildings on the premises. 16. V12 Psychiatric Rehabilitation Services Director and/or designee will audit 5 residents weekly, for a period of 8 weeks ensuring capture of any new behaviors related to elopement and reviewing resident care plans for necessary interventions. The results of the audit will be reviewed by Quality and Assurance (QAPI) Committee monthly ensuring appropriate interventions are in place for those at risk for elopement. 17. V15 Maintenance Director, or Designee performs door alarm checks 7 days a week. This audit will continue indefinitely, and results will report to QAPI monthly for the next 2 months. The facility presented an abatement plan to remove the immediacy on 1/18/24. The facility presented a revised abatement plan on 1/19/24, and the survey team accepted the revised abatement plan on 1/20/2024 at 11:00am.

Based on observation, interview, and record review the facility failed to complete wound assessments, transcribe wound orders, and administer wound treatments as ordered for three (R1, R5, R6) of four residents reviewed for wounds in the sample list of 22. The facility also failed to prevent cross contamination during wound treatments by failing to perform hand hygiene and disinfect scissors resulting in R1, R5, and R6 developing wound infections. Findings include: 1.) R1's Concern/Compliment Form dated 8/14/23 documents V22 (R1's Family Member) was concerned R1's knee infection is due to R1's wound treatment not being done daily as ordered. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact and has a surgical wound. R1's Care Plan dated 7/20/23 documents R1 is at risk for skin impairment and includes an intervention to assess and record changes in R1's skin and report changes to the physician. This Care Plan documents R1's diagnoses include Left Artificial Knee Join and Aftercare Following Joint Replacement Surgery. R1's Care Plan revised 8/14/23 documents R1 is on antibiotics for a wound infection. R1's Order Summary Report dated 7/23/23-8/23/23 documents the following orders: Bactrim (antibiotic) DS (Double Strength) Oral Tablet 800-160 Mg (milligrams) give one tablet by mouth twice daily for 2 weeks for wound infection. Daily wound packing to left knee (ordered from 8/10/23-8/20/23). There is no order which includes what to pack the wound with until 8/23/23 when an order was initiated to pack the wound daily with iodoform, covered with a sterile bordered gauze and elastic wrap. R1's July and August 2023 Treatment Administration Records (TARs) document to apply an abdominal gauze and monitor site for infection daily 7/5/23-8/14/23. The gauze treatment and monitoring for infection are not signed as administered on three dates, and wound packing treatments are not signed as administered on three dates. There are no documented assessments of R1's surgical wound in R1's medical record. On 8/22/23 at 12:57 PM R1 stated R1 was admitted to the facility about a month ago after R1 was hospitalized for left knee replacement. R1 stated R1 has an infection in R1's left knee surgical wound due to staff not changing R1's dressing as ordered. R1 stated V4 Registered Nurse (RN) only looked at R1's left knee dressing, V4 did not change the dressing when R1 asked for it to be changed and told R1 V4 was not a nurse. R1 was lying in bed with an elastic wrap covering R1's left knee. On 8/23/23 at 2:16 PM V3 Licensed Practical Nurse (LPN) removed the elastic wrap and dressing from R1's left knee. There was an open, red, moist wound approximately the size of a marble at the base of R1's left knee. V3 stated the surgeon made R1's wound slightly larger. V3 cleansed the wound and obtained scissors from V3's pocket. V3 placed the scissors on R1's overbed table and then without disinfecting the scissors, used the scissors to cut the iodoform. V3 packed the iodoform directly into R1's wound, covered with a bordered gauze dressing and applied the elastic wrap to R1's left knee. At 2:32 PM V3 stated R1's wound should be assessed weekly by the floor nurse who administers R1's wound treatment and documented under the assessments in R1's electronic medical record. V3 reviewed R1's assessments in R1's medical record and confirmed there are no documented assessments of R1's wound. V3 stated the wound started as a pinhole at the base of R1's surgical wound. V3 confirmed V3 did not disinfect V3's scissors prior to administering R1's wound treatment. On 8/23/23 at 11:31 AM V14 Certified Nursing Assistant stated last week R1 asked V4 RN to change R1's wound dressing. V4 told R1 V4 did not have the supplies to do the treatment, left R1's room, and never returned to change R1's dressing. V14 stated R1's dressing was supposed to be changed on dayshift. 2.) R5's MDS dated [DATE] documents R5 is cognitively intact. R5's Care Plan dated 7/21/23 documents R5 has a wound to the left lower lateral leg and includes an intervention to administer treatments as ordered. R5's Order Summary Report dated 7/1/23-8/23/23 documents an order dated 8/21/23 to apply calcium alginate to the left leg wound, cover with bordered gauze, and secure with a gauze/stretch wrap. This report documents an order dated 7/28/23-8/5/23 for Levofloxacin (antibiotic) 750 mg by mouth daily for a wound infection. R5's Wound Evaluation & Management Summary dated 7/19/23, recorded by V31 Wound Physician documents R5's full thickness, non-pressure wound of the left, lower, lateral leg measured 3 centimeters (cm) long by 2.5 cm wide by 0.2 cm deep. The wound was due to trauma/injury and is improving/healing. R5's Wound Evaluation & Management Summary dated 7/29/23 by V31 documents R5's wound declined, measured 3.5 cm by 2 cm by 0.4 cm, and had purulent green colored drainage (pus). This wound was exacerbated due to infection. R5's Wound Evaluation & Management Summary dated 8/16/23 recorded by V30 Nurse Practitioner documents R5's wound measured 3 cm by 2.5 cm by 0.2 cm and a treatment order to apply Calcium Alginate daily. R5's August 2023 TAR does not document R5's Calcium Alginate treatment was transcribed onto the TAR prior to 8/20/23, and this order is only documented as administered on 8/20/23 and 8/21/23. On 8/22/23 at 3:22 PM R5 stated R5 has a wound to the leg which started as a blister, V31 evaluated the wound and lanced it. R5 stated R5 had an infection in the wound and received antibiotics. On 8/23/23 at 12:56 PM V21 Licensed Practical Nurse (LPN)/Wound Nurse touched the treatment cart outside of R5's room and obtained wound care supplies. Scissors were on top of the treatment cart. Without performing hand hygiene, V21 applied gloves and entered R5's room. V21 used an alcohol prep pad to wipe the blades of the scissors and placed the scissors on the overbed table in R5's room. V21 had not disinfected the overbed table prior. V21 removed R5's dressing to the left outer calf which had minimal drainage. V21 changed V21's gloves and cleansed the wound. V21 changed gloves and used the scissors on R5's overbed table to cut the calcium alginate and placed it directly onto R5's wound. V21 cut a piece of an abdominal pad dressing secured with tape to cover R5's wound. V21 placed the scissors on top of the treatment cart and washed V21's hands. V21 did not perform hand hygiene between changing gloves and when moving from soiled to clean areas during the treatment. V21 then pushed the treatment cart to R6's room. On 8/23/23 at 12:01 PM V2 Director of Nursing (DON) stated the facility has V31's notes by the following day after V31 rounds. V2 stated V31 also gives V31's order changes verbally when rounding. V21 rounded with V30 Nurse Practitioner on 8/16/23. V2 stated the order for Calcium Alginate was transcribed incorrectly and did not prompt treatment administration on the TAR until V3 corrected the order entry on 8/19/23. 3.) R6's Care Plan revised 7/31/23 documents R6 has a wound infection of the left great toe and is receiving antibiotic therapy. This Care Plan documents R6 has a diagnosis of Diabetes Mellitus. R6's Order Summary dated 7/1/23-8/23/23 documents the following: Apply Collagen powder to the left great toe and cover with gauze bordered dressing once daily, initiated on 8/16/23. Administer Bactrim (antibiotic) DS (Double Strength) 800-160 mg by mouth twice daily for toe infection for 14 days beginning on 7/6/23 and again on 7/28/23. Administer Ceftriaxone (antibiotic) 1 gram intramuscularly daily for 14 days for toe infection beginning on 7/10/23. R6's July and August 2023 TARs document to administer bleach-soaked gauze treatments twice daily from 7/6/23-7/20/23 and administer Betadine-soaked gauze treatments twice daily 7/20/23-8/16/23 for the left great toe wound. There are 10 entries that do not document these treatments were administered as ordered. R6's Wound Evaluation & Management Summaries document the following: On 7/5/23 R6's diabetic left great toe wound measured 1.5 cm by 1.3 cm by 0.3 cm with 30% necrotic (dead) tissue, antibiotics were ordered for cellulitis (skin infection). On 7/19/23 the wound was larger and measured 1.5 by 1 by 0.3 cm with 30% necrotic tissue. On 7/29/23 the wound had recurrent peri wound cellulitis, was exacerbated due to infection, and measured 1.5 cm by 1 cm by 0.3 cm with 40 % necrotic tissue. On 8/16/23 R6's diabetic left great toe wound measured 1 cm by 0.7 cm by 0.4 cm. R6's Toe Wound Culture dated as reported on 7/8/23 documents Heavy Morganella morganii (bacterial growth). On 8/23/23 at 1:13 PM V21 pushed the treatment cart outside of R6's room. V21 did not perform hand hygiene, applied gloves, and removed the dressing on R6's left, great, toe. R6 had a circular, red, moist wound to the top of R6's toe. V21 changed gloves, used an alcohol prep pad to wipe the scissors which were on top of the treatment cart and laid the scissors back onto the cart. V21 then used the scissors to cut a piece of abdominal pad dressing. V21 cleansed R6's wound and applied the abdominal pad dressing secured with tape. V21 stated there is no order for anything else to be applied. V21 stated V31 Wound Physician told V21 today to change the order form Collagen powder to a gauze dressing. On 8/23/23 at 2:36 PM V21 LPN/Wound Nurse stated V21 has not received any facility training on hand hygiene/infection control practices during wound treatments. V21 stated V21 thought V21's hands were considered clean prior to performing R5's and R6's wound treatments, and V21 did not consider V21's hands contaminated after touching the treatment cart and wound supplies. V21 confirmed V21 did not perform hand hygiene prior to or during the wound treatments and did not disinfect the top of the treatment cart or overbed tables prior to R5's and R6's treatments. On 8/23/23 at 12:01 PM V2 DON stated the nurses should sign out the treatments on the TAR when administered. At 2:40 PM V2 stated bleach wipes are used to disinfect multi-use equipment. V2 confirmed an alcohol prep pad is not a disinfectant and scissors should be disinfected prior to cutting wound dressings. V2 confirmed wound assessments are documented under the assessments section of the resident's electronic medical record. On 8/23/23 at 1:24 PM V31 Wound Physician stated V31 changed R6's treatment from Collagen powder to Betadine-soaked gauze. V31 stated poor hand hygiene and not disinfecting scissors during wound treatments, as well as not changing dressings as often as ordered are risk factors increase the risk for developing wound infections. V31 stated V31 had concerns that dressings ordered to be changed twice daily are only getting changed once daily. The facility's Dressing Change policy dated August 2023 documents wound supplies may be placed on an overbed table after the table has been disinfected, wash hands prior to treatment administration, wash hands or use an alcohol-based hand rub to decontaminate hands when changing gloves after removing a soiled dressing, administer the wound treatment per physician's orders, sanitize scissors after use, and document on the TAR. This policy does not document to disinfect scissors prior to cutting wound dressings/supplies. The facility's Skin Condition Assessment & Monitoring- Pressure and Non-Pressure policy dated March 2023 documents Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least weekly by licensed nurses and documented in the resident's clinical record. Non-pressure skin conditions (bruises/contusions, abrasions, lacerations, rashes, skin tears, surgical, wounds, etc. (etcetera)) will be assessed for healing progress and signs of complications or infection weekly.

Failures at this level required more than one deficient practice statement. A. Based on interview and record review the facility failed to address the physical needs of a resident by overlooking a provider ordered blood work-up for a resident experiencing weakness and feelings of impending death. This failure affects one of one resident (R114) reviewed for death on the sample list of 55. This failure resulted in R114 experiencing respiratory distress and being sent to the hospital. R114 was found to be hypoxic, expiring after cardiac arrest due to Severe Anemia, Adult Failure to Thrive, and Anorexia. a. These failures resulted in an immediate jeopardy. The Immediate Jeopardy began on [DATE] when the facility failed to follow through with an order for blood work. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 1:04 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training, conduct daily audits and hold weekly Quality Assurance meetings to ensure compliance. Findings include: R114's Death Certificate dated [DATE] documents R114 expired on [DATE] at 8:43 AM. This certificate documents R114 cause of death as Cardiac Arrest due to Severe Anemia and Failure to Thrive. This certificate documents other contributing factors as Anorexia. R114's Progress Note written by V11 Nurse Practitioner dated [DATE] at 11:22 AM documents, New order blood work-up. This note also documents, ASSESSMENT/PLAN: #New order; Blood workup #Follow up visit; in one month or as needed. Plan of care discussed with nursing staff and patient. On [DATE] at 10:20 AM, V11 Nurse Practitioner stated she evaluated R114 on [DATE] and that R114 told her she felt weak and felt like she wasn't going to make it. On [DATE] at 9:17 AM, V11 stated V11 was new to the facility and she saw R114 for the first time that day. V11 stated she gave a lab requisition to V13 Assistant Director of Nursing on [DATE]. V11 stated she ordered a Complete Blood Count (CBC), a Complete Metabolic Profile (CMP), a Thyroid Stimulating Hormone (TSH), Vitamin D, and Hemoglobin A1C. R114's medical record does not contain orders for a CBC, CMP, TSH, Vitamin D, or Hemoglobin A1C after V11 made rounds on [DATE]. On [DATE] at 9:39 AM, V13 Assistant of Nursing stated she doesn't remember getting a lab order for R114. V13 stated V11 will fill out a lab requisition and then give it to me or the floor nurse. V13 stated then we take it and put an order into the computer. The lab will then come in and draw it. I am not aware of a change in condition. She wasn't a person we would talk about in clinical's. I guess we didn't notice her (R114) decline. We throw the lab requisitions away after a month. So that lab requisition would be recycled by now. R114's nursing note written by V12 Licensed Practical Nurse dated [DATE] at 10:55 AM documents, Writer informed (V11) that (R114) is having abnormal breathing. (Blood pressure),d+[DATE], (pulse) 77, (respirations) 30, (temperature) 98.0. (R114) has increased confusion. (V11) went and assessed (R114) and order to send (R114) to (emergency room ) obtained. Writer called and notified ambulance of needed transport. Writer called and informed (V14) guardian of transport. On [DATE] at 12:37 PM, V12 stated that morning ([DATE]) the CNAs (Certified Nursing Assistant) came to me and told me she wasn't breathing right I noticed her respirations were 30 and V11 came in and gave orders to send to the emergency room . On [DATE] at 10:20 AM, V11 Nurse Practitioner stated she seen R114 on [DATE] and she was weak and telling her she wasn't going to make it. V11 stated she ordered labs and they never got done. V11 stated that when she returned on [DATE] that she sent her to the emergency room and she passed away. V11 stated if the labs were completed, I would have identified that she needed sent out. V11 stated that not getting the labs contributed to R114 expiring. They didn't notify me that she wasn't eating. They should call and tell me. R114's Hospital notes dated [DATE] at 11:59 AM, document R114 was brought in via emergency medical services from the facility. R114 was diaphoretic, hypoxic, pale, and lethargic. These notes document the clinical impressions as Pneumonia of right lung due to infectious organism, Severe Anemia, Acute Renal Failure, Hyperkalemia, and Cardiac Arrest. These notes document that a Complete Metabolic Profile (CMP), a Pro time, a Lactic Acid, a Troponin and a Complete Blood Count (CBC)were obtained and all values were abnormal ([DATE] Laboratory results - CMP: Potassium 6.6 milliequivalent/Liter, Blood Urea Nitrogen (BUN) 125 milligrams/Deciliter, Albumin 2.6 grams/Deciliter, BUN to Creatinine Ratio 26 milligrams/Deciliter, A/G (Albumin/Globulin) ratio 0.7 grams/liter, GFR (Glomerular Filtration Rate) 9 milliliters/minutes; Lactic Acid 6.7 millimole/Liter; CBC: White Blood Cells 26.20 cells per microliter, Red Blood Cells 1.77 cells per microliter, Hemoglobin 5.8 grams per deciliter, Hematocrit 18.7 percent). These notes document that the hospital obtained consent for a blood transfusion and shortly afterwards R114 stopped breathing and went into asystole (heart stopped) and was pronounced dead at 1:08 PM. These notes documents R114's disposition as deceased . On [DATE] at 1:00 PM, V2 Director of Nursing stated that after V11 visited and wanted blood work an order was not written in the EHR (Electronic Medical Record) to complete the blood work. On [DATE] at 1:13 PM, V1 Administrator stated V11 was new to the building. V11 stated she heard there has been miscommunication between the nurses and V11. V1 stated the nurse managers should be reviewing progress notes after each visit to ensure all orders have been processed and written and then carried through. V1 stated the nursing staff should have called the physician and clarified what blood work needed obtained. The facility's Lab policy with a revision date of ,d+[DATE] documents, A requisition is to be completed and lab to be drawn on next scheduled lab draw day. On [DATE] between 9:00 AM to 3:00 PM and on [DATE] between 9:00 AM to 11:00 AM, the surveyor confirmed through observation, interview, and record review that the facility took the following action to remove the immediacy: 1. On [DATE] at 1:59 PM, an audit was completed by V30 Regional Nurse Consultant to ensure all orders and labs are entered into the electronic health record. 2. On [DATE] at 2:21 PM, an audit was completed by V30 Regional Nurse Consultant to ensure all Nurse Practitioner Progress notes to ensure there were not missed orders for labs. 3. On [DATE] at 2:22 PM, all nursing staff were educated on physician notification of laboratory, radiology, diagnostic results policy, order transcription for labs, order entry requisitions, requirement to review all labs at end of shift to verity lab work has been obtained after ordering, notification and documentation to medical providers and power of attorneys as needed by V30. 4. On [DATE] at 3:00 PM, V11 Nurse Practitioner was educated by V30 Regional Nurse Consultant on order entry into the electronic health record and the process on the 24-hour report review. 5. On [DATE], all other Nurse Practitioners working for the facility were educated on order entry and on the 24-hour report by V30 and V1. 40385 B. Based on interview and record review the facility failed to monitor weights, follow physician orders, and promptly report a significant weight gain for a resident (R27) with a diagnosis of Congestive Heart Failure. These failures resulted in a delay in treatment for R27's significant weight gain and R27 being hospitalized for 10 days with congestive heart failure and fluid volume overload. R27 is one of 34 residents reviewed for change in condition on the sample list of 55. Findings include: b. The facility's Physician-Family Notification- Change in Condition dates as revised [DATE] documents the physician will be notified of changes in a resident's condition and when there is a need to alter treatment. On [DATE] at 2:06 PM R27 stated: R27 told V18 Licensed Practical Nurse that R27's legs and stomach were swelled up bad. V18 disagreed with R27 that there was not fluid in R27's stomach. V18 told R27 that V18 contacted the Nurse Practitioner and told R27 to stay in bed for a few days. Nothing had changed, so the next day R27 told a nurse that R27 needed to go to the hospital. R27 stated, either the facility was going to send R27 to the hospital, or R27 was going to contact R27's family to take R27 to the hospital. R27 was put on emergency dialysis at the hospital. R27's After Visit Summary dated [DATE] documents to monitor weight daily and take medications as instructed. R27's discharge medications include Bumex (diuretic) 2 milligrams (mg) by mouth twice daily, Coreg 12.5 mg by mouth twice daily, Hydralazine 50 mg by mouth twice daily, and Imdur 60 mg by mouth daily. R27's Post-Acute Transition Document dated [DATE] documents R27 has Congestive Heart Failure, continue Bumex (diuretic) 2 milligrams twice daily and R27 needs accurate intake/output monitoring. R27 has Chronic Kidney Disease Stage 4, needs hypertension controlled, and needs access for dialysis. R27's hypertension is uncontrolled and recommendations include Coreg, Hydralazine, and Imdur as listed previously. R27's weight upon discharge was 193 pounds (lbs.). R27's [DATE] Medication Administration Record (MAR) documents: R27 had a daily fluid restriction of 1800 milliliters (ml) implemented on [DATE], 560 ml from nursing and 1240 ml from dietary. The intake is not recorded prior to night shift on [DATE]. 560 ml is incorrectly transcribed for 560 ml fluid allowance from nursing per shift, and not per day as ordered. R27 received more than the allotted 560 ml on 7 days between [DATE] and [DATE], including 1360 ml on [DATE], and 1400 ml on [DATE]. Daily weights were scheduled between [DATE] and [DATE], and do not document weights were obtained on ,d+[DATE]-[DATE]. Bumex, Coreg, Hydralazine, and Imdur was not administered as ordered/scheduled on [DATE], and documents to refer to a nursing note. Post dialysis monitoring was initiated on [DATE]. R27's weight log dated [DATE] documents R27's weights as follows. [DATE] 191.2 lbs. (pounds), [DATE] 218.7 lbs. (27.5 lb. gain in 2 days). [DATE] 223.1 (additional 4.4 lb. gain in 6 days) and 223 on [DATE]. R27 had a total weight gain of 31.9 lbs. in 8 days. R27's Nursing Notes documents R27 admitted to the facility on [DATE]. There is no documentation as to why R27's medications were not given on [DATE], or that the physician was notified of the missed doses. The Nurse Practitioner Progress Note with effective date of [DATE] and created date of [DATE] (late entry) documents: R27 recently admitted to the facility after a hospital admission for fluid volume overload and is scheduled to start dialysis in January. R27 had swelling to bilateral lower legs. R27's Chronic Kidney Disease was worsening and recommended to see a Nephrologist (kidney specialist) in one week. R27's Nursing Note dated [DATE] at 9:59 AM documents R27 notified the nurse that R27 had gained 20 pounds since admission. R27 reported having difficulty breathing and requested to go to the emergency room . An ambulance was called and R27 was transported to the hospital. There is no documentation that R27's weight gain was reported to R27's physician after [DATE] or that an appointment was made for R27 to see a Nephrologist prior to [DATE]. R27's Hospital Admission History & Physical dated [DATE] documents R27 presented to the emergency room for concerns of fluid overload. R27 reported gaining 20 pounds in one week and noted swelling in R27's lower legs and decreased urine output. R27's weight was 222 pounds on [DATE]. R27 had peripheral edema and course breath sounds. R27 was admitted for treatment of Congestive Heart Failure exacerbation. On [DATE] at 1:44 PM V2 Director of Nurses stated the physician should be notified of a weight gain of 5 lbs. or more in a week for a resident with Congestive Heart Failure, and physician notification is documented in a progress note. On [DATE] at 11:14 AM V2 stated intake/output is not recorded for fluid restrictions, dietary and nursing just give the designated amount. V2 confirmed a check mark on the MAR indicates medication was given. V2 stated a 9 on the MAR means other and prompts to record the reason the medications were not given in a nursing note. If a medication is not available the nurse should contact the pharmacy to have the medication delivered from a backup pharmacy, and the medications usually arrives within 4 hours. V2 reviewed R27's December MAR and confirmed the fluid restriction is incorrectly transcribed to allow for 560 ml fluids given by nursing per shift and not daily as ordered. V2 confirmed R27's medical record does not document daily weights were obtained between [DATE] and [DATE]. V2 was unable to provide documentation that R27 had seen a neurologist after [DATE], prior to [DATE]. On [DATE] at 10:00 AM V11 Nurse Practitioner stated the facility should have monitored R27's weights closely and followed up with the Nephrologist. Residents with Congestive Heart Failure should be weighed weekly and notified of weight changes per the physician's ordered parameter. V11 confirmed R27's Bumex should have been administered as ordered and the facility should have notified R27's physician of R27's significant weight gain prior to R27's hospitalization on [DATE]. V11 stated missed doses of Bumex could contribute to weight gain. On [DATE] at 11:55 AM V26 Nephrologist stated: V26 began seeing R27 when R27 was admitted to the hospital for Congestive Heart Failure exacerbation and fluid volume overload on [DATE] and was dialyzed (fluid removed through dialysis). We were able to remove quite a bit of fluid weight off R27. R27 had Chronic Kidney Disease Stage 4 that progressed to Stage 5 gradually. On [DATE] at 12:50 PM V1 Administrator stated the former Nurse Practitioner (V25) was not documenting her progress notes timely and charting during her visits. She was placed on suspension by her company due to not completing charting timely.

