Every finding on record at La Bella of Sterling

Based on observation, interview, and record review, the facility failed to ensure a resident was discharged in a safe manner and failed to ensure outside resources and durable medical equipment were in place prior to discharge for one of two residents (R1) reviewed for discharge in the sample of three. The findings include:R1's hospital records shows she was admitted to a psychiatric hospital on April 3, 2025, for acute stabilization and was experiencing acute psychosis and was a danger to herself prior to being admitted to the facility on [DATE].R1's Transfer Discharge Report dated June 11, 2026, shows she was admitted to the facility on [DATE], with diagnoses including bipolar disorder, diabetes mellitus type 2, unspecified psychosis, mild intermittent asthma, anxiety disorder, and major depressive disorder. R1's Face Sheet shows she was discharged from the facility on May 4, 2026.R1's Care Plan dated May 12, 2026, shows, [R1] can have short term memory issues at times in the evenings. She may return repeatedly for her scheduled medications, forget whether or not she has taken as needed medications. She may tell one provider/staff that she has pain in one area of her body but then tell another provider/staff that the pain is located elsewhere within minutes of each conversation. [R1] is high risk for falls.R1's Social Services Comprehensive assessment dated [DATE], shows that R1 was not eligible for a community pass due to not knowing the facility address, location and how to contact the facility in an emergency. R1 had a history of abuse/neglect, exposure to any form of trauma, factors that increase the resident's vulnerability, history of substance abuse, psychiatric history, and diagnosis of depression. The resident does not demonstrate sufficient adherence to medication compliance, active participation in their treatment plan, appropriate hygiene and grooming, and respectful treatment of other to be considered for an independent outside pass privilege. R1's Progress Notes dated April 29, 2026, shows that R1 had a fall. R1 was not using her cane/walker as instructed. There was a note entered on April 29, 2026, by V3 (Previous Director of Nursing/DON) that showed, Doctor here to see resident with new order to refer to neurology. On June 11, 2026, at 10:49 AM, V3 said, I believe the neurology referral was sent on [R1's] discharge. The neurology consult was ordered when the doctor was doing his rounds.R1's Plan of Care Note dated May 1, 2026, shows, Resident declined to attend care plan meeting today. Resident is scheduled to discharge on Monday May 4, 2026, to her own apartment at [name of apartment complex for low income]. (Community Independent Living Service) will be providing post discharge support and case management services. Request for durable medical equipment order for shower grab bars and tub cut out sent to medical doctor. Resident has not displayed any behaviors or fluctuation in mood. Resident currently stable at baseline and medication compliant. Weight down 32 pounds in one year. Resident is indifferent to activities of daily living (ADL) care needs. Resident has a history of neglecting self-care at times but is physically capable of performing ADLs. Requires set up help, cues, supervision, and intermittent supervision to assure ADLs are completed safely and at an adequate level.On June 10, 2026, at 1:03 PM, V4 (Certified Nursing Assistant/CNA) said she took care of R1 often. V4 said she had to remind R1 where her room was, remind her of smoke times, and remind her to let her flat iron cool off before she closed it. V4 said R1 was friendly with no aggressive behaviors. V4 said R1 was forgetful at times. V4 said towards the end of R1's stay at the facility, R1 became more forgetful and would forget that she took her medications, so she would approach the nurse multiple times per day to see if she got her medications.On June 10, 2026, at 1:31 PM, V5 (CNA) said the facility has been discharging a lot of residents recently. Most residents went to a sister facility.On June 10, 2026, at 1:49 PM, V6 (CNA) said when R1 was first admitted to the facility, R1 always dressed nice and liked to shop. Before R1 left the facility, R1 was confused, was not doing the things she used to do, R1 did not want to eat, wanted to stay in her room all the time, and would be forgetful. V6 said that R1 was declining. V6 said R1 did not always know what room she was in. V6 said staff supervised R1 during showering for safety. V7 (Registered Nurse/RN) said R1 was cooperative and pleasant but was forgetful. R1 would forget that she had already received her medications so she would come to the nurse to get them again. R1 would try and get bedtime medications too early. R1 would forget to eat. R1 was oriented to person, but not to time. V7 said she did not think R1 was appropriate to be on her own. R1 needed a standby assist. V7 said she was worried that R1 would take her medications more than once. V7 said R1 wanted to be on her own but was not as sharp cognitively. V7 said that R1 needs to be checked on. V7 said she was told to gather R1's medications together on the day of her discharge. V7 said she is a charge nurse, I thought I had no say in regard to R1's discharge. I feel like I should be a part of the meeting. I would have said 'are we sure she is ready?' V7 said R1 needed someone to give her, her medications. R1 could overdose if she took too many. V7 said R1 was gradually going downhill. R1 was losing weight and hygiene was fair, just a little unkept.On June 10, 2026, at 2:26 PM, V8 (Apartment Building Manager) said the apartment complex that R1 was moved to was independent living. There is no one to help. V8 said she has not seen R1 for a week. V8 said the day that R1 moved into the apartment, R1 did not know her name. V8 said when R1 was asked to sign her name on her lease, R1 wrote something nonsensical. V8 said R1 could not write her initials. V8 said R1 could not follow simple instructions. V8 said R1 would wander off and go on various floors and not know where she was at. It was startling. One day, R1 was found outside in the parking lot at 6:00 AM and the maintenance person asked R1 if he could help her and R1 could not tell him her name or where she lived. V8 said she had talked to V12 (Community Independent Living Case Manager) a couple of times, because V8 was concerned. V8 said R1 received a notice last week to pay rent, but R1 has not come down to sign her new lease. On June 11, 2026, at 9:30 AM, V9 (Social Services Director) said she has worked at the facility since January 2026. V9 said that R1 was the first person that she discharged from the facility. V9 said (Community Independent Living Service) from what I understand, helps assist residents go from residential living to independent community living. V9 said that V12 (Case Manager) met with R1 at the facility. V9 said that V12 helped with furnishing R1's apartment, bought her groceries, and helped set her up with low-income grocery card. V9 said that V12 was supposed to help with setting R1 up with a homemaker. V12 said that R1 was on the discharge list for a while. V9 said she did not set R1 up with home health care services, because V12 said she was going to do it. V9 said she has not gotten any messages from V12, but V9 knew that V12 had been calling the facility to talk to the administrator. V12 spoke with V11 (Dietary Manager) at one point. V9 said that V12 was not very friendly when she talked to V12. V12 told V9 that the facility was going to get in trouble because the facility allowed R1 to be discharged and R1 was very confused. V9 said that nurses and CNAs are not involved in discharging residents. The opinions are not gotten from the staff if residents are ready to be discharged , just management. At 10:02 AM, V11 said most of the time, R1 was oriented. R1 would go through phases of confusion. V11 said R1 asked V11 for two games, and V11 tried to clarify what R1 needed, and R1 told V11 she forgot the names, but later remembered and came back to say she meant two cups. V11 said R1's appetite was good until soon before discharge. V11 said, In my opinion, she was not ready to be discharged . It seemed like she was getting anxious about leaving the facility. The cup situation was about two days prior to discharge. V11 felt that R1 was not ready for discharge because of her confusion and during smoke breaks, R1 would need staff with her because she was unsteady. R1 was not remembering to eat, staff had to prompt her. Staff was worried how R1 was going to take care of herself without being prompted by someone. V11 said that R1 declined cognitively before discharge. V11 said when she spoke to V12, V12 was trying to reach administration and V12 kept getting the run around. V11 said R1 was very friendly, We miss her, we were really sad to see her go. We are all worried about her and if she is able to take care of herself. On June 10, 2026, at 11:22 AM, V12 (Case Manager) said they are an agency that helps residents readjust to the community safely when leaving a nursing home. V12 said she relies on the nursing homes to provide accurate resident assessments to them. V12 said the move of R1 went fast. V12 said she was told by the facility that R1 knows how to administer her own medications, performs all of her ADLs, and was told R1 did not need any personal assistance. V12 said her first red flag was when V12 went to the facility to meet R1 on the day of her discharge and R1's nurse pulled V12 aside and said the nurse stated she did not want to get into trouble, but that R1's narcotics needed to be locked up because R1 forgets a lot and will take her medicine more than once if R1 forgets that she took her medicine. V12 said that she did a 24 hour follow up with R1, and R1 told V12 that someone was ringing her doorbell multiple times during the night and R1 went to the door with a knife. V12 said that R1 doesn't have a doorbell on her door and told R1 that her behavior was not safe. V12 said that R1 could not set up her medications correctly. V12 said that R1 told V12 that R1 has been doing her own medications for ten years. V12 said that R1 was too confused upon discharge. V12 said that herself and her coworker went to the facility multiple times and the facility would not let them in. V12 said she was trying to talk to the facility about R1's discharge because it was not safe and not appropriate. V12 said the facility always said the Administrator and Director of Nursing was not available. V12 said that R1 stopped taking her medications. V12 said that R1 is on psychiatric medications and medications for her blood pressure. V12 said that R1 cannot do her own finances. V12 said that R1 threw out all of her important papers. V12 said that R1 does not have the ability to know what kind of help she needs. V12 said that R1 has wandered off and has gotten lost. She's not safe. She got aggressive with me, and I had to call the police and ambulance. V12 said that R1 does not have any grab bars or cut out tub in her bathroom. V12 said that the facility's typically arrange for assistance in the homes prior to a resident's discharge so that that worker can be in place on day of discharge. V12 said this did not happen with R1. V12 said none of R1's paperwork that was submitted to (Community Independent Living Service) was in R1's handwriting. (This includes budget and medication evaluations.)R1's Weights and Vitals Summary dated June 11, 2026, shows R1 had an 8.8% weight loss in the last three months and an 11% weight loss in the last five months. R1's Nursing Home Documentation Form shows that R1 was last seen by the medical doctor on March 26, 2026. Cognition and Mood are circled by the physician. R1's Quarterly Discharge Evaluation dated April 18, 2025, shows that R1 needs cues and reminders for self-care ADLs, medication monitoring/assistance, med management/behavioral health services are needed. Requires 24-hour supervision/monitoring.On June 10, 2026, at 12:00 PM, R1 was observed in her apartment. R1 had greasy hair. R1 had multiple medication bottles sitting on the floor. There was a coffee cup with about four cigarette butts in it. (R1's apartment is non-smoking). R1 said she was unsure of when she last used the bathroom. R1 said she did not take any medications that the facility provided upon discharge. The facility Discharge Planning Process Policy dated 2025 shows, It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. In cases where the resident wishes to be discharged to a setting that does not appear to meet his or her post discharge needs, or appears unsafe, the interdisciplinary team will treat this situation similarly to refusal of care: Discuss with the resident, and document the implications and/or risks of being discharge to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location. Offer other, more suitable, options of locations that are equipped to meet the needs of the resident. Document any discussion related to the options presented. Document refusals of other options that could meet the resident's needs. At time of discharge, follow policies regarding discharges Against Medical Advice, and refer to Adult Protective Services (or other state entity charged with investigating abuse and neglect), as necessary.

Based on observation, interview and record review the facility failed to maintain comfortable temperatures in the facility. This failure has the potential to effect all 41 residents residing in the facility.The findings include: The facility provided resident roster shows there were 41 residents residing in the facility on 12/15/2025. On 12/15/25 at 9:28 AM, during initial tour of the building the west hallway, group and activity (TV) room in the west wing, and the nursing station outside of the west hallway were felt to be very cold.On 12/15/25 at 9:48 AM, The main dining area of the facility felt cold, and the back half of it felt even colder. R2 and R4 were sitting in the dining room finishing breakfast and said some areas of the building are cold, including the shower rooms, the dining room and other rooms. On 12/15/25 at 10:26 AM, V3 (Maintenance) said the building is very old and needs new windows. V3 said the building has electric floor heating in certain areas, and in some resident rooms in the west wing, there are electric heat vents in the wall. V3 said it is difficult to maintain temperatures throughout the building due to the boiler system pushing out enough to heat all the areas, and we had arctic cold temperatures last weekend. V3 said the TV room in the west wing does not have an electric heating register on the floor. V3 said he uses an infrared heating gun to take temperatures in the buildingOn 12/15/25 at 10:28 AM, the surveyors and V3 went throughout the building and took temperatures in various rooms and common areas, The temperatures were all taken with the facilities temperature gun and were as follows: The wall temperature was 50.0 degrees Fahrenheit (F) in the [NAME] unit TV room. The group room temperature was 53.3 F on one wall and the wall across from the window was registering at 56.3 F. The [NAME] hallway between rooms 33-34 registered at 57.2 F. R9 and R13's room in the [NAME] wing, was very cold and R13 said the electric heating unit on their wall had not been working properly for a week or so. R9 and R13's room temperature registered at 53.3 F on the wall next to the window by R13's bed. V3 said the heating units in the wall are old and he has replaced the one in R13's room several times and they quit working so a brand new one will need to be gotten. The main dining room temperature in the back room registered at 53.9 F. V3 and the surveyor felt the electric radiator on the floor and it was cold to the touch.R2's room temperature was registered at 63.5 F.On 12/15/25 at 12:28, V3 and the surveyor went to temp the shower rooms, the South shower had an exhaust fan in the ceiling and you could feel the cold air coming down from it. The temperature from that fan registered at 41.3 F and the wall temperature was 57.5 F. The North shower exhaust fan on the ceiling registered at 35.0 F and the wall temperature was 56.3 F. V3 said he was not aware of the draft coming from the exhaust fans and that is due to the attic being above them. On 12/15/25 at 12:43 PM, V8 (Certified Nursing Assistant/CNA) was sitting at the CNA station wearing a hat and layered clothing. V8 said the temperature in the building had gotten colder over the weekend.On 12/15/25 9:30 AM, V7 (Kitchen Supervisor) said when I came in this past Saturday morning it was colder in the building, Sunday was still cold. Residents were wearing jackets over the weekend. I don't know if anyone called V3 to report it.On 12/16/25 at 9:36 AM, V1 (Administrator) said it was reported to her over the weekend that the building was drafty but she was not aware it was cold in certain areas until she arrived to work on 12/15/25. V1 said she was also not made aware that the shower rooms were cold.On 12/16/25 at 10:35 AM, V4 (Registered Nurse/RN) said the building temperature was okay on Thursday (12/11), but when I came in on Saturday it was cold in the building. Residents were wearing jackets. The nurses station was tolerable, but the CNA station was cold. Residents were saying it was cold. I did not call anyone, I thought they knew about it.On 12/16/25 at 12:06 PM, V2 (Director of Nursing) said no one called me about the cold building over the weekend, the staff call for everything else you would think they would have called me.On 12/16/25 at 9:56 AM, V3 said the thermostat was replaced in the back half of the dining room and the register was working. V3 also said he had a company in on 12/15/25 and the brought in portable units to help try to push the heat through the system better. V3 said he also covered the exhaust fans to the shower rooms. V3 and the surveyor went to take temperatures again. R2's room registered at 68 F. The back of the dining area registered at 69 F. The west hallway still felt chilly and registered at 60.0 F. The North shower registered at 69 F and the South shower room was 68.2 F.The maintenance log shows on 11/30/25 R9 and R13 had first reported issues with the heating unit in the room.The facility provided not dated, Loss of heating or Cooling policy shows the facility will take immediate action to maintain the temperatures between 71-81 degrees Fahrenheit.

Based on interview and record review, the facility failed to provide supervision to a resident (R1) while attending an outdoor activity. This failure resulted in R1 sustaining second degree burns from an outdoor fire.The findings include:R1's electronic face sheet printed on 10/3/25 showed R1 has diagnoses including but not limited to major depressive disorder, anxiety disorder, chronic obstructive pulmonary disease, schizoaffective disorder, and tremor.R1's facility assessment dated [DATE] showed R1 has no cognitive impairment.R1's nursing progress notes dated 9/23/25 showed, During afternoon activities today resident was attending an activity and was roasting marshmallows with her peers and staff. Each staff member had assigned areas to supervise and assist with for the activity. Dietary and business office manager assigned to area with marshmallows and candy. Dietary manager assisted and supervised residents with covered fire pit for entirety of activity. Dietary manager completed assistance with (R1) and (R1) was walking back to join her peers. Dietary then proceeded to assist other residents with activities, then (R1) turned around to walk back to fire pit with her marshmallow in her left hand wrapped in a paper napkin. When she got to the fire pit, she attempted to throw napkin into what appeared to be an already extinguished fire (activity was complete) the napkin stuck to her hand and ignited. Resident then started waving her hand around causing the fire to get bigger, burning her left hand and forearm. Staff immediately intervened and assisted resident to safety. Resident taken to nurse's office for assessment. First aide was provided, and physician notified. Order to send resident to emergency room for evaluation and treatment at (local hospital).On 10/2/25 at 9:02AM, R1 stated, I was standing over by the fire and I had just roasted a marshmallow and I went to throw my napkin in the fire and the napkin got stuck on my hand from the marshmallow and went up in flames. My whole hand was on fire, and I was really scared so I started screaming. The staff came right over and took care of me. R1 had a dressing to her left hand that she removed, and surveyor observed burns to R1's left hand and a blister about the size of a quarter on her left thumb. R1 stated its very painful and she's never roasting marshmallows again.R1's local emergency room notes dated 9/23/25 showed, Skin: warm, dry, erythema extending up the majority of the left palm and palmar fingers with areas of blistering/second-degree burn noted to the distal phalanx of the left thumb anteriorly, middle phalanx of the left thumb anteriorly, distal and middle phalanx of left index finger anteriorly.R1's nursing progress notes dated 9/25/25 showed, Dressing change to left hand per orders. Blister noted to left thumb measures 1.5x1.2 inches and is fluid filled. Palm is slightly red with no blistering noted.On 10/2/25 at 8:41AM, V3 (Dietary Manager) stated, We were out there with about 15-20 residents around the fire and after we were pretty much done with the fire, (R1) came out late and wanted a s'more. Her and I walked over to the fire pit and the fire was low, so I leaned down & roasted the marshmallow for her. We walked over to the table & put the s'more together and then she walked off towards the fire and sat down. All the residents thought we were going to do seconds and when I turned around to see if we were doing seconds, I heard (R1) yell, and she was holding her arm and crying.(V4-Certfied Nursing Assistant Coordinator) and (V5-Business office manager) were both out there with me at the time this happened but they were setting up a pinata so they weren't by the fire. On 10/2/25 at 8:51AM, V4 stated, I was outside doing a pinata, so I really didn't see much. I had my back towards the crowd of residents because I wasn't the one supervising them. I heard a resident ask for another marshmallow and (V3) said she would help them. I didn't hear much after that and then someone yelled someone burned themselves and I just yelled, Go to the nurse right away. On 10/3/25 at 9:18AM, V1 (Administrator) stated, I was out doing fire duty when I was out with the residents during our bonfire and s'mores. I went inside because the smoke was bothering my breathing and within 5-10 minutes of being inside, staff were bringing (R1) in and telling me she burned her hand. I'm not sure who was watching the residents around the fire after I went in but there were 4 managers outside. I didn't assign anyone for fire duty because I thought all the residents were done making s'mores.On 10/3/25 at 9:44AM, V5 stated, I was standing out by the tree, my back was facing the basketball hoop, and we were trying to get the pinata up. I didn't really see anything happen. (V3) asked if we were doing seconds and I said sure and when I turned around, I didn't see anyone by the fire. A few minutes later I heard a yell and (R1) was walking up to me and holding her hand and she had marshmallow stuck on her hand. I saw her s'more on the ground. We were all supposed to be supervising after (V1) went inside but I didn't see anyone by the fire when I looked. I was busy doing the pinata.The facility was unable to provide a policy regarding supervision of residents during outdoor activities.

Based on observation, interview, and record review, the facility failed to ensure the facility's activity program was directed by a qualified professional. This failure has the potential to affect all residents residing in the facility. The findings include: The facility's Resident Census and Condition form dated March 10, 2025 shows the facility census was 43. On March 11, 2025 at 12:25 PM, V5 Activity Director/Social Services/CNA-Certified Nursing Assistant said she has been the facility's Activity Director for about two months. V5 said she works every other weekend. V5 said when she's not working, then the residents have activity packets to work on which include crosswords, sudoku puzzles, and coloring pages. On March 11, 2025 at 3:30 PM, V1 (Regional Director of Operations) said that V5 does not have any activity director certifications.

Based on observation, interview and record review the facility failed to ensure the dishwasher sanitation solution was checked at the recommended level prior to use. This applies to all 43 residents in the facility. The findings include: The CMS 671: Application for Medicare and Medicaid dated 3/10/25 shows the facility census as 43 residents. On 3/11/25 at 8:31 AM V7 (Cook) was asked to check the sanitation level in the dishwasher. V7 found Quaternary Ammonia test strips in the drawer and handed them to V8 (Dietary Aide). V8 then put the strip into the water reservoir on the dishwasher. The strip turned yellow. V7 then noticed that the sanitizing solution bucket was almost empty and proceeded to change it to a full bucket. V7 then used the same strips again and tested the water in the same reservoir of the dishwasher. The strip was even lighter yellow. Surveyor looked at the bucket on sanitizing solution. It read, Hypochlorite. V8 then noticed there was another roll of testing strips on the floor, under the dishwasher. (The strips, the plastic container and the key (chart) were all scattered under the dishwasher). V8 picked up all three pieces and gave them to V7. V7 then tested the dishwasher water reservoir with those strips and it registered at 50 ppm (parts per million). V7 then showed Surveyor the log book. The form entitled Low Temp Dish Machine Log shows that V8 checked the dishwasher before use and the sanitizing solution measured 100 ppm. V8 was then asked if she checked the dishwasher prior to use and she stated, yes. On 3/11/25 at 8:50AM V6 (Dietary Manager) stated, The (sanitation level) of the dishwasher should be 100 (ppm). We were using quaternary ammonia until the new company took over. We ran out of the old chemicals about a month ago and switched to this one (Hypochlorite). They should be checking the dishwasher with every meal. At 9:46 AM V6 brought the strips the staff had used on the third test to the Surveyor and stated, These are the ones we always use. Surveyor stated, V8 stated she checked the dishwasher this morning however the strips were found under the dishwasher on the floor. V6 stated, Well we know that is not true, obviously. Well I know the strips were there on Sunday because I used them. The facility policy entitled Dishwasher Temperature dated 1/2025 states, The sanitizing solution shall be 50ppm Hypochlorite (chlorine) on dish surface in final rinse. This same policy states, Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded.

Based observation, interview and record review the facility failed to provide behavioral health care services for residents with diagnoses of mental illness. This applies to 4 of 4 residents (R32, R41, R26, R22) reviewed for behavioral services in the sample of 12. The findings include: 1. R32's face sheet shows he is a [AGE] year old male admitted to the facility on [DATE], with diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms, PTSD (post traumatic stress disorder), generalized anxiety, and insomnia. R32's PASRR II (Preadmission Screening and Resident Review) dated 6/16/24 shows he has a diagnosis of schizophrenia, major depressive disorder, and PTSD. R32 has a hard time interacting with others, has unclear thoughts, gets easily upset, has feelings of worthlessness, hopelessness, trouble sleeping, sees and hears things, has nightmares R32 needs help to coordinate his care, needs encouragement and support to remain active and engaged in treatment, requires monitoring from supportive staff through the coordination and medical management of behavioral health symptoms programs to teach daily living skills, mental health education, crisis intervention services or plan, individual, group and family psychotherapy services. R32's facility assessment dated [DATE] shows he is cognitively intact, has little interest in doing things, feeling down and depressed, feeling tired, having little energy, and trouble concentrating. On 3/10/25 at 9:56 AM, R32 was observed in his room playing video games. He said he has been at the facility for seven months of complete boredom. He came to the facility because he was told there would be a counselor on site, he was lied to on what this place was. He said he goes out for counseling services every two weeks but that's not enough. He said it would help if they had services in the facility, life skills offered and someone to talk to. On 3/12/25 at 1:50 PM, R32 was observed walking up and down the hall. He said he wants something to do, he said he asked the staff if he could get a job working in the kitchen and wants to know when he will be discharged . On 3/11/24 at 9:33 AM, V13 (Certified Nursing Assistant-CNA) said R32 keeps to himself, he isolates, sleeps a lot and is really quiet. On 3/11/25 at 12:25 PM, V5 (Activity Director/Social Services) said she was a CNA at the facility for two years. She has been the activity director for about two months and started social services less then one month. There was no social service staff prior to her. The Administrator helps her with the referral and new admissions. She does 1:1 counseling services with the residents and started psychosocial groups weekly but does not have any behavioral health background. She is not sure what psych services the resident needs. V9 (MDS Coordinator) goes over the residents PASRR and updates the careplan. She said she is not sure what services R32 is receiving. He has expressed he wants to get a job and this is the first time she's assisting a resident with seeking employment. R32's Physician Progress note dated 1/9/25 documents he reported feeling depressed because he is still at facility and wants to be discharged . R32's current careplan shows initiated June 24, 2024 shows he is risk for depression and self harm with interventions to assess physiological needs and seek to resolve, assess for deepening depression-increased withdrawal, lack of appetite and change in self care .provide appropriate interactions/attention and practice appropriate coping/behavior management skills. R32 also has history of paranoid thoughts and behaviors with interventions including psychotherapy, encourage and praise participation in group therapy meetings. 2. R41's face sheet shows he is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including major depressive disorder severe with psychotic features, bipolar, attention deficit disorder, and post traumatic stress disorder, disc displacement, lumbar region, and generalized anxiety. R41's PASSR II dated 1/10/25 shows he has diagnosis including anxiety, ADHD, depression, bipolar, and PTSD. The services and supports the facility staff are provide theses services include rehabilitate services including pharmotherpay including administration and monitoring, provision of a structured environment, socialization and recreation activities to decrease isolation, improve mood, and increase peer interaction. Your favorite past time is writing .crisis interventions services or plan, individual, group and family psychotherapy .supportive psychotherapy may be helpful to discuss your thoughts and feelings within a supportive setting and teach you healthy coping skills for self care. Substance use counseling to help identify triggers, avoid relapse, and maintain sobriety. Group therapy led by a behavioral heath professional to help learn practice strategies to cope with mental health concerns, build interpersonal skills and develop social support form others who may be able to relate to you development of appropriate personal support networks who can connect with you. R41's Physician Progress note dated 2/7/25 documents (R41) will be looking into another facility with more intense psych services as he thought that is what this facility was. R41's Physician Progress note dated 1/24/25 documents (R41) has been at facility for two weeks, it has been a big adjustment was sent from behavioral health to get more intensive care for mental health issues and said was going to a SMHRF (Specialized Mental Health Rehabilitation Facility) .will also look into another facility with more intense psych services as he thought that is what this facility was. On 3/10/25 at 10:15 AM, R41 was observed in his room with the door closed. He said he's been at the facility since January. He said he should have not been brought here, he was told he was going to a SMHRF to receive mental health services. He said since he's been at the facility, he found his own therapy. On 3/12/25 at 11:25 AM, R41 said he is feeling overwhelmed, there is no counselor or staff he can talk to when he feels this this. V9 (Social Services/Activity) is new to the role, she's nice but she also is in charge of activities. He said he's been invited to one group about being the best you can be while at the facility. He has therapist he's been seeing for about a decade, but there no psych services the facility provides him. On 3/11/25 at 12:25 PM, V5 (Activity Director/Social Services) said she was a CNA (Certified Nursing Assistant) at the facility for two years. She has been the activity director for about two months and started social services less then one month. There was no social service staff prior to her. The Administrator helps her with the referral and new admissions. She does 1:1 counseling services with the residents and started psychosocial groups weekly but does not have any behavioral health background. She is not sure what psych services the resident needs. V9 (MDS Coordinator) goes over the residents PASRR and updates the careplan. R41 came to the facility with a lot of his own services, he sees the psych NP (Nurse Practitioner), and does not know what psych services the facility is providing him. On 3/11/25 at 2:03 PM, V9 (MDS/Careplan/Restorative Nurse) said she has been at the facility over 4 years. She asks the residents what psych services work for them, and refers them to an outside counseling service. The facility offers tele health visits every two weeks with the psych NP. She makes sure the resident has a PASRR II, showing they have a mental illness but she does not review it or implement the behavioral heath services they need. We used to have behavioral health aides in the facility who were trained to manage residents with behaviors. On 3/12/25 at 11:54 PM, V11 (Psych Nurse Practitioner) said she does tele health visits with the residents every two weeks. The facility used to have an in person psychiatrist, but he has retired and the residents should receive outside mental health services. We are looking for an in-person psychiatrist the residents do better and would like to have more frequent visits. The previous social worker was having groups that would benefit the residents for trauma, anxiety, grief, PTSD, and behavior management and would like to see the groups come back. R41's current careplan does not include a careplan for his anxiety, bipolar disorder or PTSD. His careplan shows he may display sign and symptoms of depression but does not specify what signs with interventions to remain in contact with his therapist and group therapy. The facility did not provide evidence of any behavioral groups provided to residents. 34506 3. R22's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including bipolar disorder, psychotic features, obesity, alcohol abuse, major depressive disorder, and insomnia. R22 is less than [AGE] years old. On March 10, 2025 at 9:59 AM, R22 said the facility only provides psych services on the screen. R22 said there is no psychiatrist that comes to the facility. R22 said he would rather see a psychiatrist in person. R22's Nursing Facility Placement Notice of Determination dated February 14, 2019 shows special services: Mental Health Rehabilitation activities, professional observation for medication monitoring, adjustment and/or stabilization, illness self management, and substance use/abuse management. 4. R26's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including major depressive disorder, alcohol abuse, cocaine abuse, generalized anxiety disorder, and insomnia. R26 is less than [AGE] years old. R26's Illinois preadmission screening and resident review dated February 1, 2024 shows, You need help with managing your mental health symptoms. You will benefit from continuous psychiatric services for monitoring your medication and how well your medication is working for you, individual, group, and family psychotherapy. On March 10, 2025 at 10:19 AM, R26 said he has been at the facility for three years. R26 said he's never met the psych doctor. R26 said the appointments are only on a screen. R26 said he would rather see a psychiatrist in person.