Based on observation, interview and record review the facility failed to develop a plan of care for skin impairment, monitor skin impairment, and notify the physician to alter treatment for one (R55) of two residents reviewed for skin conditions on the sample list of 55. These failures resulted in R55 developing psoriasis and erythema intertrigo to over half of her body. R55 experienced severe itching and pain that interfered with Activities of Daily Living and participation in activities. Findings include: On 3/12/23 at 11:21 AM R55 stated, Finally after all these weeks I get to see a dermatologist Tuesday (3/14/23). R55 stated R55 last saw a dermatologist for R55's psoriasis a few months ago. On 3/13/23 at 12:03 PM R55 stated R55 can't sit up in R55's wheelchair for extended periods or attend activities as often as R55 did previously due to R55's pain/itching caused from R55's psoriasis. R55 described the pain as an ache rated as an 8 on a 1-10 scale. R55 stated R55 itched R55's back so hard one time it bled. R55 became tearful and stated I (R55) just want to feel better. On 3/12/23 at 10:54 AM V15 and V16 Certified Nursing Assistants entered R55's room and provided incontinence care. R55's incontinence brief was saturated with urine and a large amount of soft bowel movement. There was a small amount of urine on R55's bed sheets. There was a strong urine odor. R55's abdominal folds, groin, and underneath R55's breasts were red/inflamed. R55 said Ow when V15 cleansed R55's perineal area, groin, and abdominal fold. There were large scaly, red patches covering R55's back, buttocks, and posterior thighs. V15 stated R55 has had Psoriasis for a while now and this area (pointing to abdominal fold) looks worse. R55's Diagnoses List dated 3/15/23 documents diagnosis of Psoriasis (skin disease with itchy, scaly patches, most commonly on the knees, elbows, trunk and scalp) as of 2/8/22 and Erythema Intertrigo (inflammation caused by skin-to-skin friction, often in warm, moist areas of the body, such as the groin, between folds of skin on the abdomen, under the breasts, under the arms or between toes) as of 9/26/19. R55's Care Plan dated 9/1/21 documents R55 is at risk for skin impairment. Interventions include to administered medications, monitor the effectiveness, assess and record skin changes, avoid scratching, keep hands and body parts from excessive moisture, notify the physician of changes in skin condition, and wound doctor to assess and treat as needed. R55's Care Plan has not been updated since 9/1/21 and does not include R55's skin impairment and psoriasis. R55's February and March 2023 Medication Administration/Treatment Administration Record (MAR/TAR) documents: R55 has received Ketoconazole Shampoo 2% topically to body twice weekly since 6/27/22 and Nystatin External Cream 100,000 Unit/gram topically to breasts and lower abdomen every 12 hours as needed for reddened areas as of 12/15/22. Nystatin is only documented as administered one time on 3/11/23. There are no other treatments for R55's skin impairment. R55's weekly skin assessments document a check as completed, but do not document a description of R55's skin. R55's Skin Condition Report dated 1/28/23 documents R55 has moisture associated skin damage (MASD) and does not document the location or extent of the skin impairment. There are no other detailed skin assessments until 3/13/23. R55's 3/13/23 Skin Condition Report documents denuded/excoriation skin and MASD noted to groin, upper/mid back and under breasts. This report documents R55's skin condition was not new and did not warrant physician notification. R55's February and March 2023 Shower Sheets document R55 had reddened areas including R55's chest, back, buttocks and groin on 2/25, 3/1, 3/4, 3/8. R55's Dermatology Progress Notes document R55 was evaluated on 9/30/22 for a rash beneath breasts and thighs. The rash is itchy and red/irritated. R55 had used topical steroids in the past that improved the rash. R55's diagnoses was Dermatitis and Triamcinolone 0.1% steroid cream was ordered for twice a day alternating between two weeks on and two weeks off. There is no documentation that R55's Dermatologist was contacted regarding R55's skin condition after 9/30/22, or that R55's skin condition was reported to R55's physician in February or in March 2023. R55's Dermatology After Visit Summary dated 3/14/23 documents: R55 has diagnoses of Psoriasis Vulgaris and Erythema Intertrigo, and orders for Triamcinolone 0.1% topical ointment applied to body twice daily for two weeks on and then two weeks off. New orders were given for the following laboratory tests for Complete Blood Count, Comprehensive Metabolic Panel, Hepatitis B Surface Antigen, human immunodeficiency virus Ag/AB screen, and tuberculosis infection QuantiFERON. V23 Physician Progress Note dated 1/18/23 documents R55 has severe Psoriasis and Candidal Dermatitis (fungal infection). R55 receives Hydroxyzine 50 milligrams twice daily for refractory pruritis (itching not responding to system treatment). R55's active medication list includes Calcipotriene 0.005 % (psoriasis treatment) topically to psoriatic patches twice daily x 21 days, Betamethasone Dipropionate 0.05 % steroid cream topically to psoriatic patches daily x 21 days and (over the counter medicated power) twice daily x 21 days. V11 Nurse Practitioner Progress Note dated 3/6/23 documents R55 was evaluated for an eye infection. This note documents R55 had Psoriatic skin lesions to back of left thigh, between 2 legs, left arm fold, and back, and intermittent itching with Diflucan (antifungal) prescription. This note does not document new orders or adjustments in R55's psoriasis treatment. There is no documentation that R55 received Diflucan in February or March 2023. On 3/12/23 at 1:48 PM V13 Licensed Practical Nurse stated: R55 does not have any scheduled treatments. R55 refuses to get out of bed and refuses R55's showers. R55's groin looks raw and it is really red. It flares up, goes away, and comes back again. R55 had a flare up and was supposed to see a dermatologist in December 2022. Treatment orders were implemented at that time. We have also had changes in the last three months with our physicians and nurse practitioners as well. On 3/14/23 at 9:04 AM V2 Director of Nursing (DON) stated skin assessments are completed weekly and recorded on the MAR/TAR with a check mark indicating completed. V2 confirmed the MAR does not document a description of the resident's skin. V3 Psychiatric Rehabilitation Services Director stated the facility also uses skin assessments to document resident's skin assessments. On 3/14/23 10:40 V13 Assistant DON stated V13 oversees skin/wounds in the facility. V13 stated R55 has psoriasis and excoriation of the grain. R55 sees a dermatologist, but was last seen a few months ago, has Ketoconazole shampoo and Nystatin ordered. V13 confirmed Nystatin is as needed and R55 has no topical creams scheduled routinely. V13 stated the nurses should follow up with the dermatologist when R55's skin conditions worsen or flair up to adjust R55's treatment orders. On 3/14/23 at 11:46 AM V13 Assistant Director of Nursing stated skin conditions are expected to be on the resident's care plan. On 3/14/23 at 4:18 PM V1 Administrator provided R55's 9/30/22 dermatology notes. V1 stated: 9/30/22 was the last time that R55 was evaluated by a dermatologist. R55 had COVID-19 in January 2023, and V1 wonders if staff had canceled a prior appointment and forgot to reschedule during that time. Either way we dropped the ball on this. On 3/14/23 at 10:00 AM V11 Nurse Practitioner stated: V11 last saw R55 a few weeks ago, but it was for an eye infection and not for psoriasis. They should notify me or her physician of any changes in her skin or if there's no improvement. V11 is in the facility frequently. There are problems with the facility not regularly notifying us (the practitioners) of resident changes. V11 will need to follow up and evaluate R55 today. The facility's Skin Condition Assessment & Monitoring- Pressure and Non-Pressure dated as revised June 2018 documents: non-pressure related skin conditions including rashes will be assessed weekly for healing progress and complications. Assessments are documented in the residents medical record. The facility's Physician-Family Notification- Change in Condition dates as revised November 2018 documents the physician will be notified of changes in a resident's condition and when there is a need to alter treatment.

Based on observation, interview, and record review the facility failed to supervise and assist with meals and document meal intake for two of two residents (R78, R114) reviewed for Nutrition on the sample list of 55. This failure resulted in R78 losing 20 pounds in six months' time which is a significant weight loss of 10.95%. Findings include: 1. R78's Physician Order Sheet (POS) dated March 2023 documents R78 is diagnosed with Dementia, Type II Diabetes, Chronic Kidney Disease Stage 4, Unspecified Protein-Calorie Malnutrition, and Altered Mental Status. R78 is ordered a Low Concentrated Sweets diet with thin liquids. Frozen Nutritional Supplement at lunch and supper, Fortified Cereal at breakfast, High Protein/Calorie Diet for Weight Loss, House Supplement (nutritional supplement) three times per day and Nutritional Drink two times per day for Weight Loss. R78's Minimum Data Set, dated dated dated [DATE] documents R78 is Severely Cognitively Impaired and requires Supervision (Oversight, Encouragement, Cueing), for eating. R78's Care Plan dated 3/2/23 documents the facility identified R78 has impaired cognitive function, is at nutritional risk related to Dementia, Diabetes Type II, Chronic Kidney Disease, Depression, and Advanced Age, and has nutritional issues (weight loss) related to loss of appetite. The facility is to provide and serve R78's diet as ordered, serve supplements as ordered, chart meal intakes, monitor/document/report any signs of Dysphagia- swallowing issues- meal refusals, encourage R78 to eat at least 50% of two meals, reorient and cue R78 as needed, and refer R78 to a registered dietician to evaluate when needed. R78's Weight Records document R78 weighed 184.4 pounds on 9/6/22 and has since trended down to 164.2 pounds on 3/6/23. This is a significant weight loss of 10.95%. R78's Task Documentation for Eating for February 2023 documents no meal intake recorded for 45 out of 84 meals. The March 2023 Task Documentation for Eating documents no meal intake recorded for 18 out of 38 meals so far for the month. R78's Dietary Note dated 2/21/23 documents V22 Dietician completed an assessment for R78 and noted R78 had significant weight loss over three months and recommended fortified cereal at breakfast and pudding at lunch. On 3/12/23 at 12:00 PM R78 was lying in R78's bed, food untouched, with no supervision or assistance. On 3/12/23 at 12:15 PM R78 was still lying in R78's bed, food untouched, with no supervision or assistance. On 3/12/23 at 12:30 PM R78 was still lying in R78's bed, food untouched, with no supervision or assistance. On 3/13/23 at 12:00 PM R78 was lying in R78's bed, food untouched, with no supervision or assistance. On 3/13/23 at 12:15 PM R78 was still lying in R78's bed, food untouched, with no supervision or assistance. On 3/13/23 at 12:30 PM R78 was still lying in R78's bed, food untouched, with no supervision or assistance. On 3/13/23 at 12:45 PM R78 was still lying in R78's bed food untouched. V21 Certified Nurse Assistant picked up R78's lunch tray to put back on the cart. R78's lunch tray had a nutritional shake that was untouched and unopened. The lunch meal did not include a pudding cup. On 3/14/23 at 9:20 AM V11 Nurse Practitioner (NP) confirmed R78 has had significant weight loss and has dementia and a cognitive decline. V11 confirmed staff should be supervising and assisting R78 with eating R78's meals and should accurately record R78's intake. V11 stated the staff often leave R78 in bed and do not bring R78 to the dining room to eat and do not provide supervision or assist with eating. V11 stated it doesn't matter how many supplements are ordered, if the staff aren't encouraging R78 and assisting R78 with the consumption of the supplements and meals, R78 will continue to lose weight due to low intake. V11 confirmed R78 should be in the dining room, sitting upright, with supervision and assistance to eat. 35046 2. R114's meal intake log dated 2/1/23 through 2/13/23 does not document a meal intake for breakfast on 2/1/23, 2/2/23, 2/3/23, or 2/6/23 through 2/10/23. This log does not document a meal intake for lunch on 2/2/23, 2/3/23, or 2/6/23 through 2/10/23. This log does not document a meal intake for dinner on 2/3/23 through 2/7/23 or on 2/10/23. R114's meal intake log documents R114 refused the lunch meal on 2/3/23 and 2/4/23, ate zero to 25 percent for breakfast and lunch on 2/11/23 and 2/12/23, and ate zero to 25 percent for breakfast on 2/13/22. R114's Nutrition Care Plan dated 10/5/15 documents R114 is at risk for malnutrition and includes interventions to encourage R114 to eat part of the meal, encourage and monitor at meals to ensure adequate intake, monitor appetite and weights and report to physician. R114's medical record does not document that R114 was encouraged to eat when refusing meals, that R114's meal intakes were monitored, or that refusals and poor intake were reported to the physician. On 3/14/23 at 11:31 AM, V2 Director of Nursing stated the Certified Nurse's Assistants pass the trays and then they document when pick up the trays. If they don't document then it comes up on the Electronic Health Record Dashboard alerts and me and V13 Assistant Director of Nursing are supposed to monitor it. I did not know they weren't doing all this charting.

Based on observation, interview, and record review the facility failed to conduct thorough fall investigations to identify the root cause and develop/implement post fall interventions for two of three (R2, R5) residents reviewed for injuries in the sample list of seven residents. The facility failed to provide assistance with bathing in accordance with the resident's plan of care and resident assessment that resulted in R2 falling and sustaining a right humerus fracture and subdural hematoma (brain bleed). Findings include: 1. The facility's Report to IDPH (Illinois Department of Public Health) Regional Office dated 2/10/22 documents the following: R2 fell on [DATE]. On 2/3/22 R2 was found on the floor beside R2's bed. R2 stated R2 did not fall. R2 refused to go the emergency room for evaluation following the incidents. On 2/5/22 R2 had a change in condition and was admitted to the hospital with diagnoses of right humerus fracture and chronic subdural hematoma. R2's Minimum Data Sets (MDS) dated [DATE] and 1/14/22 document R2 is cognitively intact and requires physical assistance of one staff with bathing. R2's Care Plan revised 12/6/21 documents R2 has an ADL (Activities of Daily Living) self-care deficit with an intervention that R2 is able to shower R2's self with prompting and cueing. This care plan documents R2 is at risk for falls related to confusion, weakness, and impaired gait/balance with an intervention dated 1/28/22 to supervise at all times when taking a shower. This care plan does not document post fall interventions for R2's additional falls on 1/28/22 and 2/3/22. R2's Nursing Note dated 1/28/22 at 6:26 PM documents V3 Licensed Practical Nurse (LPN) was notified that R2 was on the floor. R2 was found lying prone (face down) on the floor. R2 was assessed and complained of pain to R2's right shoulder and favored R2's right arm. The physician was notified, and x-rays were ordered. R2's Un-Witnessed Fall Incident Report completed by V3 documents R2 was set up for shower this morning, and the staff person (V4) left the shower room to obtain towels. Upon return, R2 was found lying on the floor. R2 stated R2 slipped when R2 stood up. R2's Fall Incident Report dated 1/28/22 at 10:40 PM documents R2 was found lying supine (face up) on the floor near the nurse's station. R2 had bruising to R2's jaw, that was from the prior incident, and no other injuries noted. This report documents R2 was last observed 10 minutes prior sitting in a chair near the nurse's station, and R2 had refused to allow staff to assist R2 to bed. R2 was educated prior to the fall that smoke breaks were over at 6:00 PM. This report does not document the root cause of R2's fall or what post fall interventions were implemented following this fall. R2's Nursing Notes document on 2/3/22 at 12:45 PM R2 was stumbling while walking and refused to be sent to the local emergency room for evaluation. R2's Un-Witnessed Fall Incident Report dated 2/3/22 at 9:00 PM documents R2 was found lying on the floor beside R2's bed. R2 stated R2 had not fallen, and that R2 had laid down on the floor. R2 denied hitting R2's head and there were no injuries. This report does not document the root cause of R2's fall, or what post fall interventions were implemented. There is no documentation that staff were interviewed to determine when R2 was last observed or what R2 was doing prior to the fall. R2's Nursing Note by V18 LPN documents on 2/5/22 at 12:04 PM R2 was sent to the emergency room for fall follow up. R2 was sleeping in R2's chair and was minimally responsive. R2 was confused and emesis was found beside R2's bed. R2's Right Shoulder X-ray dated 2/5/22 at 2:12 PM documents Acute cortical fracture of the neck of the right humerus is noted. R2's head CT (Computed Tomography) dated 2/5/22 documents R2 has altered mental status and fell on e week ago. This CT documents There is evidence of chronic bilateral subdural hematomas. The right at the area of lateral ventricle measures 8.2 cm (centimeters) x (by) 0.5 cm. The left at the area of lateral ventricle measures 9.5 cm x 0.8 cm. At subcortical level, the right subdural hematoma measures 7.8 cm x 0.9 cm seen. The left measures 10 cm x 1.2 cm. R2's Hospital Intensive Care Unit History and Physical dated 2/5/22 documents: R2 was transferred to a local hospital due to multiple falls in the last week. R2 was then transferred to this hospital for a neurosurgery consult. R2's active diagnoses include acute subdural hematoma and right humeral fracture status post fall. On 2/16/22 at 8:58 AM R2 was lying in bed. R2 stated R2 fell three times about two weeks ago, in R2's room and in the shower room. R2 stated R2 hurt R2's leg and broke R2's right arm. R2 stated R2 was showering by R2's self when R2 fell and hit R2's head. On 2/16/22 at 10:09 AM V3 LPN stated the following: On 1/28/22, V4 Certified Nursing Assistant (CNA) was assisting R2 in the shower. V4 had left the shower room to obtain towels, and left R2 unattended. V4 returned to the shower room and found R2 lying on the floor. V3 assessed R2 and R2 complained of right arm pain. R2 was not able to fully raise R2's right arm above R2's head. Prior to the fall, R2 needed limited assistance with bathing, but would refuse to let staff help R2. On 2/22/22 at 9:10 AM V4 stated: The day that R2 fell in the shower, R2 had asked V4 if R2 could take a shower. V4 let R2 into the shower room and left to go get towels, leaving R2 unattended. V4 returned and found R2 lying on the floor. R2 denied hitting R2's head and complained of right arm pain. R2 was independent with bathing prior to the fall, so V4 didn't stay in the shower room with R2. On 2/16/22 at 4:02 PM V17 Assistant Director of Nursing confirmed R2's 11/18/21 and 1/14/22 MDSs document R2 requires physical assistance of one staff person for bathing. On 2/22/22 at 9:26 AM V19 Care Plan Coordinator stated prior to R2's fall on 1/28/22, R2 used supervision assistance for bathing. R2 needed cues/reminders for bathing. If the resident requires supervision for bathing, staff should stay in the shower room with the resident during the shower. On 2/22/22 at 10:48 AM V2 stated: R2 fell twice on 1/28/22, about 10-15 minutes apart. For the first fall on 1/28/22 R2 was in the shower, and V4 had left R2 in the shower room to go get towels. When V4 returned, R2 was lying on the floor. The root cause was that R2 wasn't wearing any shoes and the floor was wet. The post fall intervention was staff are to stay in the shower room with R2 during the shower. R2 had previously refused to let staff be in the shower with R2, and refusals would be documented in a progress note. V4 was educated verbally to use the call light if V4 needs something, rather than leave a resident in the shower room. For the second fall on 1/28/22 R2 was found on the floor near the nurse's station/smoking entrance. We thought it was more of a behavior since R2 likes to smoke and likes to be the first one out to smoke. On 2/3/22 R2 was found on the floor of R2's room. R2 told staff that R2 laid down. We didn't consider it to be a fall since R2 has a BIMS (Brief Interview for Mental Status) of 13 (cognitively intact). We determined the root cause to be a behavior. Post fall interventions are documented on the care plan. On 2/22/22 at 11:46 AM V2 stated R2's post fall intervention for 2/3/22 fall was to collect a urine sample. The intervention for the second fall on 1/28/22 was R2 was educated on the need to wait for staff assistance to smoke. This should be documented on the incident report or progress note. V2 stated R2's injuries are believed to be related to one of R2's falls, and V2 was not sure which fall caused the subdural hematoma and right arm fracture. V2 stated R2 began to complain of right arm pain after the fall in the shower, but R2 denied hitting R2's head for the falls. On 2/22/22 at 12:50 PM V2 confirmed R2's care plan does not document post fall interventions for R2's second fall on 1/28/22, and fall on 2/3/22. V2 was unable to provide documentation that R2 refused to allow staff assistance for bathing on 1/28/22. 2.) R5's Admission Record dated 2/22/22 documents R5 admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, weakness, and repeated falls. R5's MDS dated [DATE] documents R5 is frequently incontinent of bowel and bladder, requires extensive assistance of two staff for transfers, limited assistance of one staff person for walking, and extensive assistance of one staff person for toileting. R5's Care Plan revised on 1/12/22 documents (R5) is at risk for falls related to confusion, gait/balance problems, history of falls, poor communication/comprehension, psychoactive drug use, (and) unaware of safety needs. This care plan documents interventions dated 1/31/22 for a mattress to be placed next to R5's bed, 2/6/22 for a scoop mattress for R5's bed, and 2/15/22 for a protective helmet. R5's Nursing Notes document the following: On 1/31/2022 at 10:39 PM R5 had a fall today and has a wound to the back of R5's head. On 2/6/2022 at 9:05 PM documents R5's roommate came into the hall to report that R5 was on the floor. R5 was found sitting on the fall mat beside R5's bed. R5 was awake and talking in word salad per R5's norm. On 2/14/2022 at 2:20 PM R5 was found lying on R5's back in the hallway. R5 complained of a headache and there was a small amount of blood noted on the floor. R5 stated R5 was going to get coffee. On 2/14/22 at 10:47 PM there was a hematoma that measured 6cm x 4cm to the back of R5's head. R5's Unwitnessed Fall Incident Report dated 1/31/22 at 12:30 PM documents V5 LPN heard a resident across the hall yell out that R5 had fallen. R5 was found on the floor of R5's room. There was blood on the back of R5's head. R5 was alert, confused, and unable to give a description of the incident. R5's Fall Report dated 2/6/22 at 8:55 PM documents R7 (R5's roommate) came out into the hall to report that R5 had fallen. These reports do not document interviews were conducted with staff or residents. There is no documentation of the last time R5 was checked on or toileted, or what R5 was doing prior to the fall. R5's Un-witnessed Fall Report dated 2/14/22 at 9:00 AM documents R5 was found on the floor in the lobby with bleeding and a hematoma to the back of R5s head. R5 stated R5 was going to get coffee and wasn't sure what happened. There is no documentation that staff or residents were interviewed regarding R5's fall. On 2/16/22 at 11:26 AM V5 Registered Nurse stated: On 2/14/22 R5 fell in the foyer and hit R5's head. Staff witnessed R5's fall. R5 had been in R5's wheelchair, had gotten up and fell . R5 was attempting to get coffee, but R5 had coffee and R5's meal tray at the table where R5's wheelchair was. On 2/22/22 at 10:48 AM V2 stated the fall reports are the facility's fall investigations. V2 confirmed there was no other documentation to provide for R2's and R5's fall investigations. V2 stated when staff call to report resident falls to V2, V2 asks the staff questions such as when the resident was last observed and toileted. V2 stated V2 does not document the interviews. V2 stated R5 is very confused and was trying to get up out of bed for the fall on 1/31/22. R5 was found on the floor in R5's room. The root cause of R5's fall was that R5 was getting more restless and having increased confusion. The post fall intervention was to use a mattress on the floor beside R5's bed. V2 stated on 2/14/22 R5 had an unwitnessed fall and was found on the floor in the lobby. The root cause of R5's fall was that R5 was restless. A helmet was ordered as a post fall intervention. On 2/22/22 at 11:46 AM V2 stated: R5 had an unwitnessed fall on 2/6/22. R5 was found on the floor of R5's room after R5's roommate (R7) came out to alert staff. The root cause of the fall was due to R5's confusion, and the post fall intervention was a scoop mattress. The facility's Fall Prevention Program revised 11/21/17 documents the following: The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Care plan incorporates identification of all risk/issue; addresses each fall; interventions are changed with each fall, as appropriate; (and) preventative measures. Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. Fall interventions may include the following: observe residents approximately every 2 hours for safe positioning, provide care including toileting needs in accordance with the resident's care plan, and residents who require staff assistance will not be left alone after being assisted to bathe, shower or toilet.

Based on observation, interview and record review, the facility failed to provided skin treatments as ordered for one of four residents (R78) reviewed for non-pressure wounds on the sample list of 68. This failure resulted in R78 having uncontrolled itching and discomfort. Findings Include: R78's MDS (Minimum Data Set), dated 10/11/21, documents that R78 is alert and oriented. R78's Care Plan dated 10/26/21 documents, R78 has Impaired Skin Integrity, multiple [CONDITION(S)] to multiple areas of the R78's body due to immobility, weakness, severe malnutrition, adult failure to thrive, and [CONDITION(S)] (skin condition that causes large fluid-filled blisters). This Care Plan documents R78 creates wounds due to excessive scratching, sometimes with a back scratcher even when educated not to do so with interventions to encourage good nutrition and hydration, and to see TAR (Treatment Administration Record) for orders for wound treatment and perform as ordered. On 12/05/21 at 8:41 AM, R78 was lying in bed yelling out that R78's leg is hurting. V16 Restorative Nurse/Care Plan Coordinator entered R78's room at this time. V16 went to get an unidentified nurse, who entered R78's room and administered liquid [MEDICATION(S)] {Narcotic} for R78's pain. R78 had open sores/skin [CONDITION(S)] covering all R78's visible skin other than R78's face; arms, chest, and feet. R78 stated R78 has a skin condition causing the sores and is being seen by a physician for it. R78 stated they {staff} are to put cream on R78 but that it doesn't get applied twice a day like it is supposed to. R78 stated the sores itch, causing discomfort, and make R78 miserable, therefore R78 don't want to be bothered. On 12/6/21 at 10:15 am, R78 was lying in bed and stated staff has not completed the skin treatment yet and R78 is itching bad and uncomfortable. I (R78) just want to sleep so I (R78) don't itch so bad. On 12/7/21 at 12:16 pm, R78 was asleep in bed with R78's lunch tray untouched on the overbed table. On 12/7/21 at 1:53 pm, R78 was lying in bed awake but stated R78 just wanted to rest and not talk. R78's December Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] {Corticosteroid to reduce itching} 0.1 %, with directions to apply all over body topically every day and evening shift related to [CONDITION(S)] - apply to neck, chest, abdomen, back, hand, armpits. These orders also document an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R78's November 2021 TAR (Treatment Administration Record) does not document that R78's cream was applied on 11/10, 11/11, 11/12, 11/13, 11/23, 11/24, 11/29 and 11/30 on day shift, at all on 11/14 and 11/19, and 11/25 evening shift. R78's December 2021 TAR does not document R78's cream was applied on 12/1 or 12/3 day shift. On 12/8/21 at 10:00 AM, V2 DON (Director of Nursing) confirmed R78's treatments are not signed off, on the above dates, and stated when a treatment is completed, it needs to be signed out on the TAR. On 12/08/21 at 10:06 AM, V27 RN (Registered Nurse) stated R78 is supposed to get cream to R78's entire body twice a day, and it should be signed off in TAR when completed. V27 stated R78 goes through a lot of it at a time, so it might not have been signed out due to not having any cream to apply. V27 checked both treatment carts and could not find any of R78's cream in either one. The facility Medication Administration Policy, dated 1/1/2015, documents only a licensed nurse (RN, LPN (Licensed Practical Nurse)) may prepare, administer and/or record the administration of medications (prescription ointments are considered medications), and that the time, date and initials of the licensed nurse who administered the medications should document the administration, once administered on the MAR (Medication Administration Record) or TAR. Medications must be administered in accordance with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to develop and implement pressure relieving interventions, assess for pressure ulcer risk, complete weekly skin assessments, administer treatments as ordered, and assess wounds weekly for three of three residents (R1, R2, R3) reviewed for pressure ulcers in the sample list of seven residents. This failure resulted in R3 developing a Deep Tissue Injury to the right heel and three Stage II pressure ulcers. Findings include: The facility's Pressure Injury and Skin Condition Assessment policy, revised on 1/17/18, documents: Wounds will be measured weekly and skin assessments will be completed weekly by the nurse. Pressure Ulcer Risk assessments will be completed upon admission and quarterly. Dressings shall include the date the nurse administered the treatment and treatment administration will be documented on the TAR. The resident's care plan will be updated to include skin alterations, approaches and goals of care. 1.) R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact, is frequently incontinent of bowel and bladder, and uses extensive assistance of two staff for transfers, bed mobility, and toileting. This MDS documents R3 is at risk for developing pressure ulcers, admitted to the facility without any pressure ulcers, and R3 uses a turning and repositioning program. R3's Base Line Care Plan, dated 3/4/21, does not document R3 has skin integrity issues. R3's physician's orders [REDACTED]. R3's medical record does not document that a Pressure Ulcer Risk Assessment was completed as ordered upon admission and weekly for three weeks after admission. There are no documented weekly skin checks completed after R3's admission on 2/26/21 until 3/6/21. R3's Skilled Charting notes, dated 2/26/21 and 3/6/21, document R3's skin is intact and the section for pressure relieving interventions is not completed. R3's Initial Wound Evaluation & Summary, dated 3/10/21, by V23, Wound Physician, documents R3 has an Unstageable deep tissue injury to the right heel that measured 1.5 cm (centimeters) (long) by 1 cm (wide) by no measurable depth. This summary documents treatment orders to apply a skin protectant daily and heel protectors worn when in bed. R3's Skin Condition Report, dated 3/11/21, documents: R3 has two shear wounds to the right buttock that measured 8 mm (millimeters) by 2 mm by 1 mm(depth) and 4 mm by 3 mm by 1 mm. R3 has a shear wound to the posterior left thigh that measured 0.5 cm by 4 mm by 1 mm. R3's physician's orders [REDACTED]. heel, and cleanse and apply a [MEDICATION NAME] dressing three times weekly to the right buttock and posterior thigh wounds. There is no documentation in R3's medical record that a turning and repositioning program was implemented or pressure relieving interventions for R3's bilateral heels were implemented prior to 3/11/21. R3's Nursing Notes document: On 3/11/21 at 12:37 PM shearing areas were noted to the right buttock and posterior left thigh during incontinence care. R3 was turned and repositioned and pillows were used for comfort. R3 had poor appetite documented on 3/2, 3/3, 3/9 and 3/10/21. There is no documentation that the facility consulted a registered dietitian since R3's admission or when R3's wounds were identified on 3/10/21 and 3/11/21. On 3/11/21 at 1:43 PM, V14, Registered Nurse (RN), V16, and V17, Certified Nursing Assistants, entered R3's room to provide incontinence and wound care. R3 was lying in bed with R3's heels lying directly on the mattress. R3's heels were not floated with a pillow. V14 stated R3 admitted to the facility with a pressure wound to the right heel and developed two more wounds to R3's buttocks from shearing. V16 removed R3's incontinence brief and V17 turned R3 onto R3's left side. There were two open areas to R3's right buttock. V17 turned R3 onto R3's right side there was a small open area to R3's left posterior thigh. There was bloody drainage noted on R3's brief. V14 cleansed the wounds and applied a [MEDICATION NAME] dressing. At this time V13, Director of Rehab, delivered pressure relieving boots to R3's room. V14 applied a skin protectant to R3's right heel. R3's heel had a small area that was purple/black in color. V14, V16, and V17, applied R3's pressure relieving boots. V17 stated pressure relieving interventions for R3 include turning and repositioning every 2 hours and floating R3's heels. On 3/11/21 at 2:12 PM, R3 stated staff have been turning R3 from side to side throughout the day, but R3 has not had R3's heels floated. R3 stated R3 needs staff assistance with turning and repositioning and incontinence care. R3 stated R3 has not gotten out of bed regularly, and R3 has had a poor appetite. On 3/15/21 at 2:28 PM, V4, RN, stated V4 has been assisting with monitoring wounds for the past couple of weeks since V21, Former Wound Nurse, resigned. V4 stated Pressure Ulcer Risk Assessments should be completed on admission and quarterly. V4 confirmed R3's orders document for Pressure Ulcer Risk Assessment to be completed upon admission and weekly for 3 weeks. V4 confirmed there are no completed Pressure Ulcer Risk Assessments in R3's medical record since R3 admitted to the facility on [DATE]. V4 stated if the physician's orders [REDACTED]. V4 stated R3 has shear wounds to the right buttock and left posterior thigh that were identified on 3/11/21, and V4 stated V4 thought R3 admitted to the facility with the deep tissue injury to R3's right heel. V4 confirmed there is no documentation in R3's medical record that R3's deep tissue injury was present on admission. V4 stated the nurses are responsible for completing weekly skin assessments which are documented on the TARs (Treatment Administration Records) and as an assessment in the resident's medical record. V4 stated pressure relieving interventions are documented on the resident's care plan and R3's interventions included turning and repositioning every 2 hours and as needed. V4 confirmed there is no documentation in R3's medical record that a turning and repositioning schedule was implemented or pressure relieving interventions were implemented for R3's heels prior to 3/11/21. On 3/16/21 at 9:41 AM, V23, Wound Physician, stated residents who are at risk for developing pressure ulcers with risk factors including impaired mobility, should have pressure relieving interventions implemented such as turning and repositioning every 2 hours, a pressure relieving mattress, and not sitting in the same position for more than 2 hours. V23 stated not implementing pressure relieving interventions can contribute to the development of pressure ulcers. V23 stated V23 saw R3's deep tissue injury on 3/10/21, and recommended the use of bilateral heel protectors. On 3/16/21 at 11:20 AM, V2, Director of Nursing (DON), stated the facility's dietitian rounds at the facility monthly and assesses residents who are newly admitted , have weight loss, and wounds. V2 was unsure if the facility had notified V25, Registered Dietitian, of R3's admission, or after R3 developed pressure ulcers. On 3/16/21 at 1:30 PM, V2, Director of Nursing, stated V2 was unable to provide documentation that Pressure Ulcer Risk Assessments were completed, skin assessments were completed between 2/26/21 and 3/6/21, V25 was consulted in regards to R3's wounds, and pressure relieving interventions were implemented for R3 prior to R3 developing pressure ulcers on 3/10/21 and 3/11/21. 2.) R1's Pressure Ulcer Risk Assessment, dated 12/1/20, documents R1 is at high risk for developing pressure ulcers. There are no documented Pressure Ulcer Risk Assessments completed after 12/1/20 in R1's medical record. R1's MDS, dated [DATE], documents R1 had Unstageable pressure ulcers that were present upon admission. R1's MDS, dated [DATE], documents R1 is cognitively impaired, is always incontinent of bowel and bladder, is dependent on two staff for transfers and bed mobility, uses extensive assistance of one staff person for toileting. This MDS documents R1 has three Stage 1, two Stage III, and two stage IV pressure ulcers that were not present upon admission. R1's Care Plan, revised on 2/24/21, documents R1 has impaired skin integrity with interventions for heel protectors to be worn in bed initiated on 12/3/20, pressure reducing mattress, pillows to protect skin, pressure relieving cushion for wheelchair, alternating air mattress initiated on 12/18/20, refer to physician orders [REDACTED]. R1's Wound Evaluation & Management Summaries by V23, Wound Physician, document the following: On 10/21/20 R1 had abrasions to R1's left lateral foot 9 cm long by 2.5 cm wide and left lateral heel 1.5 cm by 3 cm. V23 recommended heel protectors to be worn in bed. On 10/28/20 R1 had an abrasion to the left lateral foot 7 cm by 1 cm and left distal medial foot 1 cm by 1 cm. On 11/11/20 R1 had the following abrasion wounds: left lateral foot abrasion measured 3 cm by 0.5 cm, left distal medial foot 1 cm by 1 cm, right medial foot 1.5 cm by 1 cm, right heel 1.2 cm by 0.5 cm, left heel 1 cm by 0.8 cm by 0.1 cm. On 12/2/20 R1 had an Unstageable necrotic (dead tissue) wound with a duration of greater than 76 days duration to the left, proximal, lateral foot that measured 2 cm long by 1.5 cm wide by 0.2 cm deep. R1 had an Unstageable necrotic wound with a duration of greater than 56 days to the left, distal, lateral foot the measured 1.5 cm by 1 cm by no measurable depth. R1 had an Unstageable deep tissue injury to the right distal, lateral foot that measured 9 cm by 2.5 cm by no measurable depth. On 12/9/20 R1 had the following wounds: stage IV pressure ulcer to the left proximal, lateral foot 2 cm by 1.5 cm by 0.2 cm, Unstageable necrotic left distal, lateral foot pressure ulcer 1.5 cm by 1 cm, Unstageable necrotic pressure ulcer to the right distal, lateral foot 9 cm by 2.5 cm, deep tissue injury to the right hip 3 cm by 2 cm, stage I pressure ulcer to the left heel 1.5 cm by 1 cm, stage III sacral pressure ulcer 0.8 cm by 1 cm by 0.1 cm. On 12/16/20 R1 had the following pressure ulcers: Stage IV left proximal, lateral foot 2 cm by 1.5 cm by 0.2 cm, Unstageable left distal lateral foot 1.5 cm by 1 cm, Unstageable right distal, lateral foot 9 cm by 2.5 cm, right hip deep tissue injury 4.5 cm by 2 cm, Stage III sacrum 4.5 cm by 1.5 cm by 0.1 cm, and Unstageable left distal medial foot 1.5 cm by 1.5 cm. On 2/18/21 R1 had the following pressure ulcers: Stage IV left distal, lateral foot 2.5 cm by 1.5 cm, Stage IV right distal, lateral foot 2.5 cm by 2 cm by 0.1 cm, Stage II left distal medial foot 2 cm by 1.3 cm by 0.2 cm, Stage III left buttock 3.5 cm by 2.5 cm by 0.5 cm, Stage IV left proximal lateral foot 1.5 cm by 1.5 cm by 0.2 cm, Stage III right hip 0.4 cm by 0.2 cm by 0.1 cm, Stage IV right proximal lateral foot 2 cm by 1 cm by 0.2 cm, Stage II left lateral heel 0.3 cm by 0.2 cm, Stage III right ear 0.3 cm by 0.2 cm, Stage II right buttock 2.5 cm by 2 cm, Stage I left hip 6 cm by 3 cm, Stage 1 left lower medial thigh 5 cm by 1.5 cm. On 2/24/21 R1 had the following pressure ulcers: Stage IV left distal lateral foot 1 cm by 2 cm, Stage IV right distal lateral foot 1 cm by 1 cm by 0.2 cm, Stage III left distal medial foot 1.5 cm by 1 cm by 0.2 cm, Stage III left buttock 4 cm by 2 cm by 0.2 cm, Stage IV left proximal lateral foot 1.5 cm by 0.9 cm by 0.2 cm, Stage IV right proximal lateral foot 2 cm by 1.2 cm by 0.3 cm, Stage II left lateral heel 0.5 cm by 1 cm, Stage III right ear 1.5 cm by 0.8 cm, Stage I left hip 5 cm by 3.5 cm, Stage I left medial thigh 4 cm by 1 cm, and Stage I left lateral ankle 0.8 cm by 1.5 cm. There are no documented measurements of R1's wounds until 3/10/21. On 3/10/21 R1's wounds are documented as: Stage IV right distal lateral foot 0.5 cm by 0.4 cm by 0.2 cm, Stage IV left distal lateral foot 0.4 cm by 0.3 cm by 0.1 cm, Stage III left buttock 3.5 cm by 2 cm by 0.2 cm, Stage IV right proximal lateral foot 1.5 cm by 1 cm by 0.1 cm, Stage III right ear 1.2 cm by 0.5 cm, and Stage I right hip 2 cm by 1 cm. R1's medical record does not document skin assessments were completed weekly as ordered in October 2020, between 11/5 and 11/16, upon readmission on 11/30/20, weekly between 12/1/20 until 12/21/20, and weekly after 2/17/2. R1's Nursing Notes document: On 11/30/20 R1 returned to the facility from the hospital with wounds to bilateral feet and buttocks and R1 will be referred to the wound nurse. There is no documentation that R1's wounds were assessed or measured until R1 was seen by V23 on 12/2/20. R1's Orders Listing Summary, dated 12/1/20 - 3/31/21, documents the following treatment orders: Cleanse left buttock wound, apply calcium alginate, and a foam dressing daily. Cleanse right buttock wound, apply calcium alginate and a foam dressing daily. Cleanse left and right distal and proximal lateral foot wounds and apply: [MEDICATION NAME] dressing, one fourth strength bleach soaked gauze, abdominal pad, and gauze wrap twice daily. R1's TARs dated January 2021, February 2021, and March 2021, do not document that R1's treatments were administered as ordered to: R1's left and right buttock wounds on 2/4, 2/9, 2/10/21, and 3/1-3/4/21, and left: distal and lateral foot wounds and right distal and lateral foot wounds on 2/25 and 2/26/21. R1's Weekly Skin Assessments are not documented as being completed in March or on 2/22/21. On 3/11/21 at 12:10 PM, V10, RN, entered R1's room and administered R1's left buttock wound treatment. R1's left buttock wound was red with some yellow tissue. There was a foam dressing to R1's right hip. V10 removed the dressing and there was a small red scabbed area to R1's right hip. R1's right ear wound was red. On 3/11/21 at 3:12 PM, V10 administered R1's treatments to R1's bilateral foot wounds. R1 had one wound to the left lateral and inner foot and two wounds to the right lateral that were small with red wound beds. On 3/15/21 at 2:38 PM, V4, RN, stated: V4 has been assisting with monitoring wounds for the past couple of weeks since V21, Former Wound Nurse, resigned. V23 did not round on 3/3/21 and there wasn't anyone assigned to assess and measure the wounds that day since V21 had resigned that same week. Pressure Ulcer Risk Assessments should be completed on admission and quarterly. The nurses are responsible for completing weekly skin assessments which are documented on the TARs and as an assessment in the resident's medical record. Nurses should sign out the TAR when a treatment is administered. R1 had declined after having COVID-19 (Human Coronavirus Infection) and then developed multiple pressure ulcers while in the facility. R1 used to be up in a wheelchair and was more mobile prior to having COVID-19. V4 confirmed R1's last completed Pressure Ulcer Risk Assessment was 12/1/20 and there are no documented weekly skin assessments after 2/17/21. On 3/16/21 at 9:41 AM, V23, Wound Physician, stated residents who are at risk for developing pressure ulcers with risk factors including impaired mobility, should have pressure relieving interventions implemented such as turning and repositioning every 2 hours, a pressure relieving mattress, and not sitting in the same position for more than 2 hours. V23 stated not implementing pressure relieving interventions can contribute to the development of pressure ulcers. V23 stated V23 would expect V23's recommendations to be implemented within a day or two, and the facility has access to V23's Physician Notes the day after V23 rounds at the facility. On 3/16/21 at 9:00 AM, V2, DON, stated V2 would expect an alternating air mattress to be initiated if a resident has multiple stage II, stage III, or stage IV pressure ulcers. On 3/16/21 at 1:30 PM, V2 stated V2 had no additional skin assessments that were completed in October 2020, between 11/5 and 11/16, upon readmission on 11/30/20, weekly between 12/1/20 until 12/21/20, and weekly after 2/17/2. V2 was unable to provide documentation that pressure relieving boots were implemented for R1 on 11/11/20 as ordered or that an alternating pressure mattress was implemented prior to 12/18/20. 3.) R2's Admission Record, dated 3/15/21, documents R2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's MDS, dated [DATE], documents R2 is dependent upon two staff for transfers and bed mobility, dependent upon one staff person for toileting, is frequently incontinent of bladder and always incontinent of bowel. R2's Pressure Ulcer Risk Assessments, dated 1/14/21, documents R2 is at high risk, and 1/21/21 document R2 is at very high risk for developing pressure ulcers. There are no documented Pressure Ulcer Risk Assessments after 1/21/21. R2's Care Plan, revised on 2/5/21, documents R2 has impaired skin integrity and admitted with shearing to the lower sacrum. R2's Care Plan documents interventions including dietitian consult, encourage R2 to shift weight, monitor for moisture and apply barrier product as needed, and administered treatments as ordered by the physician. R2's Physician Orders, dated 3/15/21, documents an order for [REDACTED]. wounds, apply a calcium alginate dressing and foam dressing every shift from 1/14/21-1/20/21. R2's TARs, dated January, February, and March 2021, do not document R2's sacral wound treatments were administered on 8 shifts in January, 12 shifts in February, and 11 shifts in March. R2's Skin - Pressure/Diabetic/Venous/Arterial Wound Report, dated 1/14/21, documents R2's: stage II left medial sacral pressure ulcer measured 3.5 by 1 by 0.1 cm, Stage II left lower sacral pressure ulcer measured 3 by 1 by 0.1 cm, and Stage II left upper distal sacral pressure ulcer measured 1.5 by 1.5 cm. R2's Skin Condition Report dated 2/10/21 documents R2's shear wound to the left lower sacrum measured 1 cm by 0.3 cm by 0.1 cm. There are no documented skin assessments or wound assessments until 2/24/21. R2's Skin Condition Report, dated 2/24/21, documents R2's shear wound measured 0.4 cm by 0.3 cm by 0.1 cm. There are no documented skin assessments or wound assessments after 2/24/21. On 3/11/21 at 11:46 AM, V19 and V20, CNAs, provided incontinence care for R2. R2 had a small pink, superficial open wound to R2's coccyx. V19 confirmed R2's wound is open and stated R2 admitted to the facility with the wound. On 3/15/21 at 2:38 PM, V4, RN, stated: V4 has been assisting with monitoring wounds for the past couple of weeks since V21 Former Wound Nurse resigned. V23 did not round on 3/3/21 and there wasn't anyone assigned to assess and measure the wounds that day since V21 had resigned that same week. Pressure Ulcer Risk Assessments should be completed on admission and quarterly. If the physician's orders [REDACTED]. The nurses are responsible for completing weekly skin assessments which are documented on the TARs and as an assessment in the resident's medical record. Nurses should sign out the TAR when a treatment is administered. V4 confirmed there are no documented skin assessments after 2/24/21 for R2. V4 stated: R2 was not seen by V23 on 2/17/21 and I (V4) don't see a skin assessment or wound assessment completed on 2/17/21. R2 may have been out for [MEDICAL TREATMENT] at the time V23 rounded at the facility. On 3/15/21 at 9:00 AM, V2, DON, stated, V23 did not round at the facility on 3/3/21 and that was the same week that V21 had resigned. V2 stated V2 was not sure who would have been responsible for wound assessments and measurements in V23's absence. V21 was responsible for assessing and measuring wounds. V2 stated V2 could not provide R2's Pressure Ulcer Risk Assessments completed after 1/21/21 and skin assessments or wound measurements on 2/17/21 or after 2/24/21.

Based on interview and record review, the facility failed to provide timely and appropriate emergency [MEDICAL CONDITION] care for a resident who was found unresponsive with their breathing tube removed, failed to ensure all caregivers were trained to respond appropriately to [MEDICAL CONDITION] emergencies, failed to consult with respiratory care professionals following previous incidents of decannulation/extubation, failed to assess and develop targeted interventions for previous incidents of internal decannulation/extubation, and failed to develop and implement policy guidance for staff to follow for [MEDICAL CONDITION] emergencies. These failures affect one of one residents (R1) reviewed for emergency respiratory care in a sample list of three. R1 died of Acute [MEDICAL CONDITION] Infarction and Acute Hypoxic [MEDICAL CONDITION] after being found unresponsive without R1's [MEDICAL CONDITION]. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remained out of compliance at a severity level two. The facility is in the process of implementing newly revised policy, and re-educating all staff on proper [MEDICAL CONDITION] emergency response and nursing staff on emergency [MEDICAL CONDITION] care. Findings include: R1 was admitted on [DATE], with [DIAGNOSES REDACTED]. There are no physician orders for [MEDICAL CONDITION] care, supplies, or suctioning documented until [DATE]. R1's care plan, dated [DATE], documents interventions for R1's pulling out [MEDICAL CONDITION] and self- suctioning as: Educate (R1) on the importance of leaving (R1's) [MEDICAL CONDITION] in place, (R1) being patient with staff, (R1) allowing staff to provide (R1's) care, Staff providing (R1) encouragement and active support when (R1) uses these strategies, Staff to explain to (R1) what is being done before performing the task, Staff to talk to (R1) when passing (R1's) room and monitor behavior episodes and attempt to determine underlying cause. R1's progress notes document education as the only intervention implemented for R1's repeated [MEDICAL CONDITION] removal. R1's progress notes document R1 intentionally removing internal cannula (tube) (of [MEDICAL CONDITION]) on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. R1's progress note, dated [DATE] at 2:01 PM documents, (V20) Assistant Director of Nursing (ADON) (was) called into (R1's) room by another nurse who found (R1) unresponsive. Upon assessment of (R1), this ADON found that (R1) had pulled entire [MEDICAL CONDITION] out and was bleeding from the site. (R1) was gasping for air. (V20) tried to replace [MEDICAL CONDITION], but the airway was blocked. (V20) held [MEDICAL CONDITION] halfway in airway to allow for a patent airway, and ten liter [MEDICAL CONDITION] mask applied. R1 was then sent to the emergency department. On [DATE] 9:21 AM, V6, Registered Nurse/Care Plan Coordinator (RN/CPC), stated, (R1) frequently attempted to pull out (R1's) inner cannula. We educated him over and over. On [DATE] at 9:30 AM, V6, Registered Nurse (RN), stated V6 sent (R1) to the hospital several times because (R1) removed his [MEDICAL CONDITION]. (V6) witnessed him loosening the ties and (V6) educated (R1) every time. On [DATE] at 10:25 AM, V7, Registered Nurse (RN), stated, The biggest battle (V7) had with (R1) was (R1) taking out (R1's) inner cannula. On [DATE] at 3:29 PM, V16, Licensed Practical Nurse (LPN), stated V16 found (R1) unresponsive on [DATE] at approximately 10:00 AM. (V6) immediately ran out (of R1's room) to get a more experienced nurse. It took (V19) Registered Nurse (RN) and I (V16) at least five minutes to get back into the room. I don't have emergency training on tracheostomies, just on cleaning and suctioning. (V16) didn't check (R1's) pulse when (V16) found him. (V16's) instinct was to get help. R1's patient care record from local Ambulance Service, dated [DATE], documents, 10:38 AM at (R1's) bedside found nurse giving the patient a nebulizer treatment via (R1's) stoma. Nurse stated she did not know how long (R1) had been without (R1's)[MEDICAL CONDITION]. Nurse also stated that the (R1) had pulled (R1's)[MEDICAL CONDITION] several times this morning. (R1) was pale and mottled, no respirations noted, pupils fixed and dilated. (R1's) extremities were cold to the touch. (Post- mortem blood pooling) noted to R1's lower back. Time of death noted 10:51 AM. On [DATE] at 4:00 PM, V12, Medical Director, stated, (V12) would expect ,[DATE] (around the clock) observation or four point restraints, which we don't do anymore, for a patient who persistently tried to remove his ([MEDICAL CONDITION]). On [DATE] at 2:00 PM, V19, Registered Nurse (RN), stated on [DATE] at approximately 10:00 AM, V19 was called to R1's room and found R1 with the [MEDICAL CONDITION] out. After assessing vital signs, V19 put the cannula back in using the obturator. We cranked up the oxygen, but he was gone. On [DATE] at 10:45 AM, V1, Administrator in Training, stated, I (V1) don't know what my (V1) expectations (for emergency care) would have been. On [DATE] at 10:50 AM, V13, Certified Nursing Assistant (C.N.A.), stated regarding emergency [MEDICAL CONDITION] training, I've (V13)not got training on trachs (tracheostomies) I (V13) would get the nurse.On [DATE] at 10:53 AM, V14, Certified Nursing Assistant (C.N.A.), stated regarding emergency [MEDICAL CONDITION] training, I (V14) would get the nurse. On [DATE] at 2:00 PM, V19, Registered Nurse (RN), stated regarding emergency [MEDICAL CONDITION] training, I (V19) have not gotten emergency training (for tracheostomies) at work. On [DATE] at 2:15 PM, V24, Licensed Practical Nurse (LPN), stated, I (V24) did not receive any emergency training to care for a [MEDICAL CONDITION] resident at this facility. On [DATE] at 10:30 AM, V2, Director of Nursing (DON), stated V2 trained the staff on the ([MEDICAL CONDITION] care) supplies at the bedside. V2 stated in an emergency, V2 would expect the nurse to cover the stoma and oxygenate the area or place a smaller cannula in the [MEDICAL CONDITION]. When asked why V2's treatment for [REDACTED]. Facility In-services documented on [DATE], [DATE], [DATE], [DATE], [DATE] documents education on [MEDICAL CONDITION] care, policies and procedures. No emergency care training pertaining to tracheostomies was documented. On [DATE] at 8:45 AM, V23, Respiratory Therapist (RT), stated V23 set (R1's [MEDICAL CONDITION]) up on admission. I (V23) told them that if they wanted an in-service or needed any help, to call and (V23) would provide it. (V23) never got a call. In the case of an alert and oriented resident complaining of their [MEDICAL CONDITION] being plugged or pulling it out, (V23) would have expected them to call (RT). (V23's) other homes would have called. I (V23) have seen other places use ,[DATE](around the clock) sitters to prevent patients from pulling out their trachs ([MEDICAL CONDITION]). Anyone caring for the [MEDICAL CONDITION] patient should be trained on how to handle an emergency with the emergency equipment at the head of the bed including a (manual breathing bag) and more [MEDICAL CONDITION]. They should have done something. On [DATE] at 10:23 AM, V12 stated the cause of death for R1 was [MEDICAL CONDITION] Infarction (heart stopped beating) due to Hypoxic [MEDICAL CONDITION] (not enough oxygen in the blood) caused by the [MEDICAL CONDITION] not being in (R1). V12 stated, I (V12) would expect the facility to follow their policy. That is why they have them. R1's Death Certificate, dated [DATE], documents cause of death as Acute [MEDICAL CONDITION] Infarction due to or as a consequence of Acute Hypoxic [MEDICAL CONDITION], signed by V12, Medical Director. Facility policy, revised on [DATE], documents, If outer tube comes out, stay with resident and summon assistance. A rubber tipped hemostat may be used to maintain opening. If necessary, suction the resident through the opening. An Immediate Jeopardy situation was identified on [DATE]. The immediate jeopardy was identified to have begun on [DATE] when the facility was first aware of R1's intentional self-removal of R1's [MEDICAL CONDITION] inner cannula. On [DATE] at 3:50 PM V1 was notified of the Immediate Jeopardy situation. The surveyor confirmed through interview and record review that the facility took the following actions to remove the immediate jeopardy: 1. On [DATE] R1 expired in the facility. 2. On [DATE] at 10:00 AM V2 Director of Nursing confirmed that there were no residents with tracheostomies residing in the facility. 3. Continuing Education and Skills Certificate dated [DATE] documents V2 Director of Nursing attended an educational program on tracheostomies. Completed by Respiratory Care Consultant. 4. On [DATE] at 9:53 AM V27 Administrator confirmed that the facility will not admit residents with tracheostomies until the staff are trained on emergency care procedures for residents with tracheostomies. 5. On [DATE] at 8:45AM V2 Director of Nursing confirmed that all staff had been in-serviced on the policy and procedure for emergency tracheostomies, appropriate for their role. Completed by V2. 6. On [DATE] at 9:00 AM V1 Administrator in Training stated that the Emergency [MEDICAL CONDITION] Policy and Procedure was reviewed and updated on [DATE]. Completed by V27 Administrator and Respiratory Care Consultant. 7. On [DATE] at 9:55 AM V1 Administrator in Training confirmed that no staff will work without [MEDICAL CONDITION] emergency care in-servicing.