Based on observation, interview and record review the facility failed to ensure medically related social services were provided for 4 of 4 residents (R32, R41, R142, R26) reviewed for social services in the sample of 12. The findings include: 1. R32's face sheet shows he is a [AGE] year old male admitted to the facility on [DATE], with diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms, PTSD (Post Traumatic Stress Disorder), generalized anxiety, and insomnia. On 3/10/25 at 9:56 AM, R32 was observed in his room playing video games. He said he has been at the facility for seven months of complete boredom. He came to the facility because he was told there would be a counselor on site, he was lied to on what this place was. He said he goes out for counseling services every two weeks but that's not enough. He said it would help if they had services in the facility, life skills offered and someone to talk to. On 3/12/25 at 1:50 PM, R32 was observed walking up and down the hall. He said he wants something to do, he said he asked the staff if he could get a job working in the kitchen and wants to know when he will be discharged . R32's current care plan shows for discharge planning shows staff will establish pre-discharge plan with the resident and evaluate progress and revise. R32's electronic record does not show evidence of quarterly discharge plan. 2. R41's face sheet shows he is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including major depressive disorder severe with psychotic features, bipolar, attention deficit disorder, and, post traumatic stress disorder, disc displacement, lumbar region, and generalized anxiety. On 3/12/25 at 11:25 AM, R41 was observed in room. The frame of his glasses were held together by tape. He said he was just informed by his insurance provider he qualifies for dental and vision. He said he needs new glasses and needs to see the dentist. No one at the facility has helped him. He said he is feeling overwhelmed, there is no counselor or staff he can talk to when he feels this this. V9 (Social Services/Activity) is new to the role, she's nice but she also is in charge of activities. On 3/12/25 at 12:32 PM, V2 (DON/Director of Nurses) said the facility should be providing arrangements for dental care, she could not find if any residents are on a list for dental or vision services. R41's current careplan shows his teeth are in poor condition with multiple cavities. Intervention shows to coordinate arrangements for dental care and transportation. R41's electronic health record shows there is no documentation of social service notes. 3. R142's face sheet shows R142 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses including major depressive disorder, schizoaffective disorder, PTSD-chronic, borderline personality disorder and suicidal ideation's. On 3/10/25 at 9:37 AM, R142 was observed in R142's room with the door closed. R142 said R142 was recently hospitalized for suicide ideation and came to the facility for psych services and has been at the facility for about one month. R142 said R142 prefers to go by a different name and identifies as a male. R142 said R142 is in between therapists and has had one tele health session with the psych NP (Nurse Practitioner). R142 prefers to have in person visits and stated, I do better in person. On 3/11/25 at 11:35 AM, R142 was observed in R142's room with the door closed. R142 said prior to coming to the facility R142 was receiving counseling for Internal Family Counseling Services and is not receiving those services now. There are no groups for trauma, wellness, life skills or managing behaviors at the facility to attend. 4. R26's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including major depressive disorder, alcohol abuse, cocaine abuse, generalized anxiety disorder, and insomnia. R26 is less than [AGE] years old. R26's Illinois preadmission screening and resident review dated February 1, 2024 shows, You need help with managing your mental health symptoms. You will benefit from continuous psychiatric services for monitoring your medication and how well your medication is working for you, individual, group, and family psychotherapy. On March 10, 2025 at 10:19 AM, R26 said he has been at the facility for three years. R26 said he's never met the psych doctor. R26 said the appointments are only on a screen. R26 said he would rather see a psychiatrist in person. On 3/11/25 at 12:25 PM, V5 (Activity Director/Social Services) said she was a CNA (Certified Nurses Assistant) at the facility for two years. She has been the activity director for about two months and started social services less than one month. There was no social service staff prior to her. She does not have a degree or training for this position. She does not know what services residents are receiving or what services they should be receiving.

Based on interview and record review the facility failed to ensure the pneumonia vaccine was consented or declined prior to administration. This applies to 4 of 5 residents (R34, R35, R12 and R39) reviewed for immunizations in the sample of 12. The findings include: On 3/11/25 R35 and R34's EMRs (Electronic Medical Records) show that R35 received the PCV 20 vaccine on 12/21/23. No consents were found in R35 and R34's EMR. On 3/11/25 R12 and R39's EMRs show that R12 and R39 both declined the Pneumonia vaccine. No declinations were found in R12 and R39's EMR. On 3/12/25 V1 (Corporate Regional Director of Operations) confirmed that the facility did not have the pneumonia consents or declinations for these 4 residents. The facility policy entitled Pneumococcal Vaccine dated 10/2023 states, The resident/representative retains the right to refuse the immunization. The facility will document in the clinical record the reason for refusal or the medical contraindications of the immunization. and A consent form shall be signed prior to the administration of the immunization and filed in the individual's medical record.

Based on observation and interview the facility failed to ensure a residents room was maintained in a comfortable homelike environment. This applies to 1 of 12 residents (R33) reviewed for resident rights in the sample of 12. The findings include: On 3/11/25 at 8:45 AM, R33 was observed in her room lying in her bed. A section of the baseboard wall on the left lower side next to the bathroom door was missing approximately one foot fully exposed open hole. On the right lower side next to the bathroom door another section of the wall was missing approximately six inches with wood exposed and several ants observed around the area. R33 said she has notified the staff, but nothing has been done to repair the wall and ants are present year round. On 3/11/25 at 1:41 PM, V10 (Maintenance Supervisor) said the facility has been neglected over the years and it's catching up with lots of repairs needed. He is aware of the R33's room wall near the bathroom needing repair it has been like that for some time, but he is the only maintenance staff and has not had time to repair her wall. The facility did not provide a policy regarding maintenance of the building.

Based on observation, interview, and record review, the facility failed to ensure activities that meet residents physical, mental, and psychosocial well being were provided for two of 12 residents (R22, R26) in the sample of 12. The findings include: 1. R22's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including bipolar disorder, psychotic features, obesity, alcohol abuse, major depressive disorder, and insomnia. R22's Care Plan written February 28, 2019 shows R22 independently structures his daily activities as evidenced by pursuing independent leisure activities daily and/or attending activities/groups of choice. Remind R22 of all activities available that are of his interest, R22 likes to go on dine outs with staff, donuts and coffee, offer one on one visits/activities as R22 will accept. R22's Minimum Data Set (MDS) dated [DATE] shows he is cognitively intact. R22's MDS shows it is somewhat important to have books, newspapers, and magazines to read and participate in religious services or practices. It is very important to him to do things with groups of people, do his favorite activities, and very important to go outside to get fresh air when the weather is good. On March 10, 2025 at 9:59 AM, R22 said, The activities suck. It is all second grade activities. I don't color pictures, I don't play second grade games, I don't like arts and crafts. I would like to do something age appropriate. We used to be able to go to restaurants. I like to read the newspaper, but we don't get that anymore now that the new company took over. R22 said he goes outside with the residents that smoke, but he does not smoke. 2. R26's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including major depressive disorder, alcohol abuse, cocaine abuse, generalized anxiety disorder, and insomnia. R26's MDS dated [DATE] shows he is cognitively intact. R26's Activity assessment was not completed. R26's MDS dated [DATE] shows it is somewhat important to him to have books, newspapers, and magazines to read and to do things with groups of people. It is very important to R26 to do his favorite activities, to get outside, and to listen to music he likes. On March 10, 2025 at 10:19 AM, R26 said the previous activity director quit. R26 said the new activity director is the social services person now. R26 said he cannot just go outside when he wants. R26 said there's not enough staff to be able to go outside when he wants. On Monday March 10, 2025 at various times throughout the day, there was no activity staff seen. There were a few residents playing cards in the TV room. There were no staff directing any activities on Monday March 10, 2025. On Tuesday, March 11, 2025, there was an activity calendar that was hanging up by the dining room. The activity calendar showed that at 9:00 AM there was devotions, 9:30 AM-exercise, 12:00 PM fast food, and 2:00 PM olympic games. There was no devotions going on at 9:00 AM and no exercise going on at 9:30 AM and no staff observed in the activity room. Multiple residents were observed wandering the halls back and forth. The facility's Resident Council Minutes dated February 2025 shows, Residents expressed that they would like to see more stem science activities and outside groups. On March 12, 2025 at 9:55 AM, V14 CNA (Certified Nursing Assistant) said the facility doesn't get the newspaper everyday. V14 said the newspaper comes in the mail. We get it when we get it. We just got the end of Februarys newspaper. V14 said when the facility gets the newspaper, its set on the CNA desk and residents can get it when they want. V14 said the facility gets one newspaper when they get the newspaper. On March 11, 2025 at 12:25 PM, V5 Activity Director/Social Services/CNA-Certified Nursing Assistant said she has been the facility's Activity Director for about two months. V5 said she works every other weekend. V5 said when she's not working, then the residents have activity packets to work on which include crosswords, sudoku puzzles, and coloring pages. The facility's Activities Policy reviewed September 2024 shows, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will be designed with the intent to: enhance the resident's sense of well-being, belonging, and usefulness. Create opportunities for each resident have a meaningful life, promote or enhance physical activity, promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence, reflect resident's interests and age .