Failures identified required more than one deficient practice statement. A.) Based on observation, record review, and interview, the facility failed to ensure a staff member with an elevated temperature, multiple COVID (Novel Human Coronavirus Infection) symptoms, and exposure to a COVID positive person outside of the facility, did not report to and continued to work in the facility with COVID symptoms. The facility also failed to ensure staff were not medically screening themselves, and failed to implement infection control precautions to prevent the spread of COVID-19 in the facility. These failures have the potential to affect all 132 residents residing in the facility. These failures resulted in V14 working with multiple COVID symptoms, including a fever of over 100 degrees for 6 and a half hours, and using multiple tissues for upper head congestion, placing them in the open trash can at the front desk, screening staff entering the facility to provide care to the residents and environment inside the facility, which put the facility at risk for transmitting COVID throughout the facility. These failure resulted in an Immediate Jeopardy. While the immediacy was removed on 11/5/2020, onsite record review and interview verified that the facility is in the process of evaluating staff re-education on the facility infection control policies and protocols. The facility remains out of compliance at a severity level two. B. Based on observation, interview, and record review, the facility failed to implement hand hygiene, and failed to disinfect the multiple resident use blood glucose test device (glucometer) after each use. These failures have the potential to affect 16 residents (R2, R14, R15, R16, R18, R20, R21, R22, R23, R26, R30, R45, R49, R50, R51, R52) reviewed during medication administration and use of the glucometers in the sample of 52. Findings include: a.) The facility's Infection Control - Interim policy addressing healthcare crisis related to Human [MEDICAL CONDITION], dated 10/6/2020, documents the Infection Preventionist or designee will monitor staff compliance with hand hygiene and Personal Protective Equipment (PPE) practices. Healthcare Providers (HCP) must not touch or adjust their facemask and if they do they must immediately perform hand hygiene. Staff will have screening for symptoms, possible exposures and temperature completed prior to starting their shift. Staff may not perform self-screening. In Illinois, staff will be screened mid-shift or approximately every 4 hours. Any staff with a fever and/or onset of COVID-19 symptoms will result in the staff being screened and sent home with local health department being notified. Facility will utilize the following PPE and infection control precautions: Hand Hygiene is to be performed before and after all patient contact and before putting on and after removing PPE, including gloves. Universal Eye protection should be worn in addition to their facemask to ensure the eyes, nose and mouth are all protected from exposure to respiratory secretions during patient care encounters. After removing gloves, immediately perform hand hygiene. If there are gown shortages, gowns should be prioritized for aerosol-generating procedures and care activities where splashes and sprays are anticipated. The facility's Interim COVID-19 Testing - Residents and Staff policy, dated 8/31/2020, documents staff with symptoms or signs of COVID-19 must be tested , and are expected to be restricted from the facility pending the results of COVID-19 testing. Staff who do not test positive for COVID-19 but have symptoms should follow facility policies on returning to work. On 10/19/2020 at 9:10am, V14, Receptionist, was sitting at the receptionist desk at the main entrance to the facility. V14 looked as though V14 did not feel well and when asked V14 stated, I feel horrible and had head congestion and stuffiness. V14 screened herself prior to V14's shift, and documented a temperature of 100.1 and yes for new symptoms as well as recent exposure or close contact with a COVID positive person outside of the facility. Mid-shift, V14 completed V14's screening per herself and V14's temperature was 100.9 and V14 answered yes to Any new symptoms since the beginning of shift? End of shift - Prior to leaving, V14 documented V14's temperature at 100.6 and yes to new symptoms. V14's timecard documents V14 checked in to work at 7:58am and left at 2:30pm, which was verified by V14's supervisor, V13, Human Resources. V14 is the receptionist that is responsible for screening the employees coming in to work at the facility and screened 26 staff (including self), potentially exposing the 25 other employees (V1, Administrator, V2, Director of Nursing (DON), V8, Registered Nurse (RN), V13, Human Resources (HR), V21, Care Plan Coordinator, V26 and V27 RN, V39, Housekeeping, V40, Dietary, V41, V42, V43, Housekeeping, V44, V54, Dietary, V45, V49, V50, V53, Certified Nursing Assistant (CNA), V46, illegible title, V47, V51 Transport, V48, Marketing, V52 and V56, Therapy and V55, Vendor) prior to working with the residents throughout the facility, potentially exposing the residents throughout the day. V13 stated V13 was made aware about 12:30pm on 10/19/2020 and V2, DON, completed a rapid COVID screen on V14 that was negative. V14 remained working while symptomatic at the reception desk, despite V14's temperature and history of positive COVID exposure until 2:30pm. At 3:00pm, the trash can located at the desk of the reception area contained multiple tissues that were discarded while V14 was on duty. V1 provided the COVID positive test results for employees with testing performed between 10/19/2020 and 10/26/2020, documenting six employees (V2, V8, V14, V21, V26, V27) screened by V14, Receptionist, on 10/19/2020 tested positive for COVID. On 10/21/2020 at 9:25am, V2, Director of Nursing (DON), provided [MEDICAL CONDITION] (trach) care and suctioning for R6. V2 was not wearing a gown during the procedure while standing within 2 feet of R6. R6 was forcibly coughing attempting to bring up the mucus from R6's [MEDICAL CONDITION]. At 9:29am, V2's mask straps were behind V2's neck and V2's mask had moved below V2's nose. V2 made several attempts to suction R6'[MEDICAL CONDITION] V2's mask was not properly positioned over V2's nose, exposing R6 to V2 and V2 to R6. V8, Registered Nurse (RN) also suctioned R6 multiple times without a gown on as well as adjusted V8's protective eye wear with contaminated gloves after coming in contact with multiple items in R6's room including R6's [MEDICAL CONDITION] supplies and contaminated suction catheter. V8 continued to care for the resident's in the facility after providing cares and contaminating protective eyewear for V8. On 10/19/2020, R6 had a COVID test performed, sent to the laboratory on 10/21/2020, and results reported on 10/23/2020 that R6 tested positive for COVID. V1, Administrator, provided documentation eight residents (R6, R10, R29, R43, R44, R45, R46, R47) tested on [DATE] tested positive for COVID. On 10/26/2020 at 10:45am, V1, Administrator, stated V2, Director of Nursing, was out for the day. V1 stated V2 was ill and began running a fever over the weekend and was going to get a test for COVID on 10/26/2020. On 10/28/2020 at 9:15am, V1 stated V2 tested positive for COVID. V1 also stated V8, RN, had also tested positive for COVID. Administrator stated the dietary staff have the potential to go between the two separate buildings at the facility to provide dietary services to the residents. On 10/27/2020 at 9:20am, V38, Public Health Administrator, stated the facility reported V14, Receptionist, had reported to work not feeling well. V38 stated the facility did not tell V38 that V14 was feverish and continued working until 2:30pm with symptoms of COVID. V38 stated V38 was upset to hear V14 continued working despite being symptomatic for COVID and exposing staff coming in to the facility. V38 stated with COVID being airborne/droplet, it is maddening and there was probable exposure, likely causing infections of others throughout the facility. V38 stated the facility policy should address the screening and attendance process and it should address employees not being allowed to self screen as well as work status if staff are symptomatic. The facility's Resident List Report documents 132 residents reside in the facility. An Immediate Jeopardy situation was identified on 11/5/2020. The Immediate Jeopardy was identified to have begun on 10/19/2020 when the facility allowed V14, Receptionist, to work in the facility with symptoms of COVID-19 infection thereby exposing multiple staff and subsequently multiple residents throughout the facility to COVID-19 infection. On 11/5/2020 at 11:05 AM, V1, Administrator, was notified of the Immediate Jeopardy situation. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: 1.) On 11/5/2020 at 1:30pm, V60, Nurse Consultant, confirmed V14 no longer works in the facility, effective 10/22/2020. 2.) On 11/5/2020 at 1:30pm, V60 confirmed all staff were inserviced on the medical screening process, initiated on 10/22/2020 with 100% completion. 3.) On 11/5/2020 at 1:30pm, all facility staff were in-serviced on Personal Protective Equipment (PPE) donning and doffing, Infection Control Policy: COVID-19 hand hygiene and Transmission Based Precautions. This was initiated on 10/26/2020 with 100% completion and the facility completed an audit 100% on 11/5/2020 by V60, Nurse Consultant, and V61, Facility Consultant. 4.) On 11/5/2020 at 1:30pm, an ongoing quality insurance tool was implemented to be completed five times a week for 12 weeks. 5.) On 11/5/2020 at 1:30pm, V60 confirmed a Root Cause Analysis was completed for Personal Protective Equipment use, Transmission Based Precautions (TBP) and hand hygiene was initiated on 10/26/2020 and was 100% completed by V60, V61, V2, Director of Nursing (DON), and V3, Assistant Director of Nursing (ADON). 6.) On 11/5/2020 at 1:30pm,V60 confirmed the Center for Medicaid Services (CMS) COVID-19 Facility self assessment was completed 10/27/2020. 7.) On 11/5/2020 at 1:30pm, V60 confirmed the facility implemented new screening tools for staff and visitors capturing cold symptoms which was completed on 11/2/2020. 8.) On 11/5/2020 at 1:30pm, V60 confirmed V2, DON, was educated/inserviced [MEDICAL CONDITION] and Infection Control Practices which were completed on 11/4/2020. b.) On 10/20/2020 at 11:11am, V4, Licensed Practical Nurse (LPN), obtained R14's blood glucose level. V4 opened the dry paper towel on the top of V4's medication cart and gathered supplies to perform the blood glucose finger stick. V4 used a lancet to puncture R14's finger and applied R14's blood to the testing strip in the glucometer. R14's blood glucose was 242. V4 placed the glucometer on top of the medication cart. V4 stated V4 is allergic to bleach so V4 sanitizes (glucometer) with hand sanitizer. V4 took the bottle of hand sanitizer, applied a small amount to the paper towel, wiped the glucometer with the paper towel, obtained a dry paper towel and wiped the glucometer. V4 then wrapped the glucometer in the paper towel and sat the glucometer on the top of the medication cart. The hand sanitizer label documents the sanitizer contains 65% alcohol and that it is to be used for handwashing to decrease bacteria on the skin. The product labeling makes no efficacy claim for use as a surface disinfectant. On 10/20/2020 at 11:25am, V4, LPN, obtained a blood glucose level for R15 using a glucometer from the top of V4's medication cart that was wrapped in a paper towel. V4 used a lancet to pierce R15's finger and placed R15's blood on the testing strip that was inside the glucometer. V4 used the hand sanitizer on a paper towel to wipe the glucometer, and took a second paper towel and wiped the glucometer again and wrapped the glucometer. On 10/20/2020 at 12:28pm, V19, LPN, performed a blood glucose level check on R18. V19 did not don gloves, and proceeded to use a lancet to pierce R18's skin to obtain a blood sample on the blood glucose test strip that had been placed inside the glucometer which was 333mg/dl. R18's physician's orders [REDACTED]. V19 administered the insulin to R18 without performing hand hygiene nor donning gloves. V19 returned to the medication cart and placed the glucometer with the contaminated test strip on the top of the cart, and then removed the blood glucose test strip that contained R18's blood with her bare hand and disposed of the strip. V19 did not disinfect the blood glucose glucometer after use on R18. On 10/20/2020 at 12:40pm, V19, LPN, used the same contaminated glucometer V19 used to obtain R18's blood glucose level to obtain R20's blood glucose level. V19 used a lancet to puncture R20's skin to obtain blood and placed the blood on the testing strip located inside the glucometer. V19 did not don gloves or perform hand hygiene prior to performing the blood glucose level check for R20. V19 brought the contaminated glucometer that still had the contaminated test strip inside the glucometer and placed it on the medication cart. V19 did not perform hand hygiene or don gloves prior to or after administering R20's [MEDICATION NAME]injection. On 10/20/2020 at 12:42pm, V19, LPN, used a glucometer to perform a blood glucose level check for R21. R21 was standing at the medication cart when V19 used a lancet to pierce R21's skin to obtain a sample of R21's blood and placed the blood on the test strip located inside the glucometer. V19 then placed the contaminated glucometer on top of the medication cart without disinfecting the glucometer. V19 did not don gloves prior to performing the blood glucose test or perform hand hygiene. On 10/20/2020 at 12:53pm, R22 was sitting on the side of R22's bed. V20, LPN, entered R22's room, placed the bottle of blood glucose test strips on R22's bed. V20 performed a blood glucose test on R22 which read 173. V20 went to medication cart and placed the contaminated glucometer and bottle of test strips on top of the medication cart. V20 did not remove V20's contaminated gloves, and touched the medication cart, including opening drawers to obtain insulin medication to administer to R22. On 10/20/2020 at 12:59pm, V20, LPN, performed a blood glucose glucometer test for R23. V20 pierced R23's skin, placed R23's blood on the blood glucose testing strip and placed the contaminated machine on the medication cart. V20 did not perform hand hygiene after touching the contaminated monitor with V20's hands. On 10/20/2020 at 1:10pm, V20 entered R26's room to perform a blood glucose level test with a contaminated glucometer on R26. V20 placed the glucometer on R26's bed sheets on top of R26's bed that had brown debris on the sheets and R26 had shoes on in bed with debris on the bottom of R26's shoes. On 11/9/2020, V1, Administrator, provided documentation of 15 residents (R2, R14, R15, R16, R18, R20, R21, R22, R23, R30, R45, R49, R50, R51, R52) who have the potential for blood glucose testing with the re-usable glucometer machines. The manufacturer's User's Manual for the facility's blood glucose meter dated 5/17/2016 documents, Note: Important Safety Instructions. All parts of the kit are considered bio-hazardous. The meter should be disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed. This manual documents to not use any product containing bleach to disinfect the meter and gives guidance on where to obtain a list of approved disinfectant wipes for use with the meter. This manual documents before testing, choose a clean, dry work surface and to use a new pair of clean gloves before testing each patient. The facility's Glucometer Cleaning policy, dated 1/6/2020, documents the purpose of the policy is to prevent growth and spread of microorganisms and bloodborne pathogens. This policy documents the blood glucose monitor (glucometer) should be cleaned and disinfected between each resident test using a pre-moistened wipe or towel of 1ml (milliliter) or 5-6% sodium hypochlorite solution (household bleach) and 9ml water to achieve a 1:10 dilution final concentration of 0.5-0.6% sodium hypochlorite. Wipe meter with 1:10 solution bleach wipe/towel until all surfaces of the glucometer are visibly wet. Place glucometer on a clean surface such as a paper towel and allow to air dry for no less than 3 minutes, or according to manufacturer instructions. The facility's Hand Hygiene/Handwashing policy, dated 1/10/2018, documents hand hygiene means cleaning your hands by using soap and water to wash hands or by using an antiseptic hand rub. This policy documents examples of when to perform hand hygiene including before and after having direct contact with a patient's intact skin, after contact with blood, body fluids, excretions, non-intact skin, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient and after glove removal. The facility's Injectable Medication Administration policy, dated 10/25/2014, documents to sanitize hands with approved sanitizer and put on gloves. This policy documents after administering the injection, remove and discard gloves and clean hands by washing or using sanitizer. The facility's Medication Administration policy, dated 10/25/2014, documents the person administering medications adheres to good hand hygiene, which includes thoroughly washing hands prior to handling any medication, after coming in direct contact with a resident. Examination gloves are worn when necessary. Hand sanitization is done with an approved sanitizer between handwashing's, when returning to the medication cart or preparation area (assuming hands have not touched a resident or potentially contaminated surface). Hands are washed before putting on examination gloves and upon removal for administration of topical, ophthalmic, injectable, enteral, rectal, and vaginal medications.

Based on interview and record review, the facility failed to notify a physician of abnormal laboratory results for one of five residents (R1) reviewed for change in condition on the sample of 53. This failure resulted in R1's deterioration in mental, respiratory, and cardiac status, resulting in R1's death on [DATE]. R1 died within 17 days of the unreported urine culture results, and within 7 days of R1's unreported abnormal additional laboratory results. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], onsite record review and interview verified that the facility is in the process of evaluating staff re-education on the facility notification policy and protocol. The facility remains out of compliance at a severity level two. Findings include: R1's Hospital Records, dated [DATE], document R1's problem list including Pneumonia and a history of complicated urinary tract infection. These records document R1's [DIAGNOSES REDACTED]. R1's Progress Notes, dated [DATE] at 1:38pm, document R1 received an order to start [MEDICATION NAME] (Antibiotic) 500mg (milligrams) one tablet daily for 10 days for secretions and possible Urinary Tract Infection [MEDICAL CONDITION]. R1's Urinalysis results, dated [DATE], document a handwritten note await c+s (culture and sensitivity) with the following abnormal results with normal range in parentheses: Appearance: Turbid (Clear) Leukocyte: Moderate (Negative) Protein: 100 (Negative) [MEDICATION NAME]: Positive (Negative) Blood: Trace (Negative) W.B.C (White Blood Cells): ,[DATE] (Negative) R.B.C (Red Blood Cells): ,[DATE] (Negative) Bacteria: 2+ (Negative) R1's Urine Culture results, with reported date of [DATE] at 9:04pm, document R1's urine contained greater than 100,000 Pseudomonas Aeruginosa that was resistant to the [MEDICATION NAME] ([MEDICATION NAME]) antibiotic initially ordered for R1 on [DATE]. There is no documentation in R1's medical records of V29, R1's Hospice Physician, or hospice being notified of the urine culture results. There were no orders to change R1's antibiotic to one the Pseudomonas Aeruginosa was susceptible to. R1's laboratory test sheets, dated received on [DATE], and a reported date of [DATE] document results including the following Abnormal High results with normal range in parentheses: Blood Urea Nitrogen (BUN): 51mg/DL (milligrams per deciliter) (,[DATE]) Creatinine: 2.4mg/DL (0XXX,[DATE].6) Potassium: unable to obtain result Ammonia, Plasma: 342 UG/DL (micrograms per deciliter) R1's Medical Records do not document V29 or hospice notification of R1's laboratory results from [DATE]. R1's Progress Notes dated below document the following: [DATE] 7:26pm - R1 restless [DATE] 6:14am - R1 with facial grimacing, crying. [DATE] 3:51am - R1 very restless. [DATE] 4:31am - R1 with facial grimacing with restlessness urinary catheter with straw color urine. [DATE] 12:48pm - R1 alert/responding to voices. [DATE] 3:07pm - R1 had couple of twitches earlier this morning. At 2:30pm, R1 appeared to have a [MEDICAL CONDITION] approximately 10 seconds. [DATE] 2:42pm - R1 not responsive. There is no documentation of physician or family notification. [DATE] 6:28am - R1 had intermittent twitches for about 30 minutes. No family notification documented. [DATE] 3:29am - R1 with labored breathing Respirations 26, intermittent periods of ,[DATE] second apnea. SpO2 ,[DATE]%. 4:27am R1's temperature at 100.9 degrees Fahrenheit. 4:29am R1 with labored breathing. [DATE] 2:07am - R1 very restless. Labored breathing. [DATE] 9:59pm - low blood pressure [DATE] 12:54am - Fever 100.1. There is no physician or family notification documented. 12:55am R1 very restless 3:51am R1 facial grimacing, restless. 11:01pm, R1 is sleeping most of the time but awakens when being cared for. Has copious amount of white frothy phlegm coming out from the trach. [DATE] 2:27am - very restless with facial grimacing [DATE] 4:18am - R1 continues to be restless. [DATE] 12:11am - facial grimacing with care, very restless. [DATE] 3:41am - found (R1) lethargic at 3am, checked for heart rate was 20/min (per minute), no respirations noted. Went back in to recheck pulse. Heartbeat not applicable. On [DATE] at 11:35am, V32, Regional Nurse Manager for hospice, stated the facility should be contacting hospice with laboratory results and changes in condition for R1. V32 stated there is no documentation the facility notified hospice of R1's laboratory results for the urinalysis, urine culture, or the additional lab results dated [DATE]. V32 stated the list the facility provided to hospice did not include R1's Potassium supplement medication, so that is why hospice did not order the Potassium medication to continue upon R1's admission in to the hospice program. V32 stated hospice would have continued the Potassium medication if hospice would have been given R1's accurate current medication list. V32 stated R1 was started on [MEDICATION NAME] for sediment in R1's urine while waiting for the culture results. V32 stated the facility never notified hospice of R1's urine culture results, and if they would have, R1's antibiotic would have been changed to something that the organism was susceptible to. V32 stated V33, R1's family, had reported concerns of being very uneasy related to the facility's care of R1. V32 stated hospice began seeing R1, who remained very stable, and R1's passing was not expected at the time of R1's decline and death. On [DATE] at 1:15pm, V28, Nurse Practitioner (NP) for hospice, stated V28 was not notified of R1's urine culture results, which indicated R1 needed an appropriate antibiotic prescribed that the organism in R1's urine was susceptible to. V28 stated if the facility would have notified V28 of the urine culture results, V28 would have provided orders for R1. V28 stated V28 and/or hospice should have been notified of R1's abnormal laboratory results from [DATE]. V28 stated R1 should have had R1's Potassium medication continued, and that would not have been discontinued by V28 or hospice. V28 stated the laboratory report documenting R1's Potassium level as unable to be obtained tells V28 R1's Potassium level was unable to be detected in R1's blood, which would correlate to minimal Potassium in R1's blood due to diuretic use and not receiving a Potassium medication to supplement what was being lost with R1's use of diuretic medication. V28 stated in V28's professional opinion, R1's untreated UTI due to the facility's failure to notify the physician, progressed [MEDICAL CONDITION], which along with R1's very high ammonia level and potassium lab results of unobtainable that went unreported, contributed to R1's deterioration and death. An Immediate Jeopardy situation was identified on [DATE] at 11:05am. The Immediate Jeopardy was identified to have begun on [DATE] when the facility did not follow up on abnormal urine culture laboratory results for R1, in which R1's urine infection went untreated, with worsening of R1's medical condition. R1's abnormal laboratory results from [DATE] went un-reported to V28, Hospice Nurse Practitioner. R1's unable to obtain result Potassium level, Ammonia level of 342UG/dl, BUN 51mg/dl and Creatinine of 2.4mg/dl contributed to R1's decline and eventual death on [DATE]. On [DATE] at 11:05 AM, V1, Administrator, was notified of the Immediate Jeopardy situation. The surveyor confirmed through observation, interview, and record review, the facility took the following actions to remove the immediate jeopardy: 1.) On [DATE] at 1:30pm, V60, Nurse Consultant, confirmed R1 no longer resides in the facility effective [DATE]. 2.) On [DATE] at 1:30pm, V60, Nurse Consultant, confirmed all residents labs were reviewed for orders and follow up notifications to the physician and Power of Attorney for residents residing in the facility. This was initiated [DATE] at 3:00pm, with 100% completion on [DATE] by V61, Facility Consultant. 3.) On [DATE] at 1:30pm, V60 confirmed audit findings of any incomplete orders/follow-up have been communicated to the facility Medical Director and Nurse Practitioner. New orders are being processed after V62, Medical Director, and an unidentified Nurse Practitioner review the information. The facility abatement plan documents this action was initiated on [DATE] and is ongoing, with V27, Registered Nurse (RN), and V61 completing. 4.) On [DATE] at 1:30pm, V60 confirmed Nursing staff have been educated by V2, Director Of Nursing, V3, Assistant Director Of Nursing, V27, Registered Nurse, V60, and V61 regarding : Physician Notification of Laboratory/Radiology/diagnostic results policy, PCC (Point Click Care) lab order entry, Central Clinical Labs login/reports, order entry requisitions, requirement to review all labs at end of shift, notification and documentation to medical providers and POA (as needed). This action was initiated on [DATE] and is ongoing. On [DATE], the facility had completed this action at 80% completion.