Based on observation, interview, and record review the facility failed to implement, develop, and provide resident centered mental health services for a resident with a diagnosis including PTSD (Post- Traumatic Stress Disorder). This applies to 1 resident (R142) reviewed for behavioral health in the sample of 12. The findings include: R142's face sheet shows R142 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including major depressive disorder, schizoaffective disorder, PTSD-chronic, borderline personality disorder and suicidal ideations. R142's PASRR II (Preadmission Screening and Resident Review) dated 1/30/25 shows the facility should provide R142 with rehabilitate services for systemic plans which are designed to change inappropriate behaviors, provision of a structured environment to keep yourself safe and other safe, programs to teach daily living skills to help promote independence, individual, groups and family psychotherapy to decrease mental health symptoms, development of appropriate support networks. The PASRR II shows behaviors & symptoms include serious difficulty interacting with others, excessive isolation from or avoidance of others. (R142) requires assistance thinking through or completing tasks. V11's Psych Progress noted dated 2/7/25 documents R142 has a history of sexual and physical abuse, (R142) is having panic attacks and crying every night, either sleeps all day or not at all. Has transitioned from female to either non-binary or male depending on personality. Gender Identity disorder, Possible DID (Dissociate Identify Disorder), reports multiple personalities .plan is for psychotherapy. On 3/10/25 at 9:37 AM, R142 was observed in R142's room with the door closed. R142 said R142 was recently hospitalized for suicide ideation and came to the facility for psych services and has been at the facility for about one month. R142 said she prefers to go by a different name and identifies as a male. R142 said R142 is in between therapists and has had one tele health session with the psych NP (Nurse Practitioner). R142 prefers to have in person visits and stated, I do better in person. R142 said R142 loves to be outside and likes to have tasks to do, likes reward-based systems, it helps motivate R142. R142 said R142 likes to draw and journal. R142 has history of family abuse and does not have contact with certain family members. On 3/11/25 at 11:35 AM, R142 was observed in R142's room with the door closed. R142 said prior to coming to the facility R142 was receiving counseling from a local counseling service, and is not receiving those services now. There are no groups for trauma, wellness, life skills or managing behaviors at the facility to attend. R142 said when R142 first came to the facility not all the staff were aware of R142's preference of pronouns, and R142 does not identify as female and prefers to be called by a different name. They placed me in a room with another female and a there was a sign on the door no males in female rooms. R142 told the nurse R142 identifies as male sometimes and felt triggered when the nurse asked what body part R142 was born with, R142 thought that it was creepy and inappropriate to ask what was in between a baby's legs. Another nurse referred me to as it is a she. R142's written note provided to the surveyors on 3/12/25 listed ideas to better this place. Having more groups/activities that promote and teach us ways to improve our health and wellness. A group for the demographics of us that plan on leaving here to work on life skills, like budgeting, cleaning and home safety would be a good idea. Having a group for learning life skills and tools for self-care. On 3/11/25 at 9:15 AM, V14 (CNA/Certified Nurse Assisstant) said there used to be group therapy every Tuesday and Thursday for the residents when the social worker was here. On 3/11/25 at 1:35 PM, V13 (CNA) said at first, she called R142 by her legal name and R142 told her that's not my name. I didn't know that. No one reported to me R142 prefers to be called they/them or refers to a male name. R142 does not identify as female, but V13 didn't know that. On 3/11/25 at 12:25 PM, V5 (Activity Director/Social Services) said she was a CNA at the facility for two years. She has been the activity director for about two months and started social services less than one month. There was no social service staff prior to her. The Administrator helps her with the referral and new admissions. She does 1:1 counseling service with the residents and started psychosocial groups weekly but does not have any behavioral health background. She is not sure what psych services the resident needs. V9 (MDS Coordinator) goes over the residents PASRR and updates the care plan. R142 goes out for counseling but does know what services R142 receives. R142 recently had a care plan meeting, R142 does not identify as a male and prefers to be called they/them. It's in the care plan and the CNAs should look at the residents care plan. On 3/11/25 at 2:03 PM, V9 (MDS/Care plan/Restorative Nurse) said she has been at the facility over 4 years. She asks the residents what psych services work for them and refers them to an outside counseling service. The facility offers tele health visits every two weeks with the psych NP. She makes sure the resident has a PASRR II, showing they have a mental illness, but she does not review it or implement the behavioral health services they need. We used to have behavioral health aides in the facility who were trained to manage residents with behaviors. On 3/12/25 at 11:54 PM, V11 (Psych Nurse Practitioner) said she does tele health visits with the residents every two weeks. The facility used to have an in-person psychiatrist, but he has retired, and the residents should receive outside mental health services. We are looking for an in-person psychiatrist the residents do better and would like to have more frequent visits. The previous social worker was having groups that would benefit the residents for trauma, anxiety, grief, PTSD, and behavior management and would like to see the groups come back. R142 is being worked up for DID with R142's previous psychiatrist, R142 would benefit with family counseling, and she is not sure why R142 is not receiving those services. R142's current care plan initiated on 3/10/25 (approximately one month after her admission) shows a history of suicidal thoughts, agitation, anxiety, and states different personalities the interventions show R142 is on a behavior management program. The care plan also shows R142 has ineffective coping or overt behaviors due to PTSD diagnosis. Known triggers include (Specify), known psychosocial issues/behaviors attributed to PTSD diagnosis (Specify) and other PTSD information (Specify). The care plan does not show R142's triggers or PTSD information. The care plan does not show how R142 prefers to be called and how R142 identifies. The care plan does not show R142 likes to journal, likes tasks and does well with reward based. The facility did not provide evidence of what psych services R142 is receiving. The facility did not provide a policy regarding psych services/behavior management/PTSD.

Based on observation, interview and record review the facility failed to ensure medications were administered as ordered and failed to ensure controlled medications were accounted for and reconciled. This applies to 3 of 4 residents (R41, R21, R22) reviewed for pharmacy services in the sample of 12. The findings include: 1. On 3/10/25 at 10:15 AM, R41 said on Saturday (3/9/25) he missed the evening medication pass because he was watching TV and was not paying attention to the time. About 12:30 AM, he went to the nurses station for his medications. The nurse said he was late and refused to give me my medications. She said I missed the window. He takes medication for his heart and was upset she refused to give my medications. No staff came to remind me about the time for his medications. On 3/10/25 at 11:17 AM, V2 (DON/Director of Nurses) said R41 did report to me yesterday he did not receive his evening medications on 3/9/25. If the resident does not show up to take their medications she would expect the staff to go to the residents room and remind them to go take their medications and document if the resident refuses or attempts made to remind the resident. R41's Medication Administration Record (M.A.R.) dated March 2025 shows orders to administer at 8:00 PM including lamotrigine 150 mg (milligrams) for mood stabilizer, melatonin 3 mg give two tabs at bedtime for insomnia, memantine 10 mg for anxiety, metoprolol extended release 50 mg for hypertension, singulair 10 mg, gabapentin 300 mg give three caps three times a day for anxiety. R41's M.A.R. shows these medications were not administered. 2. On 3/10/25 at 12:27 PM, during the narcotic count with V12 (LPN-Licensed Practical Nurse). R21's Controlled Substance Form dated March 2025 for hydrocodone 10-325 mg take one tablet every six hours shows two doses on 3/9/25 were not signed out and accounted for. V12 said when she did the narcotic count with the night nurse this morning the count was off, the nurse on Sunday did not sign out the medication. Who's to say he took his medications, because the nurse did not sign it off. Nursing had to fill in the dates on 3/9/25 and verified with R21 he took the medications. R21's Controlled Substance Form dated March 2025 for hydrodone 10-325 mg shows no nurse signature on 3/9/25 at 11:00 AM and 5:00 PM. This same form states, IMPORTANT: THE NURSE WHO SIGNS THIS RECORD MUST ALSO SIGN THE SEPARATE MEDICATION ADMINISTRATION RECORD FOR EACH DOSE GIVEN. R21's Medication Administration Record for March 2025 for orders including hydrocone 10-325 mg give one tablet every six hours as needed for pain. The M.A.R. on 3/9/25 shows hydrocodone 10-325 mg did not show it was documented as administered at 11:00 AM and 5:00 PM. 34506 3. R22's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including bipolar disorder, psychotic features, obesity, alcohol abuse, major depressive disorder, and insomnia. R22's Order Summary Report dated March 10, 2025 shows an order that started May 1, 2023 for benztropine (cogentin) 1 MG two times a day for tremors related to bipolar disorder, current episode depressed, severe without psychotic features and haloperidol 2 MG tablet in the morning for agitation related to bipolar disorder. On March 10, 2025 at 9:59 AM, R22 said he has not received his cogentin. R22 said he did not know why. R22 said he will not take his haldol without his cogentin. On March 10, 2025 at 1:29 PM, V12 LPN (Licensed Practical Nurse) said R22 has not gotten his cogentin because it needs a prior authorization from the doctor. V12 said that R22 will not take his haldol without his cogentin. At 1:36 PM, V2 DON (Director of Nursing) said R22 needed a prior authorization for his cogentin starting on March 3, 2025. V2 said the nurse just told her that R22 will not take his haldol without his cogentin. V2 said the nurse first sent the prior authorization form on March 3, 2025 and V2 was not sure if R22's doctor responded. V2 said she sent the form again on March 5, 2025 and the doctor did not respond. V2 sent it again on March 7, 2025 and did not receive a response from the doctor. V2 said she called R22's primary doctor office on March 7, 2025 and left a message. V2 said she sent it to the doctor again on March 10, 2025. V2 said the doctor said to send it to the psychiatrist. V2 said she sent it to the psychiatrist and the psychiatrist signed the prior authorization form on March 10, 2025. The facility's Medication Administration Policy dated November 2024 shows, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on interview and record review, the facility failed to address pharmacy recommendations for three of five residents (R18, R35, R33) reviewed for medication regimen review in the sample of 12. The findings include: 1. R18's Admission Record dated March 12, 2025 shows R18 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type, convulsions, bipolar disorder, major depressive disorder, generalized anxiety disorder, and insomnia. R18's Pharmacy Recommendations report dated February 12, 2025 shows, [R18] has orders for labs, but at the time of this review, they were not available in the medical record. The missing lab values include: CBC (Complete Blood Count), BMP (Basic Metabolic Profile), hepatic panel, GGT (Gamma-Glutamyl Transferase), ammonia, and A1C (Glycated Hemoglobin) every three months. Recommendation: Unless otherwise indicated, please ensure that ordered labs are obtained. Please disregard recommendation if these labs have been recently obtained. On March 12, 2025 at 11:49 AM, V2 DON (Director of Nursing) said the labs for R18 were not done. At 12:15 PM, V9 (MDS-Minimum Data Set/Care Plan Coordinator) said that she tries to review residents' charts to see if they got labs done. V9 said she did not know why R18's labs were not done. 2. R35's Admission Record dated March 12, 2025 shows she was admitted to the facility on [DATE] with diagnoses including bipolar disorder, generalized anxiety disorder, post traumatic stress disorder, and borderline personality disorder. R35's consultant pharmacist report dated February 12, 2025 shows, [R35] had a high TSH (thyroid stimulating hormone) of 5.79 on September 17, 2024 and receives levothyroxine 25 mcg (micrograms) daily. Please increase levothyroxine to 37 MCG daily and obtain a follow up TSH concentration in six to eight weeks. This report was not addressed by R35's physician. R35's Medication Administration Record shows she has levothyroxine 25 mcg ordered. 34117 3. The Pharmacy Recommendation Review from 2/1/25 to 2/28/25 shows recommendations for R33 to discontinue hydroxyzine PRN (as needed) for anxiety, also has an order for hydroxyzine 100 mg daily. If the medication cannot be discontinued at this time, please: fill in below. The form is blank below. On 3/12/25 at 10:17 AM, V2 (DON) said she had been at the facility less than two weeks. She found a pile of pharmacy recommendations forms in the DON's office not done. She confirmed R33's recommendation was not done.

Based on interview and record review the facility failed to address a gradual dose reduction and failed to ensure an as needed anti-anxiety medication had a stop date for two of five residents (R18, R33) reviewed for gradual dose reductions in the sample of five. The findings include: 1. R18's Admission Record dated March 12, 2025 shows R18 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type, convulsions, bipolar disorder, major depressive disorder, generalized anxiety disorder, and insomnia. R18's Consultation Report dated January 9, 2025 shows, [R18] has received buspirone 10 MG (milligrams) three times daily since February 27, 2025. Please attempt a gradual dose reduction of buspirone to 10 MG twice daily. This report was not addressed by the physician. On March 12, 2025 at 10:09 AM, V2 DON (Director of Nursing) said the DON and the MDS (Minimum Data Set) Coordinator are the staff members responsible for ensuring the gradual dose reductions are addressed. V2 said R18's gradual dose reduction has not been addressed. At 12:15 PM, V9 (MDS Coordinator) said she has not followed up to see if R18's gradual dose reduction was completed. 34117 2. R31's Physician Order Sheets dated March 2025 shows order date of 11/21/24 for hydroxyzine tablet give two tablets every six hours as needed (PRN-as needed) for anxiety without a stop date. On 3/12/15 at 10:17 AM, V2 said PRN psychotropic medications should have a stop date of 14 days. V2 confirmed R33's recommendation was not done. The facility's Pharmacy Recommendation Review from 2/1/25 to 2/28/25 shows a recommendation to discontinue PRN hydroxyzine dose rationale for Recommendation: CMS requires that PRN orders for non-antipsychotic psychotropic drugs be limited to 14 days .

Based on observation, interview, and record review the facility failed to ensure it was free from significant medication errors for one of one residents (R1) reviewed for medications in the sample of one. The findings include: R1's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including alcohol abuse with alcohol induced psychotic disorder with delusions, visual hallucinations, depression, acute embolism and thrombosis of unspecified deep veins of right lower extremity, hypertension, moderate protein calorie malnutrition, abnormal weight loss, suicidal ideations, anxiety disorder, and epilepsy. R1's Order Summary Report shows an order for apixaban oral tablet 5 mg (milligram) give one tablet by mouth two times a day related to acute embolism and thrombosis of unspecified deep veins of right lower extremity to start on November 4, 2024. R1's Progress Notes show that R1's apixaban was on order on November 4, 2024 in the evening, November 5, 2024 in the morning and evening, and November 6, 2024 in the morning and the evening. R1's Medication Administration Record dated November 1, 2024-November 30, 2024 shows that R1 missed five doses of apixaban upon admission to this facility. On November 7, 2024 at 12:58 PM, V3 LPN (Licensed Practical Nurse) said that R1's apixaban medication did not get sent by the previous facility that R1 had just come from. V3 said R1 just got his first dose today (November 7, 2024). On November 7, 2024 at 1:04 PM, V2 RN (Registered Nurse) said R1 was admitted to the facility on [DATE]. V2 said she had to fax the pharmacy R1's insurance information yesterday (November 6, 2024). V2 said that when R1 was admitted to the facility, the previous facility sent an empty medication card of apixaban. V2 said she entered R1's admitting orders Monday evening (November 4, 2024). V2 said she realized the apixaban did not come in on November 6, 2024. The facility's Medication Errors policy revised November 2024 shows, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents received care and services safely in an environment free of significant medication errors. Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following three general guidelines: Resident's condition, drug category, and frequency of error. If an error is occurring repeatedly such as an omission of a resident's medication several times.

Based on interview and record review the facility failed to ensure RN (Registered Nurse) staffing data was accurately entered in the Payroll-Based Journal (PBJ) system. This applies to all 42 residents residing in the facility. The findings include: The Long-Term Care Facility Application for Medicare and Medicaid (CMS #671) dated 5/7/24 documents there are 42 residents residing in the facility. On 05/07/24 at 10:10 AM, V1 (Administrator) said, she is not sure what the problem with reporting is. V1 said, the issue may be that the corporate office, who is responsible for submitting the PBJ data, pulls punch codes from the time clock, but outside agency staff does not punch the time clock so those hours are not submitted. V1 said, it might also be how the time clock codes the nurses when they punch in. On 05/08/24 at 12:10 PM, V1 said, V17 (from the corporate office) is the person responsible for reporting the PBJ, V1 said, V17 only works the weekends and only does reporting. V1 said, she does not have a phone number for V17, but did provide V17's email address. On 05/08/24 at 12:44 PM, this surveyor attempted to email V17 and received an immediate automatic reply that was blank. This surveyor requested V17 contact me before 5pm or tomorrow (5/9/24) between 7AM and 9AM and have gotten no response. The October 1-December 31st, 2023, PBJ Staffing Data Report shows, No RN hours, and failed to have licensed nursing coverage 24 hours a day, triggered. The nursing schedule was reviewed for that period and showed that there was RN and licensed nursing coverage as required. This shows the reporting was not accurate.

Based on observation, interview, and record review the facility failed to ensure medications were administered in accordance with manufacturer's directions; failed to monitor residents during medication administration; and failed to provide ordered medications. This applies to 2 of 3 residents (R21 & R26) reviewed for medication administration in the sample of 13. The findings include: 1. R21's Admission Record (Face Sheet) showed an admitted [DATE] with diagnoses to include high triglycerides (a specific type of fat found in the blood); bipolar; and schizoaffective disorder. R21's Order Summary Report (Physician Orders, as of 5/7/24) showed an order for Icosapent Ethyl (medication to treat high triglycerides and reduce the risk of cardiovascular disease) to be given twice daily. The order showed it was started on 8/31/23 and the order was active. On 5/7/23 at 8:20 AM, V4 Licensed Practical Nurse (LPN) administered R21's morning medications. V4 failed to provide R21 his Icosapent Ethyl. V4 stated the medication was not available and it was also not available on her previous shift, which was 5/5/24. On 5/7/24 at 2:47 PM, V2 Director of Nursing (DON) stated R21's insurance denied payment for his Icosapent Ethyl medication. V2 stated the insurance company wanted R21 to be switched to an alternative medication. V2 stated she faxed the denial letter to V6 R21's physician on 3/6/24. V2 stated she spoke with V6 regarding the denial of payment and V6 stated the alternative medication would not work for R21. V2 said V6 wanted R21 to continue the Icosapent Ethyl medication. V2 stated R21 has not had Icosapent Ethyl since March 2024. V2 stated R21 has a diagnosis of high triglycerides and Icosapent Ethyl is to treat that condition. V2 stated if a medication is not available the physician should be notified, and the notification should be documented. R21's March 2024, April 2024, and May 2024 (As of 5/7/24) Medication Administration Records (MAR) showed the last documented dose of Icosapent Ethyl was given on 3/6/24. R21's 3/1/24 through 5/7/24 progress notes showed no documented notification of V6. The facility's Medication Administration Policy (Revised 11/18/17) showed .If a medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available .Notify the physician as soon as practical when a scheduled dose of medication has not been administered for any reason . 2. R21's Admission Record (Face Sheet) showed an admitted [DATE] with diagnoses to include high blood pressure, bipolar, and schizoaffective disorder. R21's Order Summary Report (Physician Orders, as of 5/7/24) showed an order for hydrochlorothiazide to be given daily to treat high blood pressure. On 5/7/24 at 8:20 AM, V4 Licensed Practical Nurse (LPN) was administering R21's medications. V4 dispensed all R21's morning medications into a plastic medicine cup. While V4 was looking at her charting, R21 swallowed his medications and threw the medicine cup away; however, a small peach colored pill remained and was thrown away by R21. V4 did not witness this. V4 then proceeded to dispense the next resident's medications. On 5/7/24 at 8:33 AM, the peach-colored pill was found in the garbage. V4 stated she did not notice R21 had failed to take the medication. V4 stated the peach-colored pill was R21's hydrochlorothiazide. On 5/7/24 at 11:04 AM, V2 Director of Nursing stated nurses should monitor residents during medication administration to ensure the resident's take their prescribed medications. 3. R21's Admission Record (Face Sheet) showed an admitted [DATE] with diagnoses to include chronic obstructive pulmonary disorder (COPD, lung/breathing disease), bipolar, and schizoaffective disorder. R21's Order Summary Report (Physician Orders, as of 5/7/24) showed an order for a combination budesonide (steroid) and fumoterol (medication to open airways) inhaler to treat his COPD. On 5/7/24 at 8:20 AM, V4 Licensed Practical Nurse (LPN) was administering R21's medications. V4 gave R21 his inhaler, he self-administered the inhaler, then left the nurse's cart. V4 did not stop R21 and have him rinse his mouth. The inhaler instructions showed, After you finish taking [the combination inhaler], rinse you mouth with water. Spit out the water. Do not swallow it. On 5/7/24 at 11:04 AM, V2 Director of Nursing stated V4 should have instructed R21 to rinse and spit after taking his combination inhaler. V2 said the purpose of rinse and spit is to prevent fungal infections in the mouth. V2 said nursing staff should follow manufacturer instructions for the resident's medications. 4. R26's Admission Record (Face Sheet) showed diagnoses to include of diabetes, long-term use of insulin, and depression. R26's Order Summary Report showed, as of 5/7/24, an order for 10 units of Lispro Insulin (fast acting insulin) to be injected twice daily. On 5/7/24 at 7:56 V4 Licensed Practical Nurse (LPN) prepared R26's prefilled multiuse insulin syringe (commonly referred to as an insulin pen). V4 attached the needled to the pen and dialed in 10 units. V4 did not wipe the tip of the pen with an alcohol wipe, and she did not prime the pen. V4 injected the lispro into R26. The insulin pen manufacturer instructions showed, Step 1: pull the Pen Cap straight off .wipe the rubber seal with an alcohol swab. The instructions showed after the needle is attached, Prime before each injection. Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime the pen, turn the dose knob to select 2 units. Step 7: hold the ben with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Step 8: Continue holding your pen with needle pointing up. Push the dose knob until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps 6 to 8 . On 5/7/24 at 11:04 AM, V2 Director of Nursing stated V4 should have wiped the tip of the needle with alcohol to prevent infection and she should have primed the needle to ensure R26 received the correct dose of insulin. V2 stated nursing staff should follow manufacturer instructions for resident medications.

Based on observation, interview, and record review, the facility failed to ensure resident safety by utilizing portable space heaters in hallways and not monitoring air temperatures. This failure affects all 43 facility residents. The findings include: The 1/15/24 facility data sheet showed 43 residents in the facility. On 1/15/24 at 7:13 AM, there were space heaters on the floor in the north hall outside room [ROOM NUMBER], 4, 6, and 14. The space heaters outside rooms [ROOM NUMBER] were plugged into outlets inside the room and the cord was on the floor. The space heater outside room [ROOM NUMBER] was plugged into a power strip which was plugged into an outlet in the hallway ceiling. The cord rested on the hallway floor. The space heaters on the floor in the south hall (outside rooms [ROOM NUMBERS]) were plugged into an outlet inside the rooms as the heater and cord were on the floor outside the rooms. A portable space heater outside room [ROOM NUMBER] was plugged into a power strip which was plugged into an outlet in the hallway ceiling. The cord rested on the hallway floor. At 7:22 AM, R1 was seated at a dining room table with a coat on. R1 said yes it was cold in the facility, but he wasn't complaining. R3 was seated at another table with a fleece jacket and gloves on. R3 said he was all set for the cold. At 7:28 AM, V1 Administrator said they were doing everything they can, so they don't have to send anyone out. V1 said the temperature in the facility dropped to 67 degrees Fahrenheit yesterday so they put space heaters out. At 7:35 AM, V2 Director of Maintenance checked ambient temperatures and were as follows: South Hall Dining room- four separate areas- 56 degrees, 61.4 degrees, 60.2 degrees, 62.6 degrees. Activity room (separated by a plastic zipped partition from the end of the south hallway- 51.2 degrees, 48.5 degrees. room [ROOM NUMBER]-62.9 degrees, 60.8 degrees. room [ROOM NUMBER]-64.7 degrees, 62.0 degrees. Wall outside medication room near main entrance-65.6 degrees, 67.0 degrees. North Hall Room10- 61.1 degrees, 63.5 degrees. room [ROOM NUMBER]- 62.6 degrees, 68 degrees. West Hall TV Room- 56.3 degrees, 59.9 degrees. room [ROOM NUMBER]- 60.8 degrees, 66.2 degrees. West hallway- 64.4 degrees, 63.2 degrees. room [ROOM NUMBER]- 68.3 degrees, 72.8 degrees. R1 was in room [ROOM NUMBER] visiting and said it's an icebox in his room with a steady breeze coming through the window. R1 said he sleeps with his coat on. The north hall contained the only thermostat in the building. It was on a wall inside a clear locked box. The box had white paper inside and therefore could not see the temperature that was registered. V2 unlocked the box, removed the paper and the temperature was 66 degrees. Resident rooms had an outside and inside room temperature checked. The outside wall temps were consistently the lower of the two readings. The space heaters were in use in the north and south halls. The resident rooms on the west hall had heaters built into the wall of the rooms. R1-3, and R6-9 said they were asked today if they wanted to move to a warmer room. On 1/15/24 at 6:55 AM, V3 Registered Nurse said it's cold in here. I've seen a lot of space heaters in the halls. At 7:03 AM, V4 Medical Records said I think we've had an issue with the heat forever. At 7:05 AM, V5 Licensed Practical Nurse (LPN) said she doesn't know what the plan is. They have the space heaters out. Maybe move some residents to a warmer hall. At 7:08 AM, V6 Certified Nursing Assistant (CNA) said if a resident complained of being cold, she would put heavier clothes on them and go to managers. V6 said she had been at work since 2:00 AM and the space heaters were out when she got there. At 7:11 AM, V7 CNA said there's been an issue with the heat for a few months now. Some residents complain of being cold since winter started. The space heaters were put out last night before 6:00 PM. V8 CNA Coordinator put them out. Last night we warmed up some blankets in the dryer and gave them to the residents and offered them warm beverages. At 7:28 AM, V1 Administrator said the west hall rooms have wall heaters, so the room temperatures are warmer if the door is kept closed. V1 said the portable heaters are being used on the north and south halls. At 7:45 AM, V2 said the lowest temperature recorded in a resident room was 63.5 degrees. V2 said he doesn't record all temperature readings he takes. At 7:52 AM, V2 said he had done daily temperature checks in random areas since October. V2 said he did not receive any calls about low facility temperatures necessitating the use of portable space heaters. When I left Saturday morning (1/13/24) there were no space heaters out. V2 could not explain why there were no temperature checks logged since 1/8/24. At 8:50 AM, V8 CNA Coordinator said it was colder than average in the building yesterday (1/14/24). V8 said he called V1 to notify her of the cold temps and she told him to get out the space heaters. V8 said the heaters were put out around 10:30-11:30 AM, before lunch. V8 said staff don't check the air temperature in the facility, only V2 does. V8 said they offer extra blankets to the residents when it's cold. V8 took this surveyor to the laundry room where there were two clean blankets available. The clean linen closet did not have any blankets available for use. V8 said no resident room changes had been done. V2 provided this surveyor with his ambient temperature logs. There were no temperature checks recorded since 1/8/24. The lowest temperature recorded was 64.7 degrees in room [ROOM NUMBER]. A water temperature log was provided. This log showed room temperatures added next to water temperature recordings. The lowest temperature on this log was 70 degrees. The facility's undated Power Strip Surge Protector Policy showed they can only be used for small electronics (alarms, TVs, media players) and can not be used with any medical equipment or supplies. The facility's undated Cold Weather Policy and Procedures showed to provide continuing, safe, and comfortable care to its residents in the event the facility heating, and furnace systems fail during periods of unseasonably cold outside temperatures, facility personnel shall take the following action: Staff will be assigned to do 15-minute temperature checks throughout all areas of the building. Residents will be offered the option of changing rooms to warmer rooms. Facility will implement the use of space heaters with visual monitoring of space heaters to assist in maintaining/elevating the temperature. The 1/14/24 facility census report printed at 7:28 AM, showed there were ten empty beds available on the west hall. Most of the facility residents have mental illness, impaired cognition and/or head injury status and self ambulate.