Based on observation, interview, and record review, the facility failed to properly provide [MEDICAL CONDITION] care as ordered by the physician for two of two residents (R1, R6) reviewed for [MEDICAL CONDITION] care in the sample of 53. This failure resulted in R1 and R6's deterioration in respiratory status. R1 and R6 required multiple emergency room visits due to R1 and R6's tracheostomies being plugged, resulting in restricted air flow and difficulty breathing. Findings include: The facility's [MEDICAL CONDITION] Care policy, dated 8/20/18, documents the policy is used to remove secretions from the tracheo-[MEDICATION NAME] tree. To maintain an unobstructed airway for the maintenance of ventilation. This policy documents to explain the procedure to the resident, prepare the [MEDICAL CONDITION] dressing tray and remove the non-disposable inner cannula and place in hydrogen peroxide. Clean thoroughly and rinse well. Remove gloves, discard and wash hands. Suction before replacing inner cannula. This policy documents to turn on suction machine and don sterile gloves. Using sterile hand, with vent or y-connector open insert catheter 4-5 inches to aspirate trachea, or 8-10 inches to suction bronchi. Turn head to suction bronchi as appropriate. For tenacious secretions 1-3 cc (cubic centimeters) of sterile saline may be instilled via syringe, with MD (medical doctor) approval. Sterile saline will thin and loosen dry thickened secretions for easier removal. Continue suctioning until tracheo-[MEDICATION NAME] tree is clear. Assess by listening for clear breathing by ear and by stethoscope. Clean outside of outer cannula as needed before replacing inner cannula. This policy documents to document the procedure in the clinical record and/or sign on electronic treatment record as appropriate. Emergency Care: If outer tube comes out, stay with resident and summon assistance. A rubber tipped hemostat maybe used to maintain opening. 1.) R6's Admission Record dated, 10/26/2020, documents R6's [DIAGNOSES REDACTED]. R6's Progress Notes dated 8/31/2020 document R6 complains of needing to [MEDICAL CONDITION] often and is alert and oriented. R6's Progress Notes dated 9/2/2020 document R6 is anxious about the care of (R6's) [MEDICAL CONDITION]. R6's Progress notes, dated 9/17/2020 at 7:29am, R6 complained of shortness of breath with oxygen saturation 90%. R6 requested to be sent to the emergency room . R6's Progress Notes, dated 9/22/2020 at 2:00pm by V31, R6's Nurse Practitioner (NP), document staff are to provide frequent suctioning and monitor oxygen saturation. Notes dated 9/23/2020 at 3:19am - R6 requesting to be sent to the emergency room and complaining of left flank, chest, left arm pain, shortness of breath, chills then sweating. R6 stated R6 feels like (R6) has something stuck in (R6's) lungs. Notes dated 9/28/2020 at 4:11am - R6 taking the inner cannula out of R6'[MEDICAL CONDITION] wanting it cleaned every 2 hours. Notes dated 10/1/2020 at 10:00pm, R6 was transferred out to the emergency room after R6 removed the inner cannula and when V34, Registered Nurse, attempted to reinsert, there was an obstruction so R6 was sent to the hospital. R6 complained of shortness of breath at this time. Notes dated 10/12/2020 at 2:30pm, R6 complained of pain to the lower abdomen. R6's oxygen saturation was 82% on room air, R6 refused to put oxygen on. R6 had removed R6's inner cannula which was cleaned. R6's inner cannula met resistance and was unable to be re-inserted, and R6 requested to be sent to the emergency room . Notes dated 10/12/2020 at 2:01pm, documents V3, Assistant Director of Nursing (ADON), was called into (R6's) room by another nurse who found R6 unresponsive. This note documents R6 had had pulled entire [MEDICAL CONDITION] out and was bleeding from the site. (R6) was gasping for air. V3 attempted to replace [MEDICAL CONDITION] but the airway was blocked. V3 [MEDICAL CONDITION] halfway in. R6 was sent to the emergency room . Notes dated 10/21/2020 at 1:35pm, R6 requested to be sent to the emergency room for [MEDICAL CONDITION]. R6's After Visit Summary (AVS) for multiple emergency room visits document discharge instructions as well as reason for visit and visit [DIAGNOSES REDACTED].>9/18/2020 Reason for visit - [MEDICAL CONDITION] Change with a [DIAGNOSES REDACTED]. Included with this AVS are instructions for [MEDICAL CONDITION] Care, including suctioning and clearing a mucous plug. 9/23/2020 Reason for visit - Shortness of Breath with [DIAGNOSES REDACTED]. (R6) requests that education and equipment should be available at all times in (R6's) room for self-treatment during emergent times. Thank you for your help. 10/1/2020 Reason for visit - [MEDICAL CONDITION] Change with a [DIAGNOSES REDACTED]. Included with this AVS are instructions for mucous plug,[MEDICAL CONDITION] as well as instructions for [MEDICAL CONDITION] care and cleaning. These instructions document You have a [MEDICAL CONDITION] that allows you to breathe. Mucus from your airway can collect inside the tube and block it. The buildup of thick music is called a mucous plug. It is important you take steps to prevent a mucous plug from blocking [MEDICAL CONDITION]. Suction [MEDICAL CONDITION] as told by your provider. Mucus can build up and thicken. If this happens [MEDICAL CONDITION] can become plugged. Cleaning prevents buildup of dried secretions that can block the [MEDICAL CONDITION]. When cleaning your [MEDICAL CONDITION], it's important to be well prepared with the right supplies in case of an emergency including, for example, a manual ventilator bag. R6's hospital records, dated 10/21/2020, document R6 presented to the emergency room with shortness of breath and comes back for suctioning of (R6's) [MEDICAL CONDITION]. (R6) has been here multiple times for that. These records document R6 had a small amount of dry secretions present with the left lower lung field revealing rales (abnormal lung sounds.) R6's Clinical Impression for this visit is documented as [MEDICAL CONDITION] care. R6's Physician Orders, dated 10/26/2020, document staff are to [MEDICAL CONDITION] every shift and as needed. These orders document to suction R6'[MEDICAL CONDITION] 4 hours and as needed. On 10/20/2020 at 10:00am, R6 stated R6 has had to go to the hospital multiple times [MEDICAL CONDITION]. R6 stated R6 will have trouble breathing due to the nurses not being able to [MEDICAL CONDITION] as often as R6 needs it because they are too busy, as well as the staff do not go deep enough to get the mucous. R6 stated the staff check R6's oxygen saturation every once in awhile, but not too often. An open undated bottle of saline for humidity was noted at R6's bedside at this time. R6 stated R6 uses that with suctioning. R6 stated there is no emergency obturator or ambu bag in R6's room, and R6 has had emergencies where those should have been available. R6 stated R6 has pulled out [MEDICAL CONDITION] cannula because R6 could not breathe because the tube was blocked and R6 was just trying to breathe. R6's suction tubing was located in a dingy ziplock bag that was not dated, as well as R6's suction tubing, humidifier bottle attached to the humidifier machine,[MEDICAL CONDITIONS] tubing were not labeled with date. R6 stated R6 is unsure when the facility changes the tubing,[MEDICAL CONDITION], etc. On 10/20/2020 at 10:19am, V8, RN, stated the ambu bag should be in R6's room but V8 looked around and stated there was not one in R6's room. V8 had touched R6's [MEDICAL CONDITION] and adjusted V8's protective eyewear multiple times without performing hand hygiene. V8 removed V8's gloves and proceeded to walk down the hall to the storage room to obtain [MEDICAL CONDITION] and ambu bag without completing hand hygiene after removing V8's gloves. V8 stated V8 was unsure of when some of [MEDICAL CONDITION] and humidifier bottles were placed in use for R6 and that the facility is not dating the items or documenting when the changes are happening. On 10/21/2020 at 9:00am, V8, Registered Nurse (RN), prepared R6'[MEDICAL CONDITION] supplies. V8 [MEDICAL CONDITION] to R6's inner cannula, but did not clean the plate to R6's trach. V8 removed contaminated gloves, did not perform hand hygiene, opened the sterile water [MEDICAL CONDITION], donned sterile gloves, and began suctioning R6. V8 asked R6 if R6 had another plug and R6 shook R6's head. V8 continued to attempt to suction R6 with no success. R6 became anxious, took the suction catheter from V8, and attempted to suction R6'[MEDICAL CONDITION] success. R6 began forcefully coughing and was able to cough up thick mucous about the size of a dime. R6's oxygen saturation was unknown, and not being monitored prior to or during the procedure at this time. V8 was not wearing a gown while suctioning R6. R6 requested for V2, Director of Nursing (DON), to come assist with suctioning. At 9:25am, V2, DON, came in to R6's room. V2 was wearing a mask with straps around V2's neck and protective eyewear. V2 did not wear a gown during the procedure. V8 went and got an oxygen saturation monitor and placed on R6's finger. R6's oxygen saturation was between 89% and 92%. V8 told V2, the mucous is deep in there. At 9:29am, V2, DON's mask had fallen down under V2's nose, only covering V2's mouth. V2 attempted to suction R6 multiple times with no success. During this time, R6 was not encouraged or educated related to the use of R6's [MEDICAL CONDITION]. R6 was requesting additional suctioning. V2 stated to V8 that V2 wasn't sure that R6 should have more suctioning. R6 took R6's hand and used it to act out shooting R6's head. R6 began forcefully coughing again producing a large bloody mucous plug. This was followed by yellow mucous. The tubing to the suction machine had been laid on R6's bed. V2 picked up the tubing off the bed, attached a suction catheter to the open end of the contaminated suction tubing, and suctioned R6. On 10/28/2020 at 7:20am, V22, emergency room Charge RN, stated R6 is constantly coming in the the emergency room several times with several mucous plugs. V22 stated R6 has anxiety and has ended up removing R6's trach. V22 stated the facility R6 resides in is neglectful [MEDICAL CONDITION] and you can tell the facility does not [MEDICAL CONDITION] as often as R6 needs it. V22 stated the facility is neglecting to suction R6 properly as evidenced by multiple mucous plugs and emergency room visits. V22 stated not [MEDICAL CONDITION] as each resident needs can lead to mucus plugs and death. 2.) R1's Admission Record, dated 10/27/2020, documents R1's [DIAGNOSES REDACTED]. R1's Progress Notes, dated 7/9/2020 at 6:45am, documents R1 arrived to the facility from the hospital 7/8/2020 in the evening [MEDICAL CONDITION] infection, bacterial infection in the lungs, and [MEDICAL CONDITION]. R1 was to [MEDICAL CONDITION] every 15-30 minutes, and the nurse was able to suction R1 every 30-45 minutes during the shift. R1 had rhonchi and crackles (abnormal lung sounds) throughout all lung fields both anterior and posterior. R1's Hospital Medical Records, dated 8/22/2020, document R1 has [MEDICAL CONDITION] in place and it is plugged up. These records document R1 presented with shortness of breath and in acute distress with decreased air movement. R1's [MEDICAL CONDITION] is plugged up. Suctioned and irrigated with saline obtained significant amount of thick mucus. R1 had significant improvement after R1'[MEDICAL CONDITION] suctioned. These notes document R1 had oxygen saturations from 51% to 80% at the facility prior to arriving at the emergency room . R1's [DIAGNOSES REDACTED]. R1 was discharged back to the facility on [DATE]. R1's Hospital Records from R1's hospital visit on 8/26/2020, document R1's Principal Final Diagnosis: [REDACTED]. These records document V36, emergency room Physician found R1's [MEDICAL CONDITION] plugged up and that R1 was in acute distress. These records also document notes by V36 that R1's [MEDICAL CONDITION] cannula was suctioned removing significant amount of mucus plugging with improvement following the removal of the mucus plugging with the Clinical Impression of R1's visit of mucus plugging of bronchi. These records document V22, emergency room Charge RN, spoke to V37, Licensed Practical Nurse, and V22 advised V37 to change R1's suctioning to every 30 minutes. R1's Progress Notes, dated 8/26/2020 at 5:20am, documents the unidentified nurse from the emergency room reported the hospital removed three large mucous plugs from R1'[MEDICAL CONDITION] the facility was notified by the emergency room R1 was to be suctioned every 30 minutes. Progress Notes, dated 8/26/2020 at 9:16am, are the last notes [MEDICAL CONDITION] every 30-45 minutes. R1's Treatment Administration Record (TAR), dated September and October 2020, documents R1 was to have R1'[MEDICAL CONDITION] every four hours and as needed, as well [MEDICAL CONDITION] every shift and as needed. There is no documentation in R1's TAR of suctioning R6'[MEDICAL CONDITION] 30 minutes. On 10/28/2020 at 7:20am, V22, emergency room Charge RN, stated R1 had been seen in the the emergency room several times with several mucous plugs. V22 stated the facility R1 resides in is neglectful [MEDICAL CONDITION] and you can tell the facility does not [MEDICAL CONDITION] as often as R1 needs it. V22 stated the facility neglecting to suction R1 properly was evidenced by multiple mucous plugs and emergency room visits. V22 stated if [MEDICAL CONDITION] was completed as with proper technique and as it was supposed to be, R1 would not have been to the hospital with [MEDICAL CONDITION] R1 was. V22 stated not [MEDICAL CONDITION] as each resident needs can lead to mucus plugs and death.

Failures identified required more than one deficient practice statement. A.) Based on observation, record review, and interview, the facility failed to ensure a staff member with an elevated temperature, multiple COVID (Novel Human Coronavirus Infection) symptoms, and exposure to a COVID positive person outside of the facility, did not report to and continued to work in the facility with COVID symptoms. The facility also failed to ensure staff were not medically screening themselves, and failed to implement infection control precautions to prevent the spread of COVID-19 in the facility. These failures have the potential to affect all 132 residents residing in the facility. These failures resulted in V14 working with multiple COVID symptoms, including a fever of over 100 degrees for 6 and a half hours, and using multiple tissues for upper head congestion, placing them in the open trash can at the front desk, screening staff entering the facility to provide care to the residents and environment inside the facility, which put the facility at risk for transmitting COVID throughout the facility. These failure resulted in an Immediate Jeopardy. While the immediacy was removed on 11/5/2020, onsite record review and interview verified that the facility is in the process of evaluating staff re-education on the facility infection control policies and protocols. The facility remains out of compliance at a severity level two. B. Based on observation, interview, and record review, the facility failed to implement hand hygiene, and failed to disinfect the multiple resident use blood glucose test device (glucometer) after each use. These failures have the potential to affect 16 residents (R2, R14, R15, R16, R18, R20, R21, R22, R23, R26, R30, R45, R49, R50, R51, R52) reviewed during medication administration and use of the glucometers in the sample of 52. Findings include: a.) The facility's Infection Control - Interim policy addressing healthcare crisis related to Human [MEDICAL CONDITION], dated 10/6/2020, documents the Infection Preventionist or designee will monitor staff compliance with hand hygiene and Personal Protective Equipment (PPE) practices. Healthcare Providers (HCP) must not touch or adjust their facemask and if they do they must immediately perform hand hygiene. Staff will have screening for symptoms, possible exposures and temperature completed prior to starting their shift. Staff may not perform self-screening. In Illinois, staff will be screened mid-shift or approximately every 4 hours. Any staff with a fever and/or onset of COVID-19 symptoms will result in the staff being screened and sent home with local health department being notified. Facility will utilize the following PPE and infection control precautions: Hand Hygiene is to be performed before and after all patient contact and before putting on and after removing PPE, including gloves. Universal Eye protection should be worn in addition to their facemask to ensure the eyes, nose and mouth are all protected from exposure to respiratory secretions during patient care encounters. After removing gloves, immediately perform hand hygiene. If there are gown shortages, gowns should be prioritized for aerosol-generating procedures and care activities where splashes and sprays are anticipated. The facility's Interim COVID-19 Testing - Residents and Staff policy, dated 8/31/2020, documents staff with symptoms or signs of COVID-19 must be tested , and are expected to be restricted from the facility pending the results of COVID-19 testing. Staff who do not test positive for COVID-19 but have symptoms should follow facility policies on returning to work. On 10/19/2020 at 9:10am, V14, Receptionist, was sitting at the receptionist desk at the main entrance to the facility. V14 looked as though V14 did not feel well and when asked V14 stated, I feel horrible and had head congestion and stuffiness. V14 screened herself prior to V14's shift, and documented a temperature of 100.1 and yes for new symptoms as well as recent exposure or close contact with a COVID positive person outside of the facility. Mid-shift, V14 completed V14's screening per herself and V14's temperature was 100.9 and V14 answered yes to Any new symptoms since the beginning of shift? End of shift - Prior to leaving, V14 documented V14's temperature at 100.6 and yes to new symptoms. V14's timecard documents V14 checked in to work at 7:58am and left at 2:30pm, which was verified by V14's supervisor, V13, Human Resources. V14 is the receptionist that is responsible for screening the employees coming in to work at the facility and screened 26 staff (including self), potentially exposing the 25 other employees (V1, Administrator, V2, Director of Nursing (DON), V8, Registered Nurse (RN), V13, Human Resources (HR), V21, Care Plan Coordinator, V26 and V27 RN, V39, Housekeeping, V40, Dietary, V41, V42, V43, Housekeeping, V44, V54, Dietary, V45, V49, V50, V53, Certified Nursing Assistant (CNA), V46, illegible title, V47, V51 Transport, V48, Marketing, V52 and V56, Therapy and V55, Vendor) prior to working with the residents throughout the facility, potentially exposing the residents throughout the day. V13 stated V13 was made aware about 12:30pm on 10/19/2020 and V2, DON, completed a rapid COVID screen on V14 that was negative. V14 remained working while symptomatic at the reception desk, despite V14's temperature and history of positive COVID exposure until 2:30pm. At 3:00pm, the trash can located at the desk of the reception area contained multiple tissues that were discarded while V14 was on duty. V1 provided the COVID positive test results for employees with testing performed between 10/19/2020 and 10/26/2020, documenting six employees (V2, V8, V14, V21, V26, V27) screened by V14, Receptionist, on 10/19/2020 tested positive for COVID. On 10/21/2020 at 9:25am, V2, Director of Nursing (DON), provided [MEDICAL CONDITION] (trach) care and suctioning for R6. V2 was not wearing a gown during the procedure while standing within 2 feet of R6. R6 was forcibly coughing attempting to bring up the mucus from R6's [MEDICAL CONDITION]. At 9:29am, V2's mask straps were behind V2's neck and V2's mask had moved below V2's nose. V2 made several attempts to suction R6'[MEDICAL CONDITION] V2's mask was not properly positioned over V2's nose, exposing R6 to V2 and V2 to R6. V8, Registered Nurse (RN) also suctioned R6 multiple times without a gown on as well as adjusted V8's protective eye wear with contaminated gloves after coming in contact with multiple items in R6's room including R6's [MEDICAL CONDITION] supplies and contaminated suction catheter. V8 continued to care for the resident's in the facility after providing cares and contaminating protective eyewear for V8. On 10/19/2020, R6 had a COVID test performed, sent to the laboratory on 10/21/2020, and results reported on 10/23/2020 that R6 tested positive for COVID. V1, Administrator, provided documentation eight residents (R6, R10, R29, R43, R44, R45, R46, R47) tested on [DATE] tested positive for COVID. On 10/26/2020 at 10:45am, V1, Administrator, stated V2, Director of Nursing, was out for the day. V1 stated V2 was ill and began running a fever over the weekend and was going to get a test for COVID on 10/26/2020. On 10/28/2020 at 9:15am, V1 stated V2 tested positive for COVID. V1 also stated V8, RN, had also tested positive for COVID. Administrator stated the dietary staff have the potential to go between the two separate buildings at the facility to provide dietary services to the residents. On 10/27/2020 at 9:20am, V38, Public Health Administrator, stated the facility reported V14, Receptionist, had reported to work not feeling well. V38 stated the facility did not tell V38 that V14 was feverish and continued working until 2:30pm with symptoms of COVID. V38 stated V38 was upset to hear V14 continued working despite being symptomatic for COVID and exposing staff coming in to the facility. V38 stated with COVID being airborne/droplet, it is maddening and there was probable exposure, likely causing infections of others throughout the facility. V38 stated the facility policy should address the screening and attendance process and it should address employees not being allowed to self screen as well as work status if staff are symptomatic. The facility's Resident List Report documents 132 residents reside in the facility. An Immediate Jeopardy situation was identified on 11/5/2020. The Immediate Jeopardy was identified to have begun on 10/19/2020 when the facility allowed V14, Receptionist, to work in the facility with symptoms of COVID-19 infection thereby exposing multiple staff and subsequently multiple residents throughout the facility to COVID-19 infection. On 11/5/2020 at 11:05 AM, V1, Administrator, was notified of the Immediate Jeopardy situation. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: 1.) On 11/5/2020 at 1:30pm, V60, Nurse Consultant, confirmed V14 no longer works in the facility, effective 10/22/2020. 2.) On 11/5/2020 at 1:30pm, V60 confirmed all staff were inserviced on the medical screening process, initiated on 10/22/2020 with 100% completion. 3.) On 11/5/2020 at 1:30pm, all facility staff were in-serviced on Personal Protective Equipment (PPE) donning and doffing, Infection Control Policy: COVID-19 hand hygiene and Transmission Based Precautions. This was initiated on 10/26/2020 with 100% completion and the facility completed an audit 100% on 11/5/2020 by V60, Nurse Consultant, and V61, Facility Consultant. 4.) On 11/5/2020 at 1:30pm, an ongoing quality insurance tool was implemented to be completed five times a week for 12 weeks. 5.) On 11/5/2020 at 1:30pm, V60 confirmed a Root Cause Analysis was completed for Personal Protective Equipment use, Transmission Based Precautions (TBP) and hand hygiene was initiated on 10/26/2020 and was 100% completed by V60, V61, V2, Director of Nursing (DON), and V3, Assistant Director of Nursing (ADON). 6.) On 11/5/2020 at 1:30pm,V60 confirmed the Center for Medicaid Services (CMS) COVID-19 Facility self assessment was completed 10/27/2020. 7.) On 11/5/2020 at 1:30pm, V60 confirmed the facility implemented new screening tools for staff and visitors capturing cold symptoms which was completed on 11/2/2020. 8.) On 11/5/2020 at 1:30pm, V60 confirmed V2, DON, was educated/inserviced [MEDICAL CONDITION] and Infection Control Practices which were completed on 11/4/2020. b.) On 10/20/2020 at 11:11am, V4, Licensed Practical Nurse (LPN), obtained R14's blood glucose level. V4 opened the dry paper towel on the top of V4's medication cart and gathered supplies to perform the blood glucose finger stick. V4 used a lancet to puncture R14's finger and applied R14's blood to the testing strip in the glucometer. R14's blood glucose was 242. V4 placed the glucometer on top of the medication cart. V4 stated V4 is allergic to bleach so V4 sanitizes (glucometer) with hand sanitizer. V4 took the bottle of hand sanitizer, applied a small amount to the paper towel, wiped the glucometer with the paper towel, obtained a dry paper towel and wiped the glucometer. V4 then wrapped the glucometer in the paper towel and sat the glucometer on the top of the medication cart. The hand sanitizer label documents the sanitizer contains 65% alcohol and that it is to be used for handwashing to decrease bacteria on the skin. The product labeling makes no efficacy claim for use as a surface disinfectant. On 10/20/2020 at 11:25am, V4, LPN, obtained a blood glucose level for R15 using a glucometer from the top of V4's medication cart that was wrapped in a paper towel. V4 used a lancet to pierce R15's finger and placed R15's blood on the testing strip that was inside the glucometer. V4 used the hand sanitizer on a paper towel to wipe the glucometer, and took a second paper towel and wiped the glucometer again and wrapped the glucometer. On 10/20/2020 at 12:28pm, V19, LPN, performed a blood glucose level check on R18. V19 did not don gloves, and proceeded to use a lancet to pierce R18's skin to obtain a blood sample on the blood glucose test strip that had been placed inside the glucometer which was 333mg/dl. R18's physician's orders [REDACTED]. V19 administered the insulin to R18 without performing hand hygiene nor donning gloves. V19 returned to the medication cart and placed the glucometer with the contaminated test strip on the top of the cart, and then removed the blood glucose test strip that contained R18's blood with her bare hand and disposed of the strip. V19 did not disinfect the blood glucose glucometer after use on R18. On 10/20/2020 at 12:40pm, V19, LPN, used the same contaminated glucometer V19 used to obtain R18's blood glucose level to obtain R20's blood glucose level. V19 used a lancet to puncture R20's skin to obtain blood and placed the blood on the testing strip located inside the glucometer. V19 did not don gloves or perform hand hygiene prior to performing the blood glucose level check for R20. V19 brought the contaminated glucometer that still had the contaminated test strip inside the glucometer and placed it on the medication cart. V19 did not perform hand hygiene or don gloves prior to or after administering R20's [MEDICATION NAME]injection. On 10/20/2020 at 12:42pm, V19, LPN, used a glucometer to perform a blood glucose level check for R21. R21 was standing at the medication cart when V19 used a lancet to pierce R21's skin to obtain a sample of R21's blood and placed the blood on the test strip located inside the glucometer. V19 then placed the contaminated glucometer on top of the medication cart without disinfecting the glucometer. V19 did not don gloves prior to performing the blood glucose test or perform hand hygiene. On 10/20/2020 at 12:53pm, R22 was sitting on the side of R22's bed. V20, LPN, entered R22's room, placed the bottle of blood glucose test strips on R22's bed. V20 performed a blood glucose test on R22 which read 173. V20 went to medication cart and placed the contaminated glucometer and bottle of test strips on top of the medication cart. V20 did not remove V20's contaminated gloves, and touched the medication cart, including opening drawers to obtain insulin medication to administer to R22. On 10/20/2020 at 12:59pm, V20, LPN, performed a blood glucose glucometer test for R23. V20 pierced R23's skin, placed R23's blood on the blood glucose testing strip and placed the contaminated machine on the medication cart. V20 did not perform hand hygiene after touching the contaminated monitor with V20's hands. On 10/20/2020 at 1:10pm, V20 entered R26's room to perform a blood glucose level test with a contaminated glucometer on R26. V20 placed the glucometer on R26's bed sheets on top of R26's bed that had brown debris on the sheets and R26 had shoes on in bed with debris on the bottom of R26's shoes. On 11/9/2020, V1, Administrator, provided documentation of 15 residents (R2, R14, R15, R16, R18, R20, R21, R22, R23, R30, R45, R49, R50, R51, R52) who have the potential for blood glucose testing with the re-usable glucometer machines. The manufacturer's User's Manual for the facility's blood glucose meter dated 5/17/2016 documents, Note: Important Safety Instructions. All parts of the kit are considered bio-hazardous. The meter should be disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed. This manual documents to not use any product containing bleach to disinfect the meter and gives guidance on where to obtain a list of approved disinfectant wipes for use with the meter. This manual documents before testing, choose a clean, dry work surface and to use a new pair of clean gloves before testing each patient. The facility's Glucometer Cleaning policy, dated 1/6/2020, documents the purpose of the policy is to prevent growth and spread of microorganisms and bloodborne pathogens. This policy documents the blood glucose monitor (glucometer) should be cleaned and disinfected between each resident test using a pre-moistened wipe or towel of 1ml (milliliter) or 5-6% sodium hypochlorite solution (household bleach) and 9ml water to achieve a 1:10 dilution final concentration of 0.5-0.6% sodium hypochlorite. Wipe meter with 1:10 solution bleach wipe/towel until all surfaces of the glucometer are visibly wet. Place glucometer on a clean surface such as a paper towel and allow to air dry for no less than 3 minutes, or according to manufacturer instructions. The facility's Hand Hygiene/Handwashing policy, dated 1/10/2018, documents hand hygiene means cleaning your hands by using soap and water to wash hands or by using an antiseptic hand rub. This policy documents examples of when to perform hand hygiene including before and after having direct contact with a patient's intact skin, after contact with blood, body fluids, excretions, non-intact skin, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient and after glove removal. The facility's Injectable Medication Administration policy, dated 10/25/2014, documents to sanitize hands with approved sanitizer and put on gloves. This policy documents after administering the injection, remove and discard gloves and clean hands by washing or using sanitizer. The facility's Medication Administration policy, dated 10/25/2014, documents the person administering medications adheres to good hand hygiene, which includes thoroughly washing hands prior to handling any medication, after coming in direct contact with a resident. Examination gloves are worn when necessary. Hand sanitization is done with an approved sanitizer between handwashing's, when returning to the medication cart or preparation area (assuming hands have not touched a resident or potentially contaminated surface). Hands are washed before putting on examination gloves and upon removal for administration of topical, ophthalmic, injectable, enteral, rectal, and vaginal medications.

Based on interview and record review, the facility failed to notify a physician of abnormal laboratory results for one of five residents (R1) reviewed for change in condition on the sample of 53. This failure resulted in R1's deterioration in mental, respiratory, and cardiac status, resulting in R1's death on [DATE]. R1 died within 17 days of the unreported urine culture results, and within 7 days of R1's unreported abnormal additional laboratory results. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], onsite record review and interview verified that the facility is in the process of evaluating staff re-education on the facility notification policy and protocol. The facility remains out of compliance at a severity level two. Findings include: R1's Hospital Records, dated [DATE], document R1's problem list including Pneumonia and a history of complicated urinary tract infection. These records document R1's [DIAGNOSES REDACTED]. R1's Progress Notes, dated [DATE] at 1:38pm, document R1 received an order to start [MEDICATION NAME] (Antibiotic) 500mg (milligrams) one tablet daily for 10 days for secretions and possible Urinary Tract Infection [MEDICAL CONDITION]. R1's Urinalysis results, dated [DATE], document a handwritten note await c+s (culture and sensitivity) with the following abnormal results with normal range in parentheses: Appearance: Turbid (Clear) Leukocyte: Moderate (Negative) Protein: 100 (Negative) [MEDICATION NAME]: Positive (Negative) Blood: Trace (Negative) W.B.C (White Blood Cells): ,[DATE] (Negative) R.B.C (Red Blood Cells): ,[DATE] (Negative) Bacteria: 2+ (Negative) R1's Urine Culture results, with reported date of [DATE] at 9:04pm, document R1's urine contained greater than 100,000 Pseudomonas Aeruginosa that was resistant to the [MEDICATION NAME] ([MEDICATION NAME]) antibiotic initially ordered for R1 on [DATE]. There is no documentation in R1's medical records of V29, R1's Hospice Physician, or hospice being notified of the urine culture results. There were no orders to change R1's antibiotic to one the Pseudomonas Aeruginosa was susceptible to. R1's laboratory test sheets, dated received on [DATE], and a reported date of [DATE] document results including the following Abnormal High results with normal range in parentheses: Blood Urea Nitrogen (BUN): 51mg/DL (milligrams per deciliter) (,[DATE]) Creatinine: 2.4mg/DL (0XXX,[DATE].6) Potassium: unable to obtain result Ammonia, Plasma: 342 UG/DL (micrograms per deciliter) R1's Medical Records do not document V29 or hospice notification of R1's laboratory results from [DATE]. R1's Progress Notes dated below document the following: [DATE] 7:26pm - R1 restless [DATE] 6:14am - R1 with facial grimacing, crying. [DATE] 3:51am - R1 very restless. [DATE] 4:31am - R1 with facial grimacing with restlessness urinary catheter with straw color urine. [DATE] 12:48pm - R1 alert/responding to voices. [DATE] 3:07pm - R1 had couple of twitches earlier this morning. At 2:30pm, R1 appeared to have a [MEDICAL CONDITION] approximately 10 seconds. [DATE] 2:42pm - R1 not responsive. There is no documentation of physician or family notification. [DATE] 6:28am - R1 had intermittent twitches for about 30 minutes. No family notification documented. [DATE] 3:29am - R1 with labored breathing Respirations 26, intermittent periods of ,[DATE] second apnea. SpO2 ,[DATE]%. 4:27am R1's temperature at 100.9 degrees Fahrenheit. 4:29am R1 with labored breathing. [DATE] 2:07am - R1 very restless. Labored breathing. [DATE] 9:59pm - low blood pressure [DATE] 12:54am - Fever 100.1. There is no physician or family notification documented. 12:55am R1 very restless 3:51am R1 facial grimacing, restless. 11:01pm, R1 is sleeping most of the time but awakens when being cared for. Has copious amount of white frothy phlegm coming out from the trach. [DATE] 2:27am - very restless with facial grimacing [DATE] 4:18am - R1 continues to be restless. [DATE] 12:11am - facial grimacing with care, very restless. [DATE] 3:41am - found (R1) lethargic at 3am, checked for heart rate was 20/min (per minute), no respirations noted. Went back in to recheck pulse. Heartbeat not applicable. On [DATE] at 11:35am, V32, Regional Nurse Manager for hospice, stated the facility should be contacting hospice with laboratory results and changes in condition for R1. V32 stated there is no documentation the facility notified hospice of R1's laboratory results for the urinalysis, urine culture, or the additional lab results dated [DATE]. V32 stated the list the facility provided to hospice did not include R1's Potassium supplement medication, so that is why hospice did not order the Potassium medication to continue upon R1's admission in to the hospice program. V32 stated hospice would have continued the Potassium medication if hospice would have been given R1's accurate current medication list. V32 stated R1 was started on [MEDICATION NAME] for sediment in R1's urine while waiting for the culture results. V32 stated the facility never notified hospice of R1's urine culture results, and if they would have, R1's antibiotic would have been changed to something that the organism was susceptible to. V32 stated V33, R1's family, had reported concerns of being very uneasy related to the facility's care of R1. V32 stated hospice began seeing R1, who remained very stable, and R1's passing was not expected at the time of R1's decline and death. On [DATE] at 1:15pm, V28, Nurse Practitioner (NP) for hospice, stated V28 was not notified of R1's urine culture results, which indicated R1 needed an appropriate antibiotic prescribed that the organism in R1's urine was susceptible to. V28 stated if the facility would have notified V28 of the urine culture results, V28 would have provided orders for R1. V28 stated V28 and/or hospice should have been notified of R1's abnormal laboratory results from [DATE]. V28 stated R1 should have had R1's Potassium medication continued, and that would not have been discontinued by V28 or hospice. V28 stated the laboratory report documenting R1's Potassium level as unable to be obtained tells V28 R1's Potassium level was unable to be detected in R1's blood, which would correlate to minimal Potassium in R1's blood due to diuretic use and not receiving a Potassium medication to supplement what was being lost with R1's use of diuretic medication. V28 stated in V28's professional opinion, R1's untreated UTI due to the facility's failure to notify the physician, progressed [MEDICAL CONDITION], which along with R1's very high ammonia level and potassium lab results of unobtainable that went unreported, contributed to R1's deterioration and death. An Immediate Jeopardy situation was identified on [DATE] at 11:05am. The Immediate Jeopardy was identified to have begun on [DATE] when the facility did not follow up on abnormal urine culture laboratory results for R1, in which R1's urine infection went untreated, with worsening of R1's medical condition. R1's abnormal laboratory results from [DATE] went un-reported to V28, Hospice Nurse Practitioner. R1's unable to obtain result Potassium level, Ammonia level of 342UG/dl, BUN 51mg/dl and Creatinine of 2.4mg/dl contributed to R1's decline and eventual death on [DATE]. On [DATE] at 11:05 AM, V1, Administrator, was notified of the Immediate Jeopardy situation. The surveyor confirmed through observation, interview, and record review, the facility took the following actions to remove the immediate jeopardy: 1.) On [DATE] at 1:30pm, V60, Nurse Consultant, confirmed R1 no longer resides in the facility effective [DATE]. 2.) On [DATE] at 1:30pm, V60, Nurse Consultant, confirmed all residents labs were reviewed for orders and follow up notifications to the physician and Power of Attorney for residents residing in the facility. This was initiated [DATE] at 3:00pm, with 100% completion on [DATE] by V61, Facility Consultant. 3.) On [DATE] at 1:30pm, V60 confirmed audit findings of any incomplete orders/follow-up have been communicated to the facility Medical Director and Nurse Practitioner. New orders are being processed after V62, Medical Director, and an unidentified Nurse Practitioner review the information. The facility abatement plan documents this action was initiated on [DATE] and is ongoing, with V27, Registered Nurse (RN), and V61 completing. 4.) On [DATE] at 1:30pm, V60 confirmed Nursing staff have been educated by V2, Director Of Nursing, V3, Assistant Director Of Nursing, V27, Registered Nurse, V60, and V61 regarding : Physician Notification of Laboratory/Radiology/diagnostic results policy, PCC (Point Click Care) lab order entry, Central Clinical Labs login/reports, order entry requisitions, requirement to review all labs at end of shift, notification and documentation to medical providers and POA (as needed). This action was initiated on [DATE] and is ongoing. On [DATE], the facility had completed this action at 80% completion.

Based on observation, interview, and record review, the facility failed to properly provide [MEDICAL CONDITION] care as ordered by the physician for two of two residents (R1, R6) reviewed for [MEDICAL CONDITION] care in the sample of 53. This failure resulted in R1 and R6's deterioration in respiratory status. R1 and R6 required multiple emergency room visits due to R1 and R6's tracheostomies being plugged, resulting in restricted air flow and difficulty breathing. Findings include: The facility's [MEDICAL CONDITION] Care policy, dated 8/20/18, documents the policy is used to remove secretions from the tracheo-[MEDICATION NAME] tree. To maintain an unobstructed airway for the maintenance of ventilation. This policy documents to explain the procedure to the resident, prepare the [MEDICAL CONDITION] dressing tray and remove the non-disposable inner cannula and place in hydrogen peroxide. Clean thoroughly and rinse well. Remove gloves, discard and wash hands. Suction before replacing inner cannula. This policy documents to turn on suction machine and don sterile gloves. Using sterile hand, with vent or y-connector open insert catheter 4-5 inches to aspirate trachea, or 8-10 inches to suction bronchi. Turn head to suction bronchi as appropriate. For tenacious secretions 1-3 cc (cubic centimeters) of sterile saline may be instilled via syringe, with MD (medical doctor) approval. Sterile saline will thin and loosen dry thickened secretions for easier removal. Continue suctioning until tracheo-[MEDICATION NAME] tree is clear. Assess by listening for clear breathing by ear and by stethoscope. Clean outside of outer cannula as needed before replacing inner cannula. This policy documents to document the procedure in the clinical record and/or sign on electronic treatment record as appropriate. Emergency Care: If outer tube comes out, stay with resident and summon assistance. A rubber tipped hemostat maybe used to maintain opening. 1.) R6's Admission Record dated, 10/26/2020, documents R6's [DIAGNOSES REDACTED]. R6's Progress Notes dated 8/31/2020 document R6 complains of needing to [MEDICAL CONDITION] often and is alert and oriented. R6's Progress Notes dated 9/2/2020 document R6 is anxious about the care of (R6's) [MEDICAL CONDITION]. R6's Progress notes, dated 9/17/2020 at 7:29am, R6 complained of shortness of breath with oxygen saturation 90%. R6 requested to be sent to the emergency room . R6's Progress Notes, dated 9/22/2020 at 2:00pm by V31, R6's Nurse Practitioner (NP), document staff are to provide frequent suctioning and monitor oxygen saturation. Notes dated 9/23/2020 at 3:19am - R6 requesting to be sent to the emergency room and complaining of left flank, chest, left arm pain, shortness of breath, chills then sweating. R6 stated R6 feels like (R6) has something stuck in (R6's) lungs. Notes dated 9/28/2020 at 4:11am - R6 taking the inner cannula out of R6'[MEDICAL CONDITION] wanting it cleaned every 2 hours. Notes dated 10/1/2020 at 10:00pm, R6 was transferred out to the emergency room after R6 removed the inner cannula and when V34, Registered Nurse, attempted to reinsert, there was an obstruction so R6 was sent to the hospital. R6 complained of shortness of breath at this time. Notes dated 10/12/2020 at 2:30pm, R6 complained of pain to the lower abdomen. R6's oxygen saturation was 82% on room air, R6 refused to put oxygen on. R6 had removed R6's inner cannula which was cleaned. R6's inner cannula met resistance and was unable to be re-inserted, and R6 requested to be sent to the emergency room . Notes dated 10/12/2020 at 2:01pm, documents V3, Assistant Director of Nursing (ADON), was called into (R6's) room by another nurse who found R6 unresponsive. This note documents R6 had had pulled entire [MEDICAL CONDITION] out and was bleeding from the site. (R6) was gasping for air. V3 attempted to replace [MEDICAL CONDITION] but the airway was blocked. V3 [MEDICAL CONDITION] halfway in. R6 was sent to the emergency room . Notes dated 10/21/2020 at 1:35pm, R6 requested to be sent to the emergency room for [MEDICAL CONDITION]. R6's After Visit Summary (AVS) for multiple emergency room visits document discharge instructions as well as reason for visit and visit [DIAGNOSES REDACTED].>9/18/2020 Reason for visit - [MEDICAL CONDITION] Change with a [DIAGNOSES REDACTED]. Included with this AVS are instructions for [MEDICAL CONDITION] Care, including suctioning and clearing a mucous plug. 9/23/2020 Reason for visit - Shortness of Breath with [DIAGNOSES REDACTED]. (R6) requests that education and equipment should be available at all times in (R6's) room for self-treatment during emergent times. Thank you for your help. 10/1/2020 Reason for visit - [MEDICAL CONDITION] Change with a [DIAGNOSES REDACTED]. Included with this AVS are instructions for mucous plug,[MEDICAL CONDITION] as well as instructions for [MEDICAL CONDITION] care and cleaning. These instructions document You have a [MEDICAL CONDITION] that allows you to breathe. Mucus from your airway can collect inside the tube and block it. The buildup of thick music is called a mucous plug. It is important you take steps to prevent a mucous plug from blocking [MEDICAL CONDITION]. Suction [MEDICAL CONDITION] as told by your provider. Mucus can build up and thicken. If this happens [MEDICAL CONDITION] can become plugged. Cleaning prevents buildup of dried secretions that can block the [MEDICAL CONDITION]. When cleaning your [MEDICAL CONDITION], it's important to be well prepared with the right supplies in case of an emergency including, for example, a manual ventilator bag. R6's hospital records, dated 10/21/2020, document R6 presented to the emergency room with shortness of breath and comes back for suctioning of (R6's) [MEDICAL CONDITION]. (R6) has been here multiple times for that. These records document R6 had a small amount of dry secretions present with the left lower lung field revealing rales (abnormal lung sounds.) R6's Clinical Impression for this visit is documented as [MEDICAL CONDITION] care. R6's Physician Orders, dated 10/26/2020, document staff are to [MEDICAL CONDITION] every shift and as needed. These orders document to suction R6'[MEDICAL CONDITION] 4 hours and as needed. On 10/20/2020 at 10:00am, R6 stated R6 has had to go to the hospital multiple times [MEDICAL CONDITION]. R6 stated R6 will have trouble breathing due to the nurses not being able to [MEDICAL CONDITION] as often as R6 needs it because they are too busy, as well as the staff do not go deep enough to get the mucous. R6 stated the staff check R6's oxygen saturation every once in awhile, but not too often. An open undated bottle of saline for humidity was noted at R6's bedside at this time. R6 stated R6 uses that with suctioning. R6 stated there is no emergency obturator or ambu bag in R6's room, and R6 has had emergencies where those should have been available. R6 stated R6 has pulled out [MEDICAL CONDITION] cannula because R6 could not breathe because the tube was blocked and R6 was just trying to breathe. R6's suction tubing was located in a dingy ziplock bag that was not dated, as well as R6's suction tubing, humidifier bottle attached to the humidifier machine,[MEDICAL CONDITIONS] tubing were not labeled with date. R6 stated R6 is unsure when the facility changes the tubing,[MEDICAL CONDITION], etc. On 10/20/2020 at 10:19am, V8, RN, stated the ambu bag should be in R6's room but V8 looked around and stated there was not one in R6's room. V8 had touched R6's [MEDICAL CONDITION] and adjusted V8's protective eyewear multiple times without performing hand hygiene. V8 removed V8's gloves and proceeded to walk down the hall to the storage room to obtain [MEDICAL CONDITION] and ambu bag without completing hand hygiene after removing V8's gloves. V8 stated V8 was unsure of when some of [MEDICAL CONDITION] and humidifier bottles were placed in use for R6 and that the facility is not dating the items or documenting when the changes are happening. On 10/21/2020 at 9:00am, V8, Registered Nurse (RN), prepared R6'[MEDICAL CONDITION] supplies. V8 [MEDICAL CONDITION] to R6's inner cannula, but did not clean the plate to R6's trach. V8 removed contaminated gloves, did not perform hand hygiene, opened the sterile water [MEDICAL CONDITION], donned sterile gloves, and began suctioning R6. V8 asked R6 if R6 had another plug and R6 shook R6's head. V8 continued to attempt to suction R6 with no success. R6 became anxious, took the suction catheter from V8, and attempted to suction R6'[MEDICAL CONDITION] success. R6 began forcefully coughing and was able to cough up thick mucous about the size of a dime. R6's oxygen saturation was unknown, and not being monitored prior to or during the procedure at this time. V8 was not wearing a gown while suctioning R6. R6 requested for V2, Director of Nursing (DON), to come assist with suctioning. At 9:25am, V2, DON, came in to R6's room. V2 was wearing a mask with straps around V2's neck and protective eyewear. V2 did not wear a gown during the procedure. V8 went and got an oxygen saturation monitor and placed on R6's finger. R6's oxygen saturation was between 89% and 92%. V8 told V2, the mucous is deep in there. At 9:29am, V2, DON's mask had fallen down under V2's nose, only covering V2's mouth. V2 attempted to suction R6 multiple times with no success. During this time, R6 was not encouraged or educated related to the use of R6's [MEDICAL CONDITION]. R6 was requesting additional suctioning. V2 stated to V8 that V2 wasn't sure that R6 should have more suctioning. R6 took R6's hand and used it to act out shooting R6's head. R6 began forcefully coughing again producing a large bloody mucous plug. This was followed by yellow mucous. The tubing to the suction machine had been laid on R6's bed. V2 picked up the tubing off the bed, attached a suction catheter to the open end of the contaminated suction tubing, and suctioned R6. On 10/28/2020 at 7:20am, V22, emergency room Charge RN, stated R6 is constantly coming in the the emergency room several times with several mucous plugs. V22 stated R6 has anxiety and has ended up removing R6's trach. V22 stated the facility R6 resides in is neglectful [MEDICAL CONDITION] and you can tell the facility does not [MEDICAL CONDITION] as often as R6 needs it. V22 stated the facility is neglecting to suction R6 properly as evidenced by multiple mucous plugs and emergency room visits. V22 stated not [MEDICAL CONDITION] as each resident needs can lead to mucus plugs and death. 2.) R1's Admission Record, dated 10/27/2020, documents R1's [DIAGNOSES REDACTED]. R1's Progress Notes, dated 7/9/2020 at 6:45am, documents R1 arrived to the facility from the hospital 7/8/2020 in the evening [MEDICAL CONDITION] infection, bacterial infection in the lungs, and [MEDICAL CONDITION]. R1 was to [MEDICAL CONDITION] every 15-30 minutes, and the nurse was able to suction R1 every 30-45 minutes during the shift. R1 had rhonchi and crackles (abnormal lung sounds) throughout all lung fields both anterior and posterior. R1's Hospital Medical Records, dated 8/22/2020, document R1 has [MEDICAL CONDITION] in place and it is plugged up. These records document R1 presented with shortness of breath and in acute distress with decreased air movement. R1's [MEDICAL CONDITION] is plugged up. Suctioned and irrigated with saline obtained significant amount of thick mucus. R1 had significant improvement after R1'[MEDICAL CONDITION] suctioned. These notes document R1 had oxygen saturations from 51% to 80% at the facility prior to arriving at the emergency room . R1's [DIAGNOSES REDACTED]. R1 was discharged back to the facility on [DATE]. R1's Hospital Records from R1's hospital visit on 8/26/2020, document R1's Principal Final Diagnosis: [REDACTED]. These records document V36, emergency room Physician found R1's [MEDICAL CONDITION] plugged up and that R1 was in acute distress. These records also document notes by V36 that R1's [MEDICAL CONDITION] cannula was suctioned removing significant amount of mucus plugging with improvement following the removal of the mucus plugging with the Clinical Impression of R1's visit of mucus plugging of bronchi. These records document V22, emergency room Charge RN, spoke to V37, Licensed Practical Nurse, and V22 advised V37 to change R1's suctioning to every 30 minutes. R1's Progress Notes, dated 8/26/2020 at 5:20am, documents the unidentified nurse from the emergency room reported the hospital removed three large mucous plugs from R1'[MEDICAL CONDITION] the facility was notified by the emergency room R1 was to be suctioned every 30 minutes. Progress Notes, dated 8/26/2020 at 9:16am, are the last notes [MEDICAL CONDITION] every 30-45 minutes. R1's Treatment Administration Record (TAR), dated September and October 2020, documents R1 was to have R1'[MEDICAL CONDITION] every four hours and as needed, as well [MEDICAL CONDITION] every shift and as needed. There is no documentation in R1's TAR of suctioning R6'[MEDICAL CONDITION] 30 minutes. On 10/28/2020 at 7:20am, V22, emergency room Charge RN, stated R1 had been seen in the the emergency room several times with several mucous plugs. V22 stated the facility R1 resides in is neglectful [MEDICAL CONDITION] and you can tell the facility does not [MEDICAL CONDITION] as often as R1 needs it. V22 stated the facility neglecting to suction R1 properly was evidenced by multiple mucous plugs and emergency room visits. V22 stated if [MEDICAL CONDITION] was completed as with proper technique and as it was supposed to be, R1 would not have been to the hospital with [MEDICAL CONDITION] R1 was. V22 stated not [MEDICAL CONDITION] as each resident needs can lead to mucus plugs and death.

Based on record review and interview, the facility failed to prevent the abuse of three residents (R34, R67, R128) perpetrated by a resident (R75) with known history of physical assault. This failure resulted in R75 physically assaulting three medically compromised residents causing mental anguish, intimidation, and injury. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 10/7/20, the facility remains out of compliance at a severity level two. As of 10/7/20, the facility was in the process of providing education to staff who request resident background checks, updating Care Plans as requested background check results are received, reviewing 24-hour reports by Administrator, Director of Nurses and Assistant Director of Nurses to ensure resident safety, reviewing all resident background checks completed for past two weeks (from 10/6/20), and will providing abuse education to all staff. In addition, abuse education was initiated on 10/6/20 for all staff. Findings include: R75's undated Census Report documents admission date of [DATE]. R75's Illinois State Police Criminal History Record Report, dated 7/8/2020, documents R75 as having been found guilty of aggravated battery/great bodily harm and battery/bodily harm on 11/29/12. On 10/1/2020 at 8:50 AM, V1, Administrator, stated R75 has severe mental health history and also history of physically aggressive behaviors. V1 stated the facility is unable to provide a background check that was completed within 24 hours of R75's admission on 4/15/20, and that the name-based background check, dated 7/8/20, was the only background check available. R75's Physician order [REDACTED]. R75's Minimum Data Set (MDS), dated [DATE], documents R75 as requiring limited assistance with transfers and supervision for walking in corridors. R75's Nurse Progress Notes document R75 having aggressive behaviors on 5/7/20 by punching R67 while holding R67 down; 8/19/20 by throwing a computer, papers, and desk phone at staff; 8/22/20 by attempting to throw a plate cover at R128, and then on the same date grabbing R128's leg attempting to pull R128 out of bed; 9/6/20 by throwing a computer at staff; and again on 9/22/20 by hitting, kicking and pulling R34 out of wheelchair onto floor, where R75 continued to hit and kick R34. R75's Care Plan, dated 9/8/20, documents R75 as having a history of criminal behavior, is an identified offender, and has history of verbal/physical aggression towards staff and other residents. This same Care Plan does not document any new behavior interventions for behaviors noted on 5/7/20, 8/19/20, 8/22/20, 9/6/20 and 9/22/20. Last new intervention documented was dated 3/5/2020 for this same Care Plan. 1. R67's Undated Face Sheet documents [DIAGNOSES REDACTED]. R67's Care Plan intervention, dated 3/18/19, documents to provide R67 with a wheelchair in moments of weakness. R67's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 12/15 (cognitively intact). This same MDS documents R67 as requiring limited assistance of one staff member for transfers. R67's Hospital records from 4/23/20 stay document R67 had a Nephrostomy Tube that had dislodged and not replaced. R67's Hospital record, dated 5/8/20, document R67 is at risk for infection due to [DIAGNOSES REDACTED]. R67's Nurse Progress Note, dated 5/7/20 at 1:52 PM, documents R67 reports that R75 gave R67 dirty looks two times, and on the second time R75 put R75's hands on R67's shoulders, then R75 punched R67 in the face. R67 acquired abrasion in between eyes, reddened areas under both eyes and complained of pain to right forehead. 2. R128's undated Face Sheet documents [DIAGNOSES REDACTED]. R128's Minimum Data Set (MDS), dated [DATE], documents R128 as severely cognitively impaired. This same MDS documents R128 as requiring total dependence of two staff for bed mobility, transfers and personal hygiene. R128's Care Plan, dated 6/25/19, documents an intervention for staff to pull curtain and allow private time to rest, ensure and provide a safe environment. R128's Nurse Progress Notes, dated 8/22/20 at 8:09 PM, documents R75 entered into R128's room and pulled R128's leg attempting to pull R128 from R128's bed. 3. R34's undated Face Sheet documents [DIAGNOSES REDACTED]. R34's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 10/15 (moderately impaired cognition). This same MDS documents R34 as requiring one-person physical assistance for transfers. R34's Care Plan documents a focus area of R34 being a moderate risk of increased susceptibility of abuse due to suspected history of abuse/neglect. This same Care Plan documents R34 is on antibiotic therapy due [MEDICAL CONDITION] infection in blood and [MEDICAL CONDITION]. This same Care Plan documents R34 as having an Arteriovenous (AV) Fistula in upper right arm for Renal [MEDICAL TREATMENT] access. This same Care Plan documents R34 should wear an Ankle-Foot-Orthosis (AFO) brace to right leg and should avoid activities that could result in injury. R34's Physician order [REDACTED]. R34's Physician order [REDACTED]. This same report lists therapeutic range as 2.5-3.5 seconds. R34's Nurse Progress Note documents that R34 was hit in left side of face, pulled from wheelchair and kicked several times by R75. Nurse Progress Note, dated 9/22/20 at 11:32 PM, documents returns from hospital requested to leave facility related to incident and R34 was consoled and agreed to stay. Hospital Records from 8/12/20-9/9/20 hospital stay document R34 had open heart surgery on 8/27/20 that required cardiopulmonary bypass machine for a Mitral Valve Replacement. This same hospital record documents R34's sternum was divided with a sternal saw for the surgery and closed after the surgery with wires, sutures and adhesive strips over the incision site over mid chest. Hospital emergency room records for R34, dated 9/22/20, document [DIAGNOSES REDACTED]. This same Hospital record documents R34 was examined due to an assault and someone attacked and tried to harm you (R34). On 9/30/20 at 10:00 AM, R34 stated had no previous relationship with and did not know why R75 would want to attack R34. R34 stated asked the facility to call police and have R75 arrested. R34 stated, I just had this open-heart surgery. He (R75) was hitting me in my chest right in the incision site. I was really scared. R34 also stated R75 is out of facility now but when R75 returns I am afraid R75 will attack me again. On 10/1/20 at 9:00 AM, V1, Administrator, stated R34 was involved in an altercation with R75 on 9/22/20, where R34 was hit and kicked several times. V1 stated staff intervened to aide in removing R75 from hitting and kicking R34 any further. V1 stated facility was aware that R75 was an identified offender. On 10/6/20 at 2:15 PM, V22, Social Service Director, stated V22 was unaware of aggression and behaviors documented in Nurse Progress Notes. V22 stated V22 does review documentation, but only that listed under behavior notes. V22 stated R75's Care Plan had not had any updated interventions from 3/25/20-9/22/20. V22 stated should have updated R75's Care Plan due to continued aggressive behaviors and history of violent criminal history. On 10/6/2020 at 3:00 PM, V10, Registered Nurse, stated V10 was aware of R75's aggressive behaviors. V10 stated V10 had personally witnessed R75 yelling, throwing furniture such as bed side tables and wheelchairs and hitting objects. V10 stated R75 was unpredictable in R75's behaviors. V10 stated V10 was very intimidated and scared of R75 due to R75's unprovoked aggressive behaviors. The Immediate Jeopardy was identified on 10/2/20 at 12:49 PM. The Immediate Jeopardy began on 5/7/20 when the facility failed to prevent abuse to R67 from a known identified offender who had not had a fingerprint background check or Identified Offender Recommendation Report completed. V1, Administrator, was notified of the Immediate Jeopardy on 10/6/20 at 2:28 PM. The immediate jeopardy was removed on 10/7/2020. The surveyor confirmed through observation, interview, and record review on 10/8/2020, that the facility took the following actions to remove the immediate jeopardy: Care Plans were reviewed and updated for all Identified Offenders, completed by Psychiatric Resident Services Director on 10-7-20. Background checks were requested for all residents, completed by Administrator on 10-7-20. Abuse training for staff had been initiated, completed by Administrator on 10-7-20. R75 was removed/discharged from facility and not expected to return, completed by local law enforcement and Administrator on 9-22-20. Residents are being monitored every two hours for their safety and well being while fingerprint background checks are in process, completed by Activities Director on 10-7-20.