Based on observation, interview, and record review the facility failed to reconcile controlled medications and failed to ensure controlled medications were administered immediately after preparation for 3 of 3 residents (R16, R27, R35) reviewed for medication administration in the sample of 12 and 2 residents (R8, R1) outside the sample. The findings include: 1. On [DATE] at 09:23 AM, a locked cabinet in the medication room had a medicine inventory bag labeled with R35's name. This label showed the bag contains a bottle of Norco (schedule II drug) - quantity 6 and Ativan (schedule IV drug) - quantity 6. There was no dosage for the medications on the bag label. This surveyor requested a reconciliation form for the Norco and Ativan. V3 (Registered Nurse/RN) was unable to provide a reconciliation form for R35's stored controlled medications. On [DATE] at 9:23 AM, V3 she did not count R35's Norco and Ativan at shift change and wasn't aware they were in the cabinet. V3 said she would leave them on the counter to figure it out. R35's face sheet showed a [AGE] year old male admitted to the facility on [DATE]. R35's face sheet and Physician Order Sheet (POS) showed diagnoses of major depressive disorder, alcohol abuse, cocaine abuse, chronic pancreatitis, post traumatic stress disorder, anxiety and diabetes. R35's POS does not have an order for Norco. A photocopy of R35's medicine inventory bag showed a label dated [DATE] with an inventory of Norco quantity 6 and Ativan quantity 6. There was no dosage of the pills noted. 2. On [DATE] at 08:31 AM, there were two medication carts in the medication room. One cart held medications for residents with last names beginning with the letters A-K and the second for the residents with last names beginning with the letters L-Z. On [DATE] from 8:33 AM- 8:43 AM, the controlled drug count in both medication carts were counted and were accurate. All morning medications for the morning medication pass were already removed from the individual resident medication cards. The A-K cart had prepared medication cups with resident names written on them for R1, R8, R16. The L-Z medication cart had a prepared medication cup with R27's name written on it. On [DATE] at 02:01 PM, V3 (RN) said it was ok to pre punch meds because it's a closed locked room and she didn't leave it unattended. V3 said everything is double locked. V3 said Yes, she pre punched the resident medications including the controlled drugs. V3 said the nurse is the only person with keys to the medication room. R1's POC showed a [AGE] year old female with diagnoses of chronic catatonic schizophrenia partially resolved, bipolar-depressed, obsessive compulsive disorder, and hypertension. This order sheet showed medications for morning medication administration included lorazepam 1 mg (milligram) tablet. R8's POS showed a [AGE] year old female with diagnoses of schizoaffective disorder, hypertension, paranoid schizophrenia, bipolar disorder with psychotic features, obesity, and hypertension. This order sheet showed medications for morning medication administration included lorazepam 0.5 mg tablet. R16's POS showed a [AGE] year old male with diagnoses of schizoaffective disorder, diabetes, bipolar, coronary artery disease, major depressive disorder, and obesity. This order sheet showed medication for morning administration included lorazepam 0.5 mg tablet. R27's POS showed a [AGE] year old female with diagnoses of schizophrenia, paranoid delusions, depression, anxiety, agitation, congested heart failure, and hypertension. This order sheet showed medication for morning administration included lorazepam 0.5 mg tablet (,d+[DATE] a tablet). On [DATE] at 10:30 AM, V1 (Administrator) said, It is concerning that V3 saw nothing wrong with pre-punching resident medications including controlled drugs. The nurses are not supposed to prepare the medications ahead of time. A resident could go in the med room or the nurse could grab the wrong resident's medications. They should be looking at the MARs as they're preparing the medicine just before administration. The policy is in place to prevent medication errors and drug diversion. If we're not reconciling controlled drugs, we aren't preventing diversion. On [DATE], V2 (Director of Nursing) was called for an interview, and the call was not returned. The facility's [DATE] Controlled Substances Policy showed that all drugs listed as schedule II drugs are subject to specified handling, storage, disposal and record keeping. The policy showed at the time a Controlled Substance is delivered, the Charge Nurse and the Delivery Person will count the controlled substances together to verify the count. If the Controlled Substance count is correct, a control sheet for each prescription will be initiated. The control sheet will contain: resident's name, ordering physician name, issuing pharmacy, name and strength of drug, quantity received, and date and time received. All Schedule II drugs must be administered and recorded on a disposition sheet as follows: date and time of administration, signature of nurse administering the drug, and quantity on hand/balance left. The drugs in other schedules deemed necessary for control are placed under the same restrictions as Schedule II drugs by the pharmacist. The drugs in Schedule II (and those in other schedules which have been restricted and stored in the Controlled Substance cabinet) will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty. These records shall be retained for at least one (1) year. The disposition sheet for a particular regulated drug is placed separately and it will be filed with the permanent record of the resident when that regulated drug had been administered or discontinued (Dc'd). Scheduled drugs may not be returned to the pharmacy upon a resident's discharge/transfer/death. Upon discontinuation of the medication or non-return of the resident within 7 days, the scheduled drug may be destroyed by the Director of Nursing and a Licensed Nurse, two (2) Licensed Nurses with documentation and signature of both on the drug disposition record. The facility's [DATE] Drug Release/Destruction Policy showed prescribed drugs left by a discharged resident or remaining due to a physician stop order shall be destroyed if the non-unit dose drugs do not qualify for returning to the issuing pharmacy. Discontinued medications or medications belonging to discharged residents should be destroyed as soon as practical and within 7 days of resident discharge or drug discontinuation. Drugs belonging to discharged residents who are expected to return within 7 days may be stored in the facility, under state and federal regulation and facility policy for up to seven days. Non-controlled drugs and schedule V controlled drugs may be destroyed in the presence of two (2) licensed nurses. Scheduled II, III, and IV controlled drugs must be destroyed by the Director of Nursing and a Licensed Nurse, two (2) Licensed Nurses or a Licensed Nurse and Consultant Pharmacist. The facility's [DATE] Procurement and Storage of Medications Policy showed newly admitted residents who have brought medication with them are to have new orders from the physician before any medication is administered. All other medication is sent home with the family of the resident. All discontinued/expired non-controlled medications are to be removed from the active medication storage area, and the quantity should be noted on the medication sheet. All medications should then be returned to pharmacy or destroyed per facility policy as soon as practical. All controlled substances are to be destroyed according to the facility policy and procedure. The facility's [DATE] Medication Administration Policy showed the complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. Document any medications not administered for any reason by circling initials and documenting on the back of the MAR (medication administration record) the date, the time, the medication and dosage, reason for omission and initials. Destroy medications prepared for a resident if not used immediately.

Based on observation, interview, and record review, the facility failed to remove resident medications from storage and failed to destroy medications prepared and not administered for 2 of 2 residents (R15, R29) reviewed for medication storage in the sample of 12 and three residents (R20, R39, and R41) outside the sample. The findings include: 1. On [DATE] at 8:58 AM, during the medication storage task, in the bottom drawer of the A-K medication cart there were two large clear plastic storage bags with pill bottles in them. The pill bottles were labeled as belonging to R15. There was a total of 20 pill bottles. On [DATE] at 9:00 AM, V3 (Registered Nurse/RN) said R15, R41, R29 and R20's medications found stored in the medication room were probably brought in when the resident was admitted . V3 did not know who was responsible for overseeing the facility's medication storage. On [DATE] at 10:30 AM, V1 (Administrator) said resident medications should not be stored in the facility more than 7 days according to the facility policy. On [DATE], V2 (Director of Nursing) was called for an interview, and the call was not returned. R15's face sheet showed a [AGE] year old male admitted to the facility on [DATE] and diagnoses of schizophrenia, Type 2 Diabetes, morbid obesity, obstructive sleep apnea, and chronic obstructive pulmonary disease. The facility's [DATE] Drug Release/Destruction Policy showed prescribed drugs left by a discharged resident or remaining due to a physician stop order shall be destroyed if the non-unit dose drugs do not qualify for returning to the issuing pharmacy. Discontinued medications or medications belonging to discharged residents should be destroyed as soon as practical and within 7 days of resident discharge or drug discontinuation. Drugs belonging to discharged residents who are expected to return within 7 days may be stored in the facility, under state and federal regulation and facility policy for up to seven days. Non-controlled drugs and schedule V controlled drugs may be destroyed in the presence of two (2) licensed nurses. Scheduled II, III, and IV controlled drugs must be destroyed by the Director of Nursing and a Licensed Nurse, two (2) Licensed Nurses or a Licensed Nurse and Consultant Pharmacist. The facility's [DATE] Procurement and Storage of Medications Policy showed newly admitted residents who have brought medication with them are to have new orders from the physician before any medication is administered. All other medication is sent home with the family of the resident. All discontinued/expired non-controlled medications are to be removed from the active medication storage area, and the quantity should be noted on the medication sheet. All medications should then be returned to pharmacy or destroyed per facility policy as soon as practical. All controlled substances are to be destroyed according to the facility policy and procedure. The facility's [DATE] Medication Administration Policy showed the complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. Document any medications not administered for any reason by circling initials and documenting on the back of the MAR (medication administration record) the date, the time, the medication and dosage, reason for omission and initials. Destroy medications prepared for a resident if not used immediately. 2. On [DATE] at 8:58 AM, in the bottom drawer of the A-K medication cart was a pill bottle with R41's name and labeled as containing fluoxetine 40 mg (milligram) capsules and an expiration date of [DATE]. R41's face sheet showed a [AGE] year old female admitted on [DATE] with diagnoses of major depressive disorder, intellectual disabilities, schizoaffective disorder, asthma, and hypertension. 3. On [DATE] at 8:58 AM, in the bottom drawer of the A-K medication cart were two pill bottles with R29's name. One bottle showed escitalopram 20 mg tablets and was filled on [DATE]. There were three pills in this container. The second bottle showed bupropion XL 300 mg tablet. There were 16 pills in this container. R29's face sheet showed a [AGE] year old female admitted on [DATE]. R29's Physician Order Sheet does not include a current order for escitalopram or bupropion. R29's [DATE] post acute discharge orders (admission to facility orders) showed orders for escitalopram 10 mg tablet take 2 every day and no order for bupropion. 4. On [DATE] at 09:07 AM, there were 3 clear plastic med cups stacked on top of each other in the top drawer of the L-Z medication cart. The cups had R39's name on it. One cup had 2 medication tablets and one capsule. The other cup had one tablet and 1 capsule. On [DATE] at 9:07 AM, V3 (RN) identified the pills as R39's evening and bedtime medications from [DATE]. V3 said she worked [DATE] and reported to the second shift nurse that R39 left the facility for an overnight home visit. V3 said the nurse must have punched the medications, not given them, and left them in the cart. R39's face sheet showed a [AGE] year old female with diagnoses of bipolar disorder, chronic tension-type headache, and morbid obesity. R39's Medication Administration Record (MAR) showed famotidine 20 mg tablet, Geodon 20 mg capsule, gabapentin 300 mg capsule, and trazadone 100mg tablets (2) circled for the 4:00 PM and 8:00 PM doses on [DATE]. There was no documentation on the back of the MAR to explain why the medications were not given. There was no nurse's note showing R39 was out of the facility. The facility sign out log showed R39 left the facility for a leave to home on [DATE] at 7:15 AM and returned on [DATE] at 1:00 PM. 5. On [DATE] at 09:23 AM, there was a sealed dated security bag found in a locked medication cabinet in the medication room. The bag was labeled with R20's name. The label showed a date of [DATE]. The contents of the bag listed on the label included lithium 150 mg, lipitor 20 mg, trazadone 100 mg X 2, metoprolol 25 mg, lisinopril 10 mg, synthroid 88 mcg(microgram), and buspar 10 mg. A copy of R20's security bag showed a label dated [DATE] and the contents included the medications as listed above. R20's face sheet showed a [AGE] year old female admitted on [DATE] with diagnoses of bipolar disorder, recurrent depressive disorder severe with psychosis, chronic obstructive pulmonary disease, and generalized anxiety disease. R20's Physician Order Sheet showed no orders for lithium, Lipitor, trazadone 100 mg, Synthroid 88 mcg or buspar. R20's [DATE] discharge orders (facility admission orders) showed to stop taking lithium and buspirone. There was no order to take lipitor.

Based on observation, interview and record review the facility failed to have a process in place to monitor the screening of employees and public health personnel, failed to follow infection control practices related to COVID-19, and failed to maintain social distancing for residents in the dining room. This failure could potentially cause further outbreak of COVID-19 in the facility. This non-compliance creates a need for immediate corrective action to prevent further transmission of COVID-19 within the facility. The Immediate Jeopardy began on 2/9/21 when surveyors were not screened upon entrance, there was no signage prior to entry into the isolation unit or resident rooms to identify necessary required PPE, staff were not utililizing PPE properly on and off of the isolation units, social distancing was not observed during dining and used COVID test kits were stored unprotected in an office mailbox. The Immediate Jeopardy was identified on 2/11/21. V1 Administrator was notified of the Immediate Jeopardy on 2/11/21 at 10:00 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 2/16/21, but noncompliance remains at Level Two because additional time is needed to evaluate the effectiveness of the in-service training. The findings include: The facility's Resident Census and Condition of Residents form dated 2/9/21 showed 48 residents in the facility. 1. On 2/9/21 at 12:00 PM, there was no signage at the entrance to the isolation area indicating what Personal Protective Equipment (PPE) was required to enter. All three residents (person under investigation (PUI) rooms) and the two COVID positive rooms lacked signage on the doors or in the units to indicate what PPE is required prior to entering. All PPE for PUI and COVID+ isolation is located within the yellow and red zones. Gowns and gloves are not donned prior to entrance. V8 Certified Nursing Assistant (CNA) was sitting in R149's room in the PUI unit. At 12:45 PM, V6 CNA exited the yellow zone isolation area without removing or disinfecting her goggles. At 1:05 PM, V7 CNA enters yellow zone, removed her N95 face mask and put it in her pants pocket. V7 then removed her goggles. V7 put on a surgical mask and replaced her goggles. V7 then entered R149's (PUI) room to relieve V6. V6 exited the yellow zone and zipped the plastic barrier closed. V6 did not perform hand hygiene or disinfect her goggles. V6 proceeded down the hall pulling up her pants with her ungloved hands. R149's door was open during observation on February 9th and 10th with staff present in the room at all times. On February 9, from 12:00 PM- 1:30 PM, three different CNAs entered the isolation area and R149's room. At 1:20 PM, V10 Activity Director entered the yellow zone and put on a gown and gloves. V10 did not cover her N95 mask with a surgical mask. V10 entered R149s (PUI) room and delivered a plate of food. V10 then entered R17s (PUI) room and delivered a plate of food. R17's room walls were covered in colored pages and loops of garland hanging from the ceiling. There was not much bare wall visible above R17's bed with all the colored pages affixed to the walls.V10 then entered R5s (PUI) room and delivered a plate of food. V10 went to the entrance of the yellow zone and removed her gloves and gown. V10 walked the length of the yellow zone (without a gown or gloves) and entered the red zone. V10 left the zippers open to the yellow and red zone entrances. V10 donned a gown and gloves while in the red zone and entered both R24 (COVID+) and R39s (COVID+) room to deliver plates of food. V10 removed her gloves and gown in the red zone and walked through the yellow zone before exiting. V10's goggle and face mask were not changed or disinfected before or after leaving the yellow zone. V10 did not change her PPE between resident rooms. V10 then entered R25 and R33's room (immediately outside the isolation area) wearing same mask and eye protection worn throughout the yellow and red zones. R25 has not tested positive for COVID-19. On 2/9/21 at 10:00 AM, R41 said you should see my old room next door. I have colored pages and strings of garland tacked all over the walls and ceilings. At 1:00 PM, R17 said this stuff isn't mine. The decorations (garland and colored pages) were here when I got here. On 2/10/21 at 9:23 AM, V2 Director of Nursing (DON) said the facility's PPE supplies are good. They do not have any problem obtaining PPE when needed. They do not reuse or extend the use of their PPE. V2 said there is enough PPE onsite. V10 said PPE used in the yellow zone (PUI) included a reusable gown and gloves. Staff should always wear an N95 face mask and eye protection when in the facility. Staff should apply a surgical mask over their N95 when in the yellow and red isolation areas. Staff should wear disposable gowns when in the red zone. PPE should be changed between resident rooms and removed prior to leaving the zones. N95 and goggles. It is acceptable to wear an N95 face mask all day as long as it is covered with a surgical mask while in the isolation zones. It is acceptable to wear the same goggles all day in and out of isolation zones and sanitize as needed. It is required to sanitize the goggles after leaving the isolation zones so we're not cross contaminating other residents or staff. We reuse goggles. We were never told to dispose of them after use. We try to have designated staff for the isolation units. It's important to have dedicated staff for the isolation unit to reduce the spread of COVID-19. Dietary staff should wear the PPE the same as nursing staff and change their PPE between resident rooms. A surgical mask should be worn over their N95 mask. The N95 stays on and the surgical mask is changed. V2 acknowledged there was no signage in or near the isolation unit. We need to get our laminator to work. Signage is important so staff are reminded what PPE is required. V2 said R149 had [MEDICAL CONDITION] so was placed on precautionary 1:1 observation. All room doors on the isolation unit should be closed to contain the infection and prevent the spread to others. (In regards to R17's room) V2 said all resident belongings should be removed and cleaned prior to the room being occupied by another resident. I'm sure all the walls were cleaned except for where the papers are at. The facility's 5/30/14 Routine and Terminal Cleaning of Isolation Rooms Policy showed the purpose is to ensure all resident isolation rooms are clean and to prevent the spread of microorganisms. Microorganisms are a normal contaminant of walls, floor, and other surfaces; these environmental surfaces rarely are associated with transmission of infections to residents or personnel. Therefore, extraordinary attempts to disinfect or sterilize these environmental surfaces are rarely indicated. However, routine cleaning and removal of soil are recommended. Remove all non-disposable resident care items by the double bagging method and take to the soiled utility room for cleaning and disinfecting. Discard all disposable items in the appropriate trash container in the room. Remove all trash by the double bagging method and take to the appropriate biohazard waste container. The facility's 7/29/20 COVID-19 Control Measures policy showed Contact Precautions-Post signage on door. Change gloves and gowns after contact with a resident and perform hand hygiene. Perform hand hygiene before and after touching the resident, resident's environment and/or residents respiratory secretions even if gloves are worn. Remove PPE when leaving a residents room. Droplet Precautions-Post signage on door. Wear a facemask/N95, gloves, gown, and goggles or face shields when entering room or when working within 6 feet of residents on droplet precautions. Remove PPE when leaving residents room and perform hand hygiene. New admissions and re-admissions whose COVID status is unknown, should be placed in a private room and all recommended COVID-19 PPE should be worn during care of residents under observation, which includes an N95 respirator, eye protection, gloves and gown. Staff should be assigned to primary halls, as much as possible. Increase frequency of cleaning and disinfecting of high touch areas with an EPA, hospital grade disinfectant that is effective against COVID-19. Clean all resident rooms daily. The facility's 12/7/18 Face Mask/Face Shield/ Goggles policy showed goggles are disposable and should be discarded after use. The facility's 8/26/20 COVID-19 Cohorting of Residents policy showed to minimize interaction of infectious individuals(s) from non-infected individuals. Identify health care personnel who will be assigned to work only within the dedicated (COVID) area, when in use. Increase monitoring of staff on infection control measures. The facility's 5/29/20 Emergency Plan for Infectious Disease/Epidemic/Pandemic and Staffing Strategies document showed the facility will follow all required Infection Control Policies and recommendations from CDC, local, state and federal authorities. The facility's 12/7/18 Transmission Based Precautions (TBP) Policy showed precautions are designed for patients documented or suspected to be infected with highly transmissible or epidemiologically important pathogens for which additional precautions beyond Standard Precautions are needed to interrupt transmission. Droplet Precautions are designed to reduce the risk of droplet transmission of infectious agents and apply to any resident known or suspected to be infected with epidemiologically important pathogen can be transmitted by infectious droplets. Contact precautions are designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. The facility's 12/7/18 Contact Precautions policy showed to remove gloves before leaving the residents environment and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. After glove removal and handwashing, ensure that hands do not touch potential contaminated environmental surfaces or items in the resident's room to avoid transfers of microorganisms to other resident's environment. Remove the gown before leaving the resident's environment. 2. On 02/09/21 at 8:35 AM upon entrance into the facility, no hand sanitizer was available for hand hygiene, no working thermometer was available for temperature screening. The survey team waited approximately 20 minutes for staff to locate a working thermometer. Screening papers were handed to the surveyors for completion, and V5 checked temperatures, but did not inquire about any responses on the screening tool. At no time during the survey did any staff request to review the surveyors screening tool. During this time, V1 (Administrator) entered the facility without any mask covering. On 2/9/21 and 2/10/21, no facility staff requested for surveyor team to recheck their temperatures, or review the screening form. On 2/9/21 at 10:25 AM, V5 said he reviews the screening questionnaire once a month to see if they are all completed. Staff have been pretty good about getting them done. The screening book was reviewed for the staff in the facility, and the screening forms were not located in the book. V5 said some of the staff will keep their sheets with them and he has to ask where the forms are located. He said staff should be checking their temperature every 4 hours, so they keep their forms to put the second temperature. V5 said it was acceptable to walk into the facility without a mask because the masks are on the back door wall, staff can get their mask after entering. At the employee entrance, V5 said there was now a thermometer that works, but no hand sanitizer available. V5 said the facility currently 2 positive covid residents and 2 PUI (persons under investigation). On 2/9/21 at 10:55 AM, V2 Director of Nursing (DON) said V5 and herself both make sure the screenings are completed. V5 will check them daily, but weekly to make sure the second temperature is documented. Staff have been consistent about completing the every 4 hour temps. On 2/9/21, at 2:00 PM, V2 and V5 presented their screening forms kept their office. CNA screenings were located in a cabinet. V1 had a screening in the book and another in her office. The nurse and vendor screenings were in a binder located in the chart room. Other staff screenings were located in the screening log book. On 2/10/21 at 10:10 AM, V2 DON said staff enter through the back door and put on their N95 mask, we do not require a mask to just come into the building. Once the have their mask, they take their own temperature, and answer the screening questionnaire. Staff should be using hand sanitizer and then report to the floor. V2 said the staff have been educated to report any elevated temperature or symptoms. V2 said she feels her staff is honest enough and would not lie. V2 said at the end of December the staff were in-serviced regarding checking their temperature twice a shift and record it on the screening form. On 2/10/21 at 9:50 AM, V4 LPN said she only checks her temperature once a day, she had not been instructed to check it twice a day. Each day she completes her temperature and answers the questionnaire about symptoms and files it into the book. V5 will collect the pages when they are full. V4 said the nurses and visitors screenings are kept in a different book from others. V4 said V5 is a CNA and he is reviewing the screenings, and V2 has done no oversight on the covid unit or procedures. On 2/10/21 at 7:30 AM, V5 asked this surveyor if the same screening was used for the second day of survey. V5 did not request to review the form, or what current temperature reading was for the day. The Employee, Vendor consultant COVID screening Questionnaire documents the form is to be completed upon entrance to the facility. In an effort to protect our residents and staff from illness, we are screening all employees, vendors, surveyors, ombudsmen, and consultants. Subsequent evaluation should be completed every 4 hours while in attendance of residents. The screening log book was reviewed and found 7 staff screening upon entrance and not re-screening every 4 hours. On 2/9/21 at 10:30 AM, V11 LPN MDS Coordinator was observed in the hallway. A search of the employee screening forms shows she did not screen herself prior to entering the resident areas of the facility. V11 said she came in at 10:00 AM, and took her temperature but did not remember to complete the screening form. The facility's policy for Covid-19 control measures for Monitoring and Surveillance- Employees 1. Screen all employees prior to beginning of shift and every four hours. 3. On 2/11/21 at 9:00 AM, COVID tests were observed in the DON mailbox. V2 said the tests were from yesterday's second and third shift employees. She said the tests are all negative, the staff write their name on the testing card and put it in my mailbox when they are completed. V2 said the results are logged as completed. V2 removed the used tests with an ungloved hand and the papers underneath the cards. She took the tests into her office and placed them onto a box. V2 did not perform hand hygiene after contact with the test cards. The facility's 8/26/20 policy for COVID-19 control measures documents Respiratory Hygiene/Cough Etiquette/ Hand Hygiene/PPE 5. All staff is to perform hand Hygiene when exiting a resident's room, after direct contact with residents or potentially contaminated surfaces. 4. On 2/9/21 at 1:13 PM, R25 was sitting at a four chair table eating her lunch. R35 wheeled himself into the dining room. R25 stood up and slid to the adjacent chair and sat down. R35 wheeled up to the table where R25 had just been sitting and positioned his chair at the same table. R25 and R35 were at the same table less than six feet apart and were not wearing masks. V10 (Activity Aide) brought R35 his lunch and returned to the kitchen. She did not socially distance the two residents. At 1:18 PM, V6 (CNA) came into the dining room and stood right next to R35 and spoke to R25 about her lunch. V6 left the dining room without socially distancing the two residents. At 1:25 PM, V9 (Dietary Aide) brought a new pureed sandwich to R25 and returned to the kitchen. R35 was still sitting next to R25 eating his lunch. V9 did not intervene and socially distance R25 and R35. At 1:33 PM, R35 finished his lunch and wheeled himself out of the dining room. On 2/10/21 at 9:23 AM, V2 said it is important to socially distance to prevent the spread of covid 19 to one another . The facility's policy for covid-19 measures documents Additional Actions. 2. Suspend communal dining. Identify asymptomatic residents, requiring assistance and who are high risk for choking, and allow in- dining or other designated area for observation and assistance during meals. Maintain social distancing to other residents. The Immediate Jeopardy that began on 2/11/21 was removed on 2/16/21 when the facility took the following actions to removed the immediacy: 1. The Regional Clinical Director, who is an Infection Preventionist, reeducated the Director of Nursing via phone on infection control measures, proper screening/monitoring process of staff upon entry to building, ensuring equipment needed for the screening process is available and remains stocked, proper PPE usage in all areas including PUIs and COVID unit, as well as properly disposing of COVID kits on 2/11/21 at 11:00 AM. 2. The Director of Nursing conducted an in-service with staff on duty, to educate them on the importance of educating residents on social distancing, how to properly wear masks while in the hallway to and from their rooms, on 2/11/21 at 12:00 PM. Completion of in-servicing for all staff will be done 2/12/21. 3. The Director of Nursing conducted a in-service with staff on duty, on proper PPE usage while in yellow or red zones. Instructional signs were placed in each zone to remind staff of proper PPE needed in each zone, on 2/11/21 at 12:00 PM. Completion of in-servicing for all staff will be done 2/12/21. 4. The Regional Clinical Director, conducted an in-service on terminal cleaning with the DON on process and procedures of properly terminal cleaning a room prior to admitting a new patient to that room on the PUI unit on 2/11/21 at 3:30 PM. 5. The DON in-serviced the housekeeping supervisor on process and procedures of properly terminal cleaning a room prior to admitting a new patient to that room on the PUI unit on 2/11/21 at 3:40 PM. 6. The Housekeeping Supervisor has educated housekeeping staff on the process and procedure of properly terminal cleaning a room prior to admitting a new patient to that room on the PUI unit on 2/11/21 at 4:00 PM. 7. The Director of Nursing conducted an in-service with the nurses who provide COVID-19 testing on the proper disposal of test kits on 2/11/21 at 2:45 PM and will complete all licensed staff on 2/12/21. 8. The DON has in-serviced the management team on proper screening of incoming staff when entering the building to ensure staff are symptom free/hands sanitized and afebrile. The management staff have been educated also on the screening form and what procedure to take if abnormal findings are noted. The management staff will oversee the incoming staff responses on the monitoring form and report to the DON any abnormal findings. The DON will oversee the monitoring process daily. Completed on 2/11/21. 9. The DON will in-service all staff on proper screening of incoming staff when entering the building to ensure staff are symptom free/hands sanitized and afebrile. All staff will be educated on the screening form and what procedure to take if abnormal findings are noted. In the event that the management team is unavailable on duty staff will oversee the incoming staff responses on the monitoring form and report to the DON any abnormal findings. The DON will oversee the monitoring process daily. Completed on 2/12/21. 10. The facility from 8am-5pm will have an assigned staff person at the back door monitoring compliance with the screening process which includes screening form, hand hygiene, and temperature monitoring. Assigned staff member will also ensure that items needed for screening remain stocked. After 5pm staff will need to call the facility and notify the charge nurse of their presence to complete the screening. The removal plan is executed as required in response to a Statement of Deficiencies against the facility known as Rock River Gardens. This Removal Plan is not an admission of an agreement with the validity of any facts or violations cited in the summary statement of deficiencies. This Removal Plan is not a waiver of any rights of defense, which may be available under Illinois Statutes, Illinois Administrative Code, or a Federal Law of Regulations. 11. Additional measure for continued compliance: The IDT team will meet and discuss items related to: infection control practices, screening/monitoring of staff, usage of PPE on PUI/COVID unit during the QA daily meeting. 12.The DON will conduct daily rounds to monitor for compliance of infection control practices, screening of staff and appropriate PPE usage in yellow and red zones. Ad hoc education will be given immediately to staff during such rounds.

Based on observation, interview, and record review the facility failed to ensure a resident at risk for abuse was free from sexual abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 27. This failure resulted in R1 responding physically agressively toward (R22). The findings include: R1's medical record showed R1 was a [AGE] year old female. R1's medical record showed R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's acute behavioral healthcare hospital discharge paperwork signed July 1, 2019 showed R1 had a history of [REDACTED]. R1's complete current care plan was reviewed and showed no interventions to protect her against unwanted sexual advances, did not include her history of sexual abuse, and did not include any information regarding her violent reaction to unwanted touching, perceived sexual advances, or sexually inappropriate comments made by male peers. On March 3, 2020 at 8:50 AM, R1 was ambulating independently through the halls. R1 was not making eye contact with the other residents in the hall and walked from one end of the facility to the other at a rapid pace repeatedly. This surveyor approached R1 and requested to speak with her. R1 walked down to her room which was located one room from the end of the hallway. R1 said she was upset by something that had happened. R1 reported that she was sleeping when (R2) came into her room and laid in her bed with her. R1 said R2 began rubbing her back and legs and kissed her on the mouth. R1 said she tried to get him out of her room but R2 would not leave. R1 said she felt uncomfortable and did not want R2 touching her. R1 said R2 told her he was going to sleep next to her and then asked if she has had an orgasm. R1 explained a history of sexual assault to this surveyor and said it makes her feel very uncomfortable when she is touched by other residents. The facility investigations for resident to resident incidents were reviewed and showed three incidents of sexually inappropriate behavior involving R1. 1. The facility's investigation into an incident which occurred on February 21, 2020 between R1 and R2 showed R2 touching and speaking to R1 in a sexually inappropriate manner which resulted in R2's transfer to a behavioral health hospital. The investigation showed R11 and R23 both reported R2 coming into their rooms uninvited in the past. R1's nursing progress note dated February 22, 2020 showed, (R1) has made allegation of inappropriate touching against a male resident .R2's nursing progress note dated February 22, 2020 showed, Allegation of inappropriate touching made against resident by another female resident. (R2) immediately placed on one to one status . R2's nursing progress note dated February 26, 2020 showed R2 was transported to an acute behavioral health hospital. On March 4, 2020 at 11:35 AM, R23 said R2 has come into her room in the past and tried to kiss her. R23 said she told him she did not like him doing this and to stop. On March 4, 2020 at 3:06 PM, V9 CNA (Certified Nursing Assistant) said R2 has been known to go into other resident rooms. V9 said R1 had reported to her that R2 got in her bed and was rubbing her back and kissed her. V9 said R2 has a crush on another female resident and goes into her room uninvited a lot and she will yell at him and tell him to go away. R2's face sheet showed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's complete current care plan was reviewed and showed, (R2) has behaviors of being intrusive to others. He will go into the rooms of other residents, he will obsess over the needs of others and cause conflict.ns. R2's care plan does not identify any sexually inappropriate behaviors or statements and does not include any interventions for sexually inappropriate behaviors. R2's care plan does not address entering other resident's rooms uninvited. R2's nursing progress notes from October 2019 through current showed R2 has been difficult to redirect, intrusive to other residents, and has been entering other resident rooms uninvited multiple times. 2. The facility's investigation into an incident which occurred on February 14, 2020 showed a staff member heard R1 yelling Don't touch me, get away and witnessed R3 trying to kiss R1 and reaching for R1's breasts resulting in R3's transfer to a behavioral health hospital. R1's nursing progress note dated February 14, 2020 showed, (R1) was walking down the hallway when another resident grabbed her inappropriately R3's nursing progress note dated February 14, 2020 showed, (R3) was observed inappropriately touching another female resident . R3's face sheet showed he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. (No interventions had been added since June 17, 2019) This care plan showed, Resident is known/has history of displaying inappropriate boundaries with staff members. R3's care plan did not address any sexually inappropriate behaviors or inappropriate boundaries toward other residents. 3. The facility's investigation into an incident which occurred between R1 and R22 on September 23, 2019 showed R22 was heard by staff making sexually inappropriate comments to R1 causing her to react violently and resulting in R22 being transferred to a behavioral health hospital. R1's social services progress note dated September 23, 2019 showed, (R1) reported that a male resident (R22) was making inappropriate comments towards her . she told him to stop and leave her alone but the male resident continued .(R1) also said she wanted to speak to someone about her past of 'being touched' . R22's nursing progress note dated September 23, 2019 showed, Resident was heard sexually harassing another resident . they were immediately separated and (R22's) sexual comments and verbally inappropriate comments became worse . for resident and other residents safety the resident was going to need to be sent out for evaluation . R22's social service note dated September 23, 2019 showed, (R22) was upsetting a female resident by saying things to her about sexual contact . (R22) said 'oh you want him to molest you again' . (R22) was sent out for an evaluation . The facility's investigation in to the incident that occurred between R1 and R22 on September 23, 2019 showed a staff member had heard arguing in the hallway. When the staff member responded to the area she overheard R22 making sexually inappropriate comments to R1. R1 began arguing back and in the moment was unable to control herself and made physical contact with R22's chest. During the facility's investigation R1 was interviewed and said she tried to hit R22 in the face. R1 said R22 pushed her and she hit him in the chest. R22 was unable to be calmed down and this incident resulted in R22 being sent to an acute behavioral hospital for evaluation. R22's nursing progress note dated September 23, 2019 showed, Resident was heard sexually harassing another resident. He pushed the other resident too far with his comments and she swung and made contact twice. It was once on his chin/chest and his chest the second time . R22's social services progress note dated September 23, 2019 showed, (R22) was upsetting a female resident (R1) by saying things to her about sexual contact . This is when the female turned around and punched him in the face . R1's social services progress note dated September 23, 2019 showed, (R1) reported that a male resident (R22) was making inappropriate comments towards her . she told him to stop and leave her alone but the male resident continued and (R1) turned around and started hitting him . R22's face sheet showed he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. with one intervention added since its initiation. The care plan showed an intervention added on October 20, 2019 which showed, Be firm and remind (R22) that those types of comments are inappropriate and that he needs to stop. Redirect him to another area away from others. The care plan did not address sexually inappropriate behaviors directed toward other residents. On March 5, 2019 at 10:02 AM, V7 (Social Services Director) and V8 (Psychiatric Rehabilitation Services Coordinator) were interviewed together. V7 said she was aware of the incident that occurred between R1 and R2. V7 said R1 reacts violently to sexually inappropriate touching and responds quickly and defensively. V7 said this reaction is because R1's brother had touched her inappropriately when she was a young child. V8 said during a counseling session R1 told her she was raped in the past. V7 said R2 told her he did go into R1's room. V7 said R2 does go into other residents rooms and she has had to talk with him about this. V7 said R2 likes to go into another resident's room and watch her sleep. V7 said in order to protect R1 from R2 she feels that staff would have to be with him at all times, to protect R1 from R3 they are discussing starting him on birth control shots to decrease his sexual drive, and to protect R1 from R22 they have had conversations with him reminding him not to touch or speak inappropriately to other residents. The facility's abuse prevention policy dated February 2020 showed, .this facility affirms the right of our residents to be free from abuse . This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation neglect or abuse of our residents. This will be done by . establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment, exploitation, neglect and abuse of residents . Identifying occurrences and patterns of potential mistreatment, exploitation, neglect, and abuse of residents . sexual abuse is a non-consensual sexual contact of any type with a resident . Resident Assessment. As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of mistreatment, neglect, and abuse of these residents. Staff will continue to monitor the goals and approaches on a regular basis . The facility's resident council meeting minutes were reviewed and showed in December 2019 and January 2020 concerns were discussed with residents going into other resident rooms without permission.

Based on observation, interview and record review the facility neglected to follow their policies on notification for a change in condition or status, pain prevention, emergency care and treatment and the facility policy on abuse prevention by not assessing a resident and seeking treatment for [REDACTED]. This failure resulted in a delay in treatment and an increased need for assistance with activities of daily living (ADLs). The resident was admitted to a local hospital and was diagnosed with [REDACTED]. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 7. The findings include: R1 ' s initial MDS (minimum data set) of May 15, 2016 shows independence in ambulation and locomotion and R1 has not had any falls or behaviors. The MDS shows she is 51 inches tall and 192 pounds.R1 ' s MDS shows occasional mild pain. The psychiatric evaluation dated July 21, 2016 shows R1 is a [AGE] year old white female with a history of MR (mental [MEDICAL CONDITION]), [MEDICAL CONDITION] disorder, and borderline disorder. R1 ' s nurse's note dated September 16, 2016 shows R1 yelling that she can't walk, was lying in the hallway and continued to request an ambulance. This note shows R1 crawled to her room. The nurse's notes dated September 18, 2016 (7-3 shift) show R1 fell out of a chair in the TV room after taking her morning medications, refused to get up and rolled around (on the floor) until lunch time. R1 ' s nurse's note dated September 18, 2016 (3-11 shift) shows R1 was sitting naked on the shower floor. R1 was walked to her room (almost the whole length of the hallway) with a gait belt and three assistants supporting most of her body weight. R1 told staff, I