Based on record review and interview, the facility failed to safely transfer a resident (R3) by full mechanical lift from the bed to a wheelchair. This failure resulted in an angulated distal tibial [MEDICAL CONDITION] leg. R3 is one of three residents reviewed for mechanical lift transfers in the sample of 4. This past noncompliance occurred from 06/07/18 to 06/15/18. Findings include: R3's Physician order [REDACTED]. R3's Minimum Data Set ((MDS) dated [DATE] (prior to 6/7/18 fall) documents R3 as being severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 6 out of 15. This same MDS documents R3 requires extensive physical assistance of two person for transfers. R3's Fall Risk assessment dated [DATE] (most recent, prior to fall 6/7/18) documents R3 as High Risk for falls. R3's Mobility assessment dated [DATE] documents R3's requires Sling (full mechanical) Lift for transfers. R3's Care Plan dated 4/10/18 (prior to 6/7/18 fall) documents the following: (Mechanical Lift ) Transfers with two assist. R3's Progress Note dated 6/7/18 at 5:55 pm signed by V12, Registered Nurse (RN) documents the following: Initial observation of resident; At 5:50 pm was called to nursing station by east wing (unidentified) CNA (Certified Nursing Assistant) stating resident (R3) had slipped out of (mechanical lift) sling at 5:25 pm (25 minutes prior to being reported) onto the floor. Assessed immediately reveal (revealed) resident (R3) lying in bed trembling, stating 'my leg hurts'. Physical Assessment (pain, ROM, injury); Resident (R3) was lying in beg (bed) with (R3's) hand on upper right thigh. Skin was intact. ROM (range of motion) of upper extremities was normal movement. Did not manipulate lower extremities due to complaint of pain. Cause; Possible improper use of (mechanical lift). The same Progress Note documents V3, Primary Care Physician was notified and gave a new order to send R3 to the emergency room for further evaluation. On 9/27/18 at 10:57 am V12 acknowledged the above progress note and added the following information: V12 stated R3 continued to have pain in R3's full right leg after returning from the hospital emergency roiagnom on [DATE]. V12 also stated R3's ankle was red upon R3's return from the hospital on [DATE]. V12 stated R3's leg progressed to incorporate [MEDICAL CONDITION] and bruising that extended mid foot up over the ankle for the next three days. V10, Certified Nursing Assistant's (CNA) Fall Investigation Witness Statement dated 6/7/18 documents the following: I (V10) and (V9, CNA) were transferring (R3) from bed to chair and (R3) slide (slid) out of the sling. We (V9 and V10) didn't retrieve (get) a nurse right away. We (V9 and V10) got (R3) up in bed, after 15 minutes we spoke to (V8, RN). V10 and V9 are no longer employed at the facility. V9, CNA's Fall Investigation Witness Statement dated 6/7/18 documents the following: I (V9) came in at 5:00 pm, entered (R3's) home 'room' and started to get (R3's) roommate (unidentified) in chair (roommate) was prep (preparation) already. Once (roommate) was in the chair, I (V9) started on (R3). I (V9) changed (R3) and placed (R3) on top of the (full mechanical lift) sling. I (V9) turned around (to) comb (roommates) hair, I (V9) grabbed (R3's) chair, other CNA (V10) had (R3) in the air. (V10) pulled (R3) away from the bed and (R3) slid out of the bottom of (full mechanical lift) sling onto the floor. R3's undated Investigation Follow Up Report documents the following: the sling (full mechanical lift) was to go between (R3's) legs. (R3) can not tolerate this technique. Current practice is to cross the sling behind (R3's) knees. (V9, CNA) put sling behind (R3) then (V10, CNA) hooked sling to (mechanical lift) not realizing sling was not crossed. When they (V9 and V10) raised (mechanical lift) (R3) slid to the floor. Additional information was noted in R3's fall investigation from (V9's) Employee Memorandum; Progressive Discipline Form dated 6/12/18 documents the following: On 6/7/18 you assisted (R3) transfer in which the straps of the (mechanical lift) sling were not crossed over. During the transfer the patient (R3) slid out. Following the fall you assisted (R3) to bed prior to notifying the nurse. This is not the proper procedure for patient transfers and is not the proper procedure to be followed following a fall. R3's emergency room Provider Note dated 6/7/18 documents R3 was evaluated after a fall from (mechanical lift) for constant right leg pain. The same report documents R3's hips and pelvis were x-rayed and there was no femoral neck fracture noted. R3's lower extremities were not x-rayed at this time. R3's Nurse Progress Note dated 6/7/18 at 11:26 pm documents R3 returned by ambulance on a stretcher, from the emergency room . On 6/8/18, there were no Nurse Progress Notes documenting a post fall assessment on R3 from any shift. In addition, there are no skin assessments to indicate if R3 had discoloration to the right lower leg. R3's Nurse Progress Note dated 6/9/18 at 12:19 pm documents the following: Nurse from (local hospital) emergency room called, reported no recent fractures to hip and pelvis. R3's Weights and Vital Summary documents R3 continued to complain of pain 6/7/18 - 6/14/18 at levels varying between two of ten (mild) to six of ten (moderate). R3's corresponding Medication Administration Record [REDACTED]. R3's Nurse Progress Note dated 6/9/18 at 1:24 pm documents the following: (R3) status [REDACTED]. (R3) complained of right hip and both feet pain, as needed pain medication give (given). On 6/10/18 and 6/11/18 on all shifts, there were no Nurse Progress Notes of R3 being assessed post fall or skin assessments to indicate if R3 had discoloration of R3 right lower leg. On 6/12/18 at 12:09 pm Nurse Progress Note documents (R3's) right foot was swollen and bruising noted by R3's ankle yellow in color. (R3) complained of pain and as needed pain medication given. The same Note documents (unidentified) Physician notified and X-rays were ordered. R3's Physician order [REDACTED]. On 6/15/18, R3 was evaluated by V11, Orthopedic Surgeon. V11's Progress Note documents R3 was transported by the facility after an x-ray on 6/12/18 (5 days after fall) of R3's right femur, tibia, knee, ankle, calcaneus and foot. The 6/12/18 x-ray documents an angulated distal tibia fracture acute in nature. The same progress note documents the facility did not send the x-ray disc for V11 to review. V11 repeated the above x-rays and confirmed R3's acute distal tibia fracture. The same report documents the following plan: (R3) is not an operative candidate, (R3) needs to have the fracture in her right leg protected and immobilized with a fracture brace. (R3) is not a great candidate for surgical intervention for sure because of (R3) medical problems and nonambulatory status. V3, R3's Primary Care Physician's Nursing Home Documentation Form signed by V3, dated 7/18/18 documents the following: (R3) fell last 6/7/18 and sustained an angulated distal tibial fracture of right leg. (R3) has seen Orthopedic Surgeon (V11). No surgery or casting. On boot (boot on). The facility Hydraulic Lift (full mechanical lift) policy dated 8/25/15 documents the following: Policy: All Nursing staff will be trained on the proper use of the hydraulic (full mechanical lift) lifts that are used within the facility, to ensure safe transfer for residents. (Full mechanical lifts 0 will be used as ordered and per nursing judgement. The same policy documents: Positioning sling under resident from lying down position. (bed or floor): 7. Ensure sling is centered under resident. 8. Pull leg straps under resident's thigh, ensure not (no) twisting has occurred. 9. Repeat procedure with other leg. 10. Criss cross the leg straps as shown with one strap passing through the other. 11. Prepare resident for transfer by attaching sling to (full mechanical lift) lift. The same policy documents the following: Lifting and transferring resident: Prior to lifting an individual make sure that the straps of the slings are securely placed on the hooks on the carry bars. Prior to the survey date, the facility took the following actions to correct the noncompliance: 1. QA (Quality Assurance) meeting was held on 06/11/18 with a plan of action put into place. 2. C.N.A.'s involved in the incident were re-educated and recieved disciplinary action on 06/12/18. 3. (Mechanical lifts) transfer competencies were completed on 06/14/18. 4. Nursing staff were re-educated, completed on 06/15/18 on proper transfers and on not to move residents in any circumstances until the nurse has assessed them.

Based on observation, interview, and record review, the facility failed to identify a pressure ulcer and implement preventative measures, for one of three residents (R 4) reviewed for pressure ulcers in a sample of five. This resulted in R 4 developing a stage three pressure ulcer to the left buttock. Right and left buttock ulcers worsened as a result of facility failures. Findings include: On 2/23/2018 at 11:00 AM, V4 (Nurse) completed R4's wound care treatment. The left buttocks area measured 3.3 centimeters (cm) by 3.5 cm with no measurable depth, the center of the wound had an area of yellow slough with bright red surrounding tissue. The right buttock measured 2.0 cm by 2.8 cm with no measurable depth. The area on the right and left buttocks were right next to each other with less than one half inch area between both areas. The areas were cleansed with wound cleanser, calcium alginate applied and covered with a foam bordered dressing. R 4 was lying on a regular mattress, not a pressure relieving mattress. R4's Physician order [REDACTED]. R4's facility face sheet dated 5/28/2017 documents a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R4 is severely cognitively impaired, requiring extensive assistance of one person for transfers, dressing and eating due to impairment of both upper and lower extremities. The MDS also documents a pressure reliving device in use. R4's daily skin checks dated 2/13/2018 document an open area to the right buttock. The skin sheet for 2/14/2018 documents an open area to both the right and left buttock. R4's 2/21/2018 Wound Care Specialist Physician Evaluation documents the assessment of the wound of the right upper buttock and the stage three to the left buttock as both deteriorated due to larger size. The right upper buttock wound measured 2 cm by 1.5 cm by 0.1 cm and the left buttock wound was 3 cm by 2 cm with no measurable depth. R4's 2/14/2018 Wound Care Specialist Physician Evaluation documents the initial assessment of a stage three pressure wound to the left buttocks 1.1 cm by 1.1 cm with no measurable depth which was greater than one day old. On 2/23/2018 V4 (Nurse) stated I remember that the area was not there to the left buttock then it was a stage three. I know when staff identified the open area it was already a stage three. I know (R4) use to have an air mattress due to recurrent pressure areas to the buttocks and hips. On 2/27/2018 V2 (Director of Nursing) and V8 (Minimum Data Set Coordinator) both stated that R4 was to be utilizing an air mattress and chair cushion as a post pressure area intervention. On 2/23/2018 at 11:45AM, V2 verified R4 did not have a pressure reliving mattress on R4's bed. The facility policy Pressure Ulcer Injury Prevention, Identification and Treatment revised 10/11/2017 documents When a pressure area has healed, a prevention regimen is to remain in place.

Based on observation, interview, and record review the facility failed to monitor an unintended gradual weight loss, consistently assess weight loss, and failed to complete physician ordered weekly and daily weights for three of three residents (R1, R2 and R3) reviewed for weights in a sample of five. This resulted in R4 losing 23.2 percent of body weight (26.5 pounds) in six months and becoming malnourished in appearance. Findings include: 1) R4's Weight Summary documents the following weights: 9/7/2017- 114.2 pounds, 10/12/2017-112.1 pounds, 11/3/2017-113.1 pounds, 11/13/2017-107.9 pounds, 11/27/2017- 102.9 pounds, 12/4/2017-104.9 pounds, 12/11/2017, 101.8 pounds, 12/18/2017-99 pounds, 12/26/2017-98.6 pounds, 1/8/2018- 101 pounds, 1/1/18-99.1 pounds, 1/17/2018- 100 pounds, 1/17/2018-100 pounds, 1/23/2018- 99.3 pounds, 1/29/2018-92.5 pounds, 2/6/2018-92.3 pounds, 2/12/2018- 94.6 pounds, 2/19/2018-91.8 pounds, 2/21/2018- 92.4 pounds, and 2/26/2018-87.7 pounds for a total weight loss of 26.5 pounds in a six month period of time. R4's weight sheet documents a 5% weight change from 11/3/2018 to 11/27/2018. There continued to be documented significant weight loss through 2/26/2018, with a total of a 23.2% weight loss in six months (97/2017-2/26/2018). On 2/27/2018 at 12:35PM, V6 (Registered Dietitian) stated (R4) has had a progressive weight loss. (R4's) weight stabilized a little while in (MONTH) then began a decline again on 1/23/2018. I added double protein to (R4's) regular diet on 9/21/2017. I had already added 2.0 supplement 120 cubic centimeters (cc) on 4/30/2017. This supplement will provide 720 calories and 30 grams of protein. (R4) needs a total of 1400 calories to gain weight. I did not ask if (R4) was drinking all of the supplement. The staff will tell me if there is an issue with intake. I was not told that (R4) was not eating well (0-25%) most meals or that (R4) was refusing to drink the 2.0 supplement. The dietary manager should have discussed (R4's) likes and dislikes with the family. The likes and dislikes will be documented on the diet slip. At this point there is no option but to discuss a enteral feeding tube with the family to ensure adequate nutritional intake and wound healing since (R4) has a stage three pressure area on the left buttocks and a stage two pressure area on the right buttocks. I know (R4) also has a multivitamin and Prostat ordered on [DATE] for the wound healing. I'm not sure if (R4) receives Zinc for healing, but I would also suggest that. (R4) is not currently receiving an appetite stimulant, it does not appear that has ever been utilized, that is also a possibility to increase appetite. R4's Medication Administration Record [REDACTED] R4's Physician order [REDACTED]. On 2/27/2018 at 1:10PM, V4 (Nurse) stated (R4) will sometimes drink a sip or two of the 2.0 protein supplement or will refuse to drink any of it. It is only occasionally that (R4) will drink all of the 2.0 supplement. I mark on the MAR indicated [REDACTED]. R4's Progress notes from 12/1/2017 through 2/26/2018 have no documented notes that the physician was notified of the continued weight loss. There were no new interventions documented regarding weight loss after the Prostat and multivitamin were recommended on 1/15/2018. On 2/27/2018 at 2:00PM, V5 (Dietary Manager) stated The dietary department does not monitor (R4's) intake. I believe that the Certified Nurse Aid (CNA) staff do. I did not talk to (R4's) family about what foods (R4) likes or dislikes. R4's Diet Slip has no documented likes or dislikes. On 2/27/2018 at 2:05PM, V2 (Director of Nursing) stated I not sure where the meal intake is documented. On 2/27/2018 at 2:07PM, V3 (Minimum Data Set Coordinator) and V7 (Care Plan Coordinator) both first said they were not sure where the intake data was located in the computer. After a CNA told them the data was in (electronic charting system) they then verified they were not sure how to access data from (electronic charting system) unless they looked at one meals intake at a time. Both verified they did not routinely review the food intakes for residents. V3 also stated that R4 had a significant weight loss and that a plan of care meeting should have been held to discuss the weight loss in (MONTH) and January. V3 also stated that R4's care plan should have reflected a significant weight loss not document a potential for nutritional problems like R4's current care plan documents. R4's care plan initiated 5/31/2017 documents the focus for nutrition as a potential for nutritional problems. R4's MDS, dated [DATE], documents R4 is severely cognitively impaired and requires staff assistance to eat. On 2/23/2018 at 10:30AM, R4 appeared extremely thin. R4's face was gaunt with cheeks sunken in, skin was sagging on arms, and hip bones were protruding when R4 was lying in bed. R4's amount eaten record for (MONTH) (YEAR) documents refusal of a meal on 2/3 (lunch), 2/6 (breakfast), 2/13 (lunch), 2/21 (lunch), 2/22 (lunch) and the rest of the month on average R4 consumed 0-25% of R4s meals. On 2/23/2018 at 12:00PM, R4 ate two bites of fish, two bites of cole slaw, 2 sips of juice, and 2 sips of ensure and ate 100% of peaches. R4 refused all other food or drinks. R4 was fed by V8 (CNA). V8 stated (R4) usually only eats less than 25% of (R4's) meal. On 2/27/2018 at 2:00PM V2 (Director of Nursing) verified there were no documented progress notes of the physician being notified of weight loss in (MONTH) or (MONTH) (YEAR). The facility policy Weights revised 8/25/2015 documents #5) The charge nurse will notify the physician and the Registered Dietitian of the weight variance, and indicate notification of both parties on the form as well as in the nurses notes. #7). If the resident has incurred a 5% weight loss in one month, or a 10 percent weight loss in six months, the care plan coordinator will be notified in order to initiate a Significant Change Minimum Data Set. Weight variances will be discussed with the Dietary Service Manager and will be documented in the resident's medical record. 2) R2's facility face sheet dated 1/31/2018 documents and admission date of [DATE]. R2's Physician's Standing Order dated 1/31/2018 documents an order for [REDACTED]. R2's weight record documents a weight of 154.0 pounds on 2/7/2018. R2's Treatment Administration Record documents weights on 2/8 (157.8 pounds) and 2/15 (162.8 pounds). There are blank spaces for the weight of 1/31 and 2/22. On 2/27/2018 at 9:55AM, V2 verified that there was no admission weight for R2 nor was a weight documented for 2/22/2018. V2 stated (R2) should have had a weight on admission and for four weeks after admission per the facility physician standing order policy. (R2) was admitted on [DATE]. 3) R1's Clinical physician's orders [REDACTED]. R1's weights and Vitals Summary indicate the following weights for R1- 11/24/17- 179 pounds, 12/1/17- 172 pounds, 12/21/17- 178.4 pounds, 1/4/18- 176.8 pounds, 1/28/18- 156.4 pounds, 2/7/18 - 151.1 pounds, and 2/15/18 147.2 pounds. There was no documented evidence of daily weights being completed after 2/7/18. On 2/27/18, V2 confirmed daily weights were not completed on R1.

Based on record review and interview, the facility failed to honor Advance Directives regarding Cardiopulmonary Resuscitation (CPR) as documented on the Physician order [REDACTED]. This past non compliance occurred from [DATE] to [DATE]. This failure resulted in an Immediate Jeopardy. The facility conducted a whole-house audit [DATE] of each residents' advanced directives to ensure there were no other residents with inaccurately recorded code status. The immediacy was removed on [DATE] when the facility conducted a staff inservice regarding code status policy and procedure and new admissions. Findings include: The facility's policy Advanced Directive Policy and End of Life Decision Making dated [DATE] documents, Purpose: To establish guidelines to ensure that resident's rights are provided opportunity and education on determining advance directives and the right to accept or decline treatment and other related interventions.The resident's choices will be documented in the medical record and orders related to treatment, care, and services.The facility will identify, clarify, and periodically review as part of the care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. The facility will also on an ongoing basis review the resident's condition and existing choices and modify approaches as appropriate. This would include a review for a resident condition change, significant decline or improvement in the resident's status. The facility's policy Do Not Resuscitate (DNR) Order dated [DATE] documents . Emergency Medical Services will ONLY recognize the standard form. A photocopy in the chart will not suffice . R1's Electronic Profile Sheet documents R1 was admitted to the facility [DATE], subsequently discharged to the hospital [DATE], and readmitted to the facility [DATE]. R1's Physician order [REDACTED]. medically administered nutrition including feeding tubes. R1's Social Service History and Assessment date [DATE] documents an option for DNR (do not resuscitate) which was not selected by R1. R1's Care Plan dated as initiated [DATE] documents a focus area pursuant to resident rights resident has elected full code status. The goal outlined in R1's Care Plan documents, the resident's wishes for full code status as specified in (R1's) advanced directive document will be honored and clearly delineated in the medical record in compliance with state law. The interventions for R1's Care Plan were documented as .document the code status on the POS (physician order [REDACTED]. R1's Electronic Physician order [REDACTED]. The electronic Physician order [REDACTED]. R1's Hospital Discharge Orders for R1 dated [DATE] documents yes and no selection boxes for the option DNR and this discharge order documents R1 as DNR, NO. R1's Electronic Progress Notes dated [DATE] at 9:30 am, entered by E5, Nurse Practitioner, document R1 was sitting up in the wheelchair, was continuing to work with therapy services, had no health complaints, was eating meals, had recently completed a course of antibiotic treatment due to a urinary tract infection, (R1's) recent blood laboratory values had no significant findings, no distress, and no pain. There were no subsequent progress notes in R1's medical record until [DATE] at 9:39 am. R1's Progress Note dated [DATE] at 9:39 am, entered by E6, Licensed Practical Nurse (LPN), documents, upon entering (R1's) room, (R1) was cold, clammy, pale color to skin and labored breathing. VS (vital signs) 100.4 (temperature), 82 (pulse), 26 (respirations), ,[DATE] (blood pressure). 82 percent oxygen saturation on room air. PERRLA (pupils equal, round, reactive to light and accomodation), pulse was weak and hard to palpitate in wrist and pedal pulse. Apical pulse was attempted but wasn't able to be heard. Equal weak grips. 2 L (liters) of O2 (oxygen) was applied and oxygen (sat) (saturation) is now stable at 90 percent. Resident has a slow response to verbal communication. (R1's) lower extremities are cold to touch and mottled up to hip. (E5) NP (Nurse Practitioner) completed an assessment on resident. She ordered the family be notified, continue on oxygen and keep resident comfortable. Resident's POA (Power of Attorney) (Z2) was notified of the change in condition and was advised to call the family. Resident is a DNR status. R1's progress note dated [DATE] at 9:56 am, entered by E6, LPN, documents Spoke with POA via phone in regards to resident's change in condition. The resident had a major decline in health. He (POA) was advised to call the family to visit (R1). POA stated he was the only family resident has but will come sometime today. R1's progress note dated [DATE] at 12:26 pm, entered by E6, LPN, documents resident has passed away at 10:30 am, discharged to (funeral home). On [DATE] at 9:22 am, E1, Administrator, stated, (E10, LPN) was the nurse who entered the orders from the hospital upon (R1's) readmission from the hospital. The discharge orders from the hospital documented DNR = NO. (E10, LPN) was adamant about she thought the hospital orders documented DNR. (R1) was supposed to be resuscitated, (R1) was a full code. The orders were put into the computer as DNR. (R1) was a full code from a prior admission here at our facility. When (R1) died , the nurse on duty (E6, LPN) looked at the computer which said DNR, and then looked at our book which didn't match the computer. By the time we verified (R1's) code status, it was too late, we didn't call 911, we called the coroner to investigate. Our nurse practitioner (E5) was involved with the death (of R1), she was the one who found the computer and book didn't match. We did check with the hospital to make sure (R1) didn't have any new advanced directive while (R1) was there, but there wasn't. It was our mistake. (R1) is his own person, his brother (Z2) is not the legal power of attorney. On [DATE] at 12:06 pm, E3, Social Services director, stated, With all new admissions either the resident or the POA will decide the code status, I write it on the POLST, I usually sign as a witness, then take the POLST to (E5, NP) and she signs it. Right across the desk (from E5) is (E11, Quality Assurance Nurse) who puts the code status in the Physician order [REDACTED]. For re-admissions, the nurse puts the orders into the computer. On [DATE] at 1:25 pm, E4, Acting Director of Nursing (Assistant Director of Nursing), stated, When a resident stops breathing or having a heartbeat, I expect the nurses to look in the computer to verify a resident's code status, the second place to look is the code status books for the POLST which are on each medication cart for every resident in the building, and the third option would be to look in the social services office. I worked as an emergency room nurse, so I know seconds mean lives, so I would start CPR on everybody unless I have the POLST right there in front of me that says not to. If there is any doubt as to a resident's code status, I would start CPR. On [DATE] at 1:44 pm, E5, Nurse Practitioner, stated, The nurse called me to come assess (R1) and I looked at (R1's) code status in the computer. Unfortunately, the status was not correct. Typically, it is the nurse who puts the orders into the computer when a resident is readmitted from the hospital. On [DATE] at 2:00 pm, E8, Registered Nurse, stated, We have code status books on our medication carts, also in the computer. My preference is to look at the hard copy in the book because that is where the DNR form (POLST) is signed by the resident. We used to have marks on the resident's charts, but we don't use the charts anymore, just the computer. On [DATE] at 2:03 pm, E7, Registered Nurse, stated, I look on the monitor (computer) for code status, also there is a book in the bottom drawer of the medication cart, and the POLST has a copy scanned into the computer. On [DATE] at 2:13 pm, E9, LPN, stated, Each resident's code status is in a book in the bottom drawer of our medication carts and in the computer system. On [DATE] at 2:35 pm, E2, Director of Nursing, stated, We found in the computer (R1) was supposed to be DNR, but we found in the books and clinical documents (R1) was a full code. I expect the nurses to look on the computer, or the book on the med cart with the copy of the POLST. On [DATE] at 3:17 pm, Z1, Primary Care Physician for R1, stated, If a resident has chosen to initiate CPR and is to have full medical treatment to sustain life, then yes I would expect the staff to initiate CPR if the resident has no pulse and no respirations, they needed to make an attempt. If (R1) was in declining health, they could have sent (R1) to the hospital for acute treatment. On [DATE] at 1:54 pm, E6, LPN, stated, Around breakfast time on ([DATE]) (R1) wasn't feeling too good, and wasn't looking too good. (R1) was cold and clammy, I had difficulty checking for a pulse, and (R1) was mottled. I asked the NP (E5) to come and check on (R1) and do an assessment, and I put oxygen on (R1). The NP (E5) checked the code status in the computer and (R1) was listed as DNR. The NP said we would not send (R1) to the hospital since (R1) was DNR, just keep (R1) comfortable. We decided to move (R1) to another room for privacy in case his family wanted to come visit. As soon as (R1) was taken to the other room, they came and told me (R1) wasn't breathing. I went to the room and there was no pulse and no respirations. It was less than an hour between our assessments and the time (R1) passed away. When the coroner came to the facility, he asked for a copy of (R1's) DNR sheet, and that's when I noticed the sheet said he was supposed a full code. By that time, it was too late to begin any CPR. The Certificate of Death Worksheet certified dated [DATE] documents (R1's) date of death as [DATE] and the cause of (R1's) death as Acute [MEDICAL CONDITION] Infarction and Acute [MEDICAL CONDITION]. This cause of death was determined by Z1, R1's Primary Care Physician. On [DATE] an Immediate Jeopardy was identified. E1 was notified of the Immediate Jeopardy Past Noncompliance on [DATE] at 12:07 pm. The immediate jeopardy past noncompiance began on [DATE] when the facility transcribed the wrong code status in R1's medical record. The surveyor confirmed onsite through record review and interview that the facility took the following actions to remove the Immediate Jeopardy: 1. Self-identified the issue on [DATE]. 2. R1 is deceased [DATE] and no longer resides in the facility. 3. Conducted a whole-house audit [DATE] of each residents' advanced directives to ensure there were no other residents with inaccurately recorded code status. 4. Conducted a staff inservice [DATE] regarding code status verification for admissions and readmissions. 5. Conducted a staff inservice [DATE] regarding code status policy and procedure and new admissions. 6. Confirmed with responsible parties the code status of each resident whose POLST form was 6 months old or older on [DATE]. 7. Conducted an inservice [DATE] with the Director of Nursing, Nurse Practitioner, and Quality Assurance Nurse regarding their new responsibilities for reviewing and auditing advanced directives. 8. Formulated an improvement plan [DATE] to perform ongoing audits on the 15th of each month to review each residents' code status. 9. Initiated an employee disciplinary memorandum [DATE] for E10, LPN.

Based on observation, interview and record review the facility failed to identify and accurately assess pressure ulcers, failed to obtain treatment orders and follow facility policies regarding pressure ulcer care, and failed to reassess and modify the treatment plan as needed for one of three residents(R3) reviewed for pressure ulcers in the sample of seventeen. R3 developed unstageable pressure ulcers of the left medial calf, left heel and two toes and a Stage II pressure ulcer of the left medial foot. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 7/30/12, the facility remains out of compliance at a severity level of two as the facility is still educating staff and monitoring staff performance regarding pressure ulcer prevention, identification, documentation and treatment. Findings include: On 7/25/12 at 9:15 a.m. E2, Director of Nurses (DON), provided a listing of residents with current pressure ulcers. R3 was included on the listing as having an unstageable pressure ulcer on the left "shin" and a stage II pressure ulcer on each buttock. R3's physician's orders [REDACTED]. R3's Minimum Data Set(MDS) assessment dated [DATE] documents R3 requires extensive assistance of two plus staff for bed mobility and total assist of two plus staff for transfers, has cognitive impairment, is always incontinent of bowel and bladder and is dependent on staff for personal hygiene. This assessment documents R3 had two stage II pressure ulcers and one unstageable pressure ulcer with necrotic eschar at the time of the assessment. R3's Wound/Skin Healing Records, as reviewed on 7/25/12, document the following: An unstageable area on the right fourth toe described as 0.4 centimeters (cm) x 0.3cm with "purple" eschar. This site is noted to first be identified on 6/7/12 and is documented as healed on 6/20/12. A stage II pressure ulcer of the left buttock measured as 0.9cm x 0.5cm x depth of less than 0.1cm with a date of onset of 7/4/12. A stage II pressure ulcer of the right buttock measured as 3.5cm x 1.2cm and less than 0.1cm in depth, with an onset of 7/4/12. The most recent assessment date for the two ulcers of the buttock are dated 7/11/12. An unstageable pressure ulcer of the left "shin", date of onset 5/31/12, with the most recent assessment (dated 7/11/12) documenting the site as 7.2 cm x 4.6cm x less than 0.1cm depth, serosanquinous exudate, slight odor and brown eschar. The Wound/Skin Healing Record shows the treatment for [REDACTED]. R3's POS dated 7/1 - 7/31/12 lists the current treatment to the left shin as Santyl with a Normal Saline gauze dressing. R3's pressure ulcer assessments are signed as completed by E4, Licensed Practical Nurse (LPN). On 7/26/12 at 8:35 a.m. E4 (LPN) stated she had been filling in as the wound nurse for only a couple of months, since the former wound nurse resigned. E4 stated R3 had gone to the hospital on [DATE] and she thought R3's Physician would have seen R3's pressure ulcers then, but was not sure. E4 stated R3 had not been to the wound clinic, to her knowledge. E4 confirmed that R3 had a dried area on her toe that had healed. Nurses Notes dated 7/19/12 at 5:00a.m. document a new "open area" to the left foot "anterior side." The entry states the Physician was notified via fax for treatment orders. The entry was signed by E5, LPN. There is no documented assessment of this site on the Wound/Skin Healing Record or in the Nurse's Notes. R3's Treatment Record dated 7/4 - 7/31/12 does not document a treatment to the "anterior foot." On 7/25/12 at 12:20 p.m. E5 indicated that as of 7/25/12 she had been given the responsibility of wound nurse for the facility. E5 confirmed she had not received a treatment order for R3's "anterior" foot ulcer until 7/25/12 and that 7/25/12 would be the first day for a treatment to the ulcer. On 7/25/12 at 12:30 p.m. E5 stated she did not measure the "anterior" foot on 7/19/12 and no measurements of the site had been documented. On 7/25/12 at 2:30 p.m. E2, DON confirmed that the last pressure ulcer assessments for R3 had been completed on 7/11/12. E2 stated she was unable to find documentation of an assessment of the left "shin" pressure ulcer when first identified on 5/31/12. The first available measurements on the Wound/Skin Healing Record for the "shin"are dated 6/6/12. E2 stated that the correct anatomical location for the left "shin" site was left medial calf and the site referred to as the "anterior" foot was the medial aspect of the left foot. On 7/25/12 from 9:30 a.m. until 12:30 p.m.(based on observation of 15 minute or less intervals) R3 was seated in a wheelchair without benefit of repositioning. During these observations R3 was wearing only white socks and her feet were resting directly on the floor. The wheelchair was not equipped with footrests and R3 did not have any pressure relieving device on her feet or between her knees. At 12:30 p.m. E14, Certified Nurse Assistant (CNA) and E6, Restorative Aide transferred R3 from her wheelchair to bed. E5 and E3, Assistant Director of Nurses(ADON), were present. R3 was wet with urine through her sweat pants. This was confirmed by E14. R3 had a large amount loose bowel movement coming out both leg openings of her incontinent brief. R3 had indentations on the backs of her thighs which corresponded with the edge of the pressure relieving cushion in the wheelchair. E3 confirmed the areas, stating they were due to pressure from sitting. E6 then told E3 that E6 had come on duty at 7:00 a.m. and R3 was already up in her wheelchair. On 7/25/12 at 1:25 p.m. E6 again stated that she came on duty at 7:00 a.m. and R3 had been up in her wheelchair at that time. E6 continued that R3 had not been out of the wheelchair until 12:30 p.m. E6 stated, "I just shift her in the chair from side to side. I checked her after breakfast and she was dry." E6 confirmed R3 did not have anything positioned between her knees/legs to prevent pressure. On 7/25/12 at 1:30 p.m. E7 CNA stated she and E6 were the two CNAs assigned to R3 on 7/25/12. E7 stated R3 is gotten up on the night shift and that R3 was already up in her wheelchair when E7 came on duty at 6:00 a.m. E7 stated R3 had not been removed from the wheelchair since at least 6:00 a.m. on 7/25/12. Once in bed on 7/25/12 at 12:30 p.m. the following pressure ulcers were measured by E5. Stage II pressure ulcer of the right buttock measured 0.4cm x 0.5cm. "Pinpoint" opening to left buttock. E5 removed a [MEDICATION NAME] dressing from R3's left media foot, which E5 referred to as the "anterior foot" ulcer she identified on 7/19/12. The dressing was undated and lack initials to indicate which staff had applied the dressing. Once removed the ulcer site was described by E5 as "very macerated from the moisture." The wound bed measured 1.5 cm x 1.5 cm with surrounding macerated area from 1.0 to 1.5cm in width. A dressing located on R3's medical calf was visibly soiled with a large amount of serosanquinous drainage. The dressing was not dated or initialed. E5 referred to this ulcer as being on the left "shin." E5 stated the ulcer was a stage III measuring 6.3cm x 4.4cm . The wound bed had yellow slough. . E5 described a "hard....necrotic....unstageable " black pressure ulcer on the left lateral heel which measured 3.0cm x 3.5cm. "Unstageable" dark fluid filled blisters were noted on the top of the third toe on both the right and left foot, measuring 1.3cm x 1.1cm and 1.2cm x 1.3cm respectively. E5 stated that the pressure ulcers on the toes and heel had not been previously identified by staff. On 7/25/12 at 12:30 p.m. as R3 was positioned in bed on her left side for E5 to do the assessments and treatments, R3 assumed a fetal position, with her right knee resting directly on the dressing covering the stage III pressure ulcer of left medial leg. E5 had to hold R3's right knee up off the left calf in order to change the dressing, measure and do the treatment to the left calf ulcer. Once the treatment was complete E5 allowed the right knee to rest directly on the fresh dressing over the stage III ulcer and E5 and E3(ADON) left the room. R3 remained positioned on her left side with her right knee resting directly on the Stage III pressure ulcer dressing of the left medial calf at 1:30p.m. and 2:00p.m. A document dated 7/25/12 sent to R3's Physician and signed by E5 states R3 had several areas of concern during skin check, identifying the new sites of the toes and heel and requesting an order for [REDACTED]. The document includes a request to discontinue the [MEDICATION NAME] dressing to the buttock as the areas are "pinpoint" at this time. Telephone orders dated 7/25/12 include orders for skin prep to the toes and left heel, discontinuation of the [MEDICATION NAME] dressings to the buttocks and "heel protectors while in bed." On 7/26/12 at 9:40 a.m. E5 was questioned about her assessment of R3's right hip stage II pressure ulcer on 7/25/12 which was later referred to as "pinpoint" to the Physician. E5 explained that she had thought it was open but it wasn't. E5 continued that she has not had much experience assessing dark skinned residents and was still learning. On 7/26/12 from 8:30 a.m. until 9:00a.m. (based on observation of 15 minute intervals or less) R3 was seated in her wheelchair with only white socks on and her left foot resting on the hard floor surface. R3 did not have any intervention in place to prevent pressure to the unstageable left heel pressure ulcer. On 7/26/12 at 9:00 a.m. E9 and E10, CNAs stated they were the two CNAs assigned to R3, and that R3 was already up in her wheelchair when they arrived at 6:00 a.m. E9 and E10 stated they had not gotten R3 out of the wheelchair to reposition her since they arrived. E2, Director of Nurses, then arrived in the room and E9 and E10 told E2 that R3 had been up in the wheelchair since at least 6:00 a.m. On 7/26/12 at 10:05 a.m. E9 stated R3 did not have heel protectors on when up in the wheelchair as staff only put them on when they lay a resident down in bed. E9 explained that R3 was to be repositioned every hour but it didn't happen because R3 needed a shower after breakfast. R3's Care Plan as reviewed on 7/25/12 listed the unstageable pressure ulcer of the left "shin" but did not address any pressure relieving interventions specific to the site. The Care Plan did not address the pressure ulcer of the left "anterior" foot identified on 7/19/12. On 7/25/12 at 2:15p.m. E8, Care Plan Coordinator confirmed that the left "anterior" foot was not addressed on R3's Care Plan. E8 stated that she receives knowledge of pressure ulcers via the Skin Condition Report. E8 showed a Skin Condition Report dated 7/11/12, stating it was the most recent report she had received. R3's Care Plan as reviewed on 7//26/12 included the newly identified pressure areas of the left heel, toes, and medial left foot. The Care Plan listed a new approach dated 7/25/12 for "Heel protectors while in bed." On 7/26/12 E8 stated R3's Care Plan at that time did not address pressure relieving interventions for the left medical calf and only directed the use of heel protectors while in bed. The Care Plan was void of interventions to prevent pressure to R3's heel ulcer while in the wheelchair. E8 explained that the CNAs have care instructions on the "pocket worksheet" which they are to keep on them. On 7/26/12 at 10:15 a.m. E8 asked E9 and E9 if they had their pocket worksheet for R3. E8 and E9 both stated they had not received a pocket worksheet. The Pressure Ulcer Prevention, Identification & Treatment policy (last revised on 5/20/11)directs the following: It is the responsibility of the D.O.N./Designee to monitor for healing progress, and ensure appropriate treatments are in use. It is recommended that D.O.N./Designee make frequent pressure ulcer rounds with the Charge Nurses....It is the responsibility of the CNA to report any skin conditions to the Charge Nurse immediately upon identification. When a pressure ulcer is identified, whether in house or upon a resident's admission, the area will be assessed and initial treatment started per physician orders... Documentation of the pressure ulcer must occur upon identification and at least once a week until healed. " On 7/25/12 at 4:30 p.m. E2, DON, stated she had not seen R3's Stage III pressure ulcer of the left medial calf. E2 stated her expectation was if the wound/pressure ulcer has not responding positive after 14 days of treatment, the treatment should be changed. E2 stated she was informed that R3's treatment to the stage III pressure ulcer of the left medical calf had not been changed since 6/13/12. The Immediate Jeopardy was identified on 7/26/12. The Immediate Jeopardy was determined to have begun on 7/25/12 when staff failed to provide pressure relieving interventions for R3, failed to obtain treatment orders for a new stage II pressure ulcer identified on 7/19/12. and failed to previously identify three unstageable pressure ulcers. E1, Administrator, was informed of the Immediate Jeopardy on 7/26/12 at 10:35 a.m. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 7/26/12 E15, Corporate Nurse, Wound Care Certified and E2, DON conducted a full body assessment and skin risk assessment of R3. R3 was assessed for positioning needs and nutritional interventions by E15 and E2. A low air loss mattress was implement. 2. On 7/26/12 E2 and E5, Wound Nurse/LPN were inserviced on skin/wound assessment, documentation, treatment and prevention by E15. 3. On 7/26/12 CNAs and Nurses on duty were inservice on R3's positioning needs as well as the overall program for pressure ulcer prevention, reporting and pressure relieving interventions by E15 and E2. This inservice was provided for all other CNAs and Nurses prior to working their shifts. 4. A 100% skin audit of all residents was initiated on 7/25/12 and completed on 7/27/12. 5. On 7/30/12 the Registered Dietitian assessed R3's nutritional needs and R3's Physician ordered the additional nutritional interventions as recommended. 6. On 7/30/12 R3's Care Plan was revised to accurately identify R3's pressure ulcers and provide interventions to address R3's needs related to pressure ulcers.

Based on record review and interview, the facility staff failed to consistently assess, supervise and put preventative measures in place to prevent falls for one of four residents (R4) reviewed for falls in the sample of seven. R4 fell , sustained a Subdural Hemorrhage and died . Findings include: The admission record form documents R4 was admitted on [DATE] from the hospital with [DIAGNOSES REDACTED]. Z2, family member said on [DATE] at 11:00am that R4 had fallen while in the hospital. Hospital staff placed an alarm on R4's bed and wheel chair. R4's Physician order [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R4's cognitive Status as good with some long and short term memory problems. This MDS also documents that R4 requires assist of one for transfers, ambulation, and activities of daily living. R4 also has good Range of Motion but has problems with balance and is not steady when transferring and ambulating. The fall assessment form dated [DATE] shows R4 to be assessed at high risk for falls, and on [DATE] and [DATE] assessed at high moderate risk. The facility's Policy for resident who have a history of falls or assessed at high risk says, "Any resident who has a history of falls, needs a safety device, or is on a restraint reduction program will be care planned as a high risk for falls, and to review past history prior to admission to examine incidents of previous falls. The Accident/Incident Report dated [DATE] documents R4 had fallen from her bed. The document says she slid from her bed with no apparent injury. There was no Root Cause Analysis for this incident, only R4 fell from the bed. A notation states that R4 said she had an Assist Rail at another facility that helped her. E7, Maintenance Person on [DATE] at 3:30pm could not remember when or if he attached the Assist Rail to R4's bed. E5 said on [DATE] at 3:00pm, the Assist Rail was not on R4's bed the night of [DATE] when R4 fell out of her bed three times. The Incident/Accident Reports dated [DATE] and [DATE] again found R4 on the floor by her bed in her room by facility staff. R4 did not sustain any injuries on [DATE] only a red mark on her right arm. A bed alarm was attached to her bed at this time. On [DATE] at 1:00am R4 rolled out of her bed again and hit her forehead. The report does not say if the bed alarm was sounding or not but a note documents Bed alarm attached to resident. E1, on [DATE] at 3: 15pm said the facility did not document the Root Cause Analysis for these falls. The three Accident/Incident reports filed on [DATE]th were all R4 rolling off the bed. The first fall was ar 2:20am. The report documents R4 rolled off her bed and was found laying by her bed by staff. E4, Licensed Practical Nurse on [DATE] at 1:50pm stated she did an assessment and there were no apparent injuries. R4 was put back into bed. There was no alarm on R4's bed at this time because it is noted that R4 refused the use of the alarm. According to E4 no other interventions were put in place at this time. At 5:00am on ,[DATE] the Accident/Incident Report documents R4 yelling out for help. R4 was found on the floor by her bed by E8, Certified Nurse Aide (CNA) who immediately got E4, LPN. R4 sustained a laceration to her right hand 3rd finger and hit her head causing a laceration to her forehead. R4 was sent to the Emergency Department with these injuries for evaluation. The report says R4 said she hit her head on the waste basket. When R4 returned from the hospital at 7:20am, she was put on 15 minute checks by staff. E4 said on [DATE] at 1:50pm that when E6, LPN Agency Nurse came on duty on [DATE], E4 said told her that some kind of preventative measures needed to be put in place so that R4 would not fall from her bed again. No measures were put into place. At 9:15am on [DATE] R4 was found by E5, CNA, laying on the floor by her bed and was on her right side. Interview with E5, on [DATE] at 1:45pm found that R4 was unresponsive, and was bleeding severely from her head. E5, CNA immediately called for the nurse E6, LPN Agency Nurse who did an assessment then called for an ambulance and had R4 transferred immediately to the Emergency Department. E5 said that there was blood on the bedside table, on the oxygen holder on the floor, and the nebulizer cord was covered with blood. Review of all the falls found that the only interventions put in place were an alarm on the bed that was only temporary, and 15 minute checks from the 2nd fall on [DATE] at 5:00am. No other interventions had been put in place. Z2, family said on [DATE] that the facility never called them for any recommendations that may help prevent further falls. The Care Plan dated [DATE] documents that R4's environment should be free of any accident hazards, such as poorly arranged furniture. The Diagnostic Imaging dated [DATE], done at the hospital documents, "Conclusion--Large subdural hemorrhage on the left side, extending from the left frontal to the occipital region with maximum width about 1.8 centimeters (cm) to 2 cm. Z3, Physician on [DATE] at 10:00am found that the subdural hemorrhage found with the third fall on [DATE] was the cause of death for R4.

Based on interview and record review the facility failed to notify the Physician of a chronic fever suffered by R29, one of five residents sampled for infection control/urinary tract infection out of a total sample of fourteen residents. The failure to notify the Physician allowed a urinary tract infection to ultimately become blood bourne. The treatment of [REDACTED]. Findings include: The May 2011 physician's orders [REDACTED]. A Physician's Telephone Order from the facility dated 5/16/11 reads, "...Foley cath while on bedrest..." A Hospital Progress note dated 5/24/11 reads, "...The patient is a [AGE] year-old white female who a few weeks ago had a fracture of her left (Femur)...Is a resident of the nursing home and presents with fevers...She does have a catheter in place because it was difficult for her to get to the bathroom because of the fracture. She complains of fevers and chills...Impression: A [AGE] year-old white female with: 1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Urinary tract infection...3. [MEDICAL CONDITION] disorder...5. Fracture of left femur...PLAN: 1. The patient will be admitted ..." A hospital laboratory report dated 5/24/2011documents R29 had a white blood cell count of 23.5 thousand when taken to the emergency room . The report indicates the normal range is 5.0 - 10.5 thousand. Also a urine sample collected on 5/24/2011 when R29 was taken to the hospital documents a positive bacterial culture with greater than 100,000 colony forming units of Escherichia coli. In addition a blood culture drawn on 5/24/2011 documents R29's blood is contaminated with Escherichia coli. Nurses notes for R29 show the following: "...5/17/2011 10:10 PM (temperature in degrees Fahrenheit) 100.8..., ...5/18/2011 10:30 PM (temperature) 101.9..., ...5/19/2011 2:00 PM (temperature) 99.8..., 5/21/11 6:00 AM (temperature) 99.4..., 5/22/2011 6:00 AM (temperature) 100.1..., 5/23/2011 10:00 PM (temperature) 101.6..., 5/24/2011 6:00 PM (temperature) 100.9..., 5/24/2011 7:30 PM (temperature) 103.1..." The notes show Tylenol is administered for the fevers. A facility policy titled "Physician Notification of Resident Change of Condition" states, "...The resident's attending physician will be notified of changes that occur in the residents condition by Licensed Personnel as warrented. Physician notification is to include, but is not limited to the following: a. Onset of a temperature of 100 (degrees) F. or higher, with or without symptoms..." Z1, Physician stated on 6/1/2011 at 2:00 PM by telephone, that he was not aware R29 had been running a temperature from 5/17/2011 through 5/23/2011. Z1 stated he was not notified by the facility staff of R29's chronic febrile state. Z1 stated that he had seen R29 on the day of 5/24/2011 at approximately 10:00 in the morning. Z1 stated the facility did not inform him that R29 was running a chronic temperature while he was there. Z1 stated he was not aware that R29 was febrile until the facility called him on the evening of 5/24/2011when her temperature spiked to 103.1 degrees. Z1 stated he then had R29 sent to the hospital. Z1 stated he had written a progress note dated 5/24/2011 that shows R29 had a temperature of 101.9 (degrees)at 10:32 AM and that his plan was to send R29 to the hospital. Z1 said this note was dictated two days later and did not represent the facts as he knew them on 5/24/2011 at 10:32 AM. Z1 stated if he would have been contacted sooner he would have gotten a Urinalysis, he would have had the catheter discontinued, and he would have ordered an antibiotic to treat the infection. Z1 stated the hospital admission for R29 might have been avoided.

A. Based on observation, interview and record review the facility failed to comprehensively assess, develop interventions and implement the interventions for 1of 4 residents reviewed for falls (R6) in a sample of 14. This failure resulted in (R6) sustaining a fracture of the distal femur in the right leg which required surgical intervention. Findings include: The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] states that R6 has short and long term memory problems and is cognitively moderately impaired in daily decision making skills. The MDS also states that R6's vision is moderately impaired to include problem with side vision and decreased peripheral vision. R6 requires wheelchair for mobility, is lifted mechanically and has limitation with range of motion for both sides of the body for arms, hands legs and feet. Facility form titled "Falls Risk Assessment" dated 2/15/10, 4/28/10 and 7/1/10 documents that R6 is a high risk for falls. Nurses Notes dated 7/19/10 states that R6 was sitting in wheelchair (w/c) and reaching for a box of goodies and fell out of w/c onto floor. Large bump on right leg above knee. Called doctor and ordered portable x-ray....X-ray finding displaced fracture, sent to emergency room . Facility's form titled "Accident /Incident Report" dated 7/19/10 under the section titled "Summary of Investigation: Root Cause" states "(R6) was reaching for some candy when she leaned forward too far causing her to fall onto the floor." The section titled "Past Interventions Attempted (Include Dates)" states "Staff education". No other past interventions are listed. Care Plan for R6 dated 7/19/10 states R6 had falls on 2/5/10, 4/18/10 and 6/10/10, interventions to include ...."keep res in highly visible area as much as possible to decrease potential for falls and to ensure safety, call light within reach at all times, .....inservice staff on positioning resident, pressure relieving cushion in chair...." Hospital form titled "Health Information Management- Discharge Summary" dated 8/4/10 under the section titled "discharged Diagnoses: [REDACTED]. Fracture, non-closed of the femur." The section titled "Hospital Course:" states " This is a patient who is a bilateral amputee. She fell in the nursing home, fractured her leg.......She has below-the-knee amputation on both legs. She fell from the wheelchair in the nursing home. X-ray showed fracture of the femur.........they did the surgery ......" On 9/3/10 at 10:40AM R6 was in her room sitting in the w/c leaning forward to reach for an item on the bedside table. R6 did not have any safety devices in place to protect her from falling forward out of the wheelchair. On 9/3/10 at 10:45AM R6 stated "Yes, I remember what happened. I leaned over to pull out my drawer from my dresser there (pointed to bedside table) to get some things and I fell out of my wheelchair. I was on the floor and the CNA (certified nurse assistant) saw me. No, I have never had any safety belts on my chair. This is what I normally have in my chair..." On 9/3/10 at 1:45PM Z2 (Rehab Coordinator) confirmed that R6 did not have any safety devices to help her from leaning forwarding and they did not assess her for any type of device. On 9/3/10 at 4:05PM E1, Administrator confirmed that R6 did not have any special safety devices to help her from leaning forward in her wheelchair. B. Based on observation, record review and interview the facility failed to follow physician orders [REDACTED]. Findings include: Admitting Physician order [REDACTED]. These same orders documents that R3 should be transferred by a mechanical lift for all transfers. R3's care plan dated 10/22/09 under the topic ADL"s (Activities of Daily Living) area titled "Problem/Strength/Issue" states"(R3) uses a mechanical lift with 2 person assist for transfers." Nurses notes dated 12/20/09 at 2:00PM states " Resident complains of left leg pain. Resident states she fell in Shower Room...." Facility form titled "Accident/Incident Report" dated 12/20/09 under section titled "Account of Occurrence:" states "CNA was giving (R3) a shower Friday evening (12/18/09) and was trying to take (R3) from shower chair to her wheelchair by herself. Shower chair moved so CNA lowered (R3) to floor and got help to transfer (R3). (R3) now complains of left leg pain. Scabbed abrasion lower left leg." The same report under "Interventions implemented " states "use mechanical lift on (R3)." On 9/1/10 at 3:00PM R3 stated "Two people pick me up to put me in my wheelchair also the shower chair. I don't remember ever being picked up by the mechanical lift to transfer me. People /CNA's always transfer me. The only fall I have had was when that girl picked me up in the shower by herself and I fell ." On 9/2/10 at 9:30AM E1, Adm confirmed R3 was to be transferred by mechanical lift since her admitted back in 10/1/09. R3's Minimum (MDS) data set [DATE] states that R3 is moderately impaired in daily decision making skills, is totally dependent on staff for all transfers, toilet use and personal hygiene including bathing. This MDS states that R3 has full loss of range of motion for one side of body, the wheelchair is the primary mode of locomotion, and that R3 is to be lifted manually for all transfers. physician's orders [REDACTED]. However, R3's care plan dated 6/16/10 under "ADL" indicates that R3 is to be transferred with assist of one and does not address the mechanical lift. This same care plan identifies under "Falls" that R3 is to have a lap cushion while up in the wheel chair. R3 was sitting in her wheelchair on 8/19/10 at 2:30PM, 8/26/10 at 9:30AM, 9/1/10 at 9:10AM, 10:10AM and 12N, no lap cushion was being utilized while in the wheelchair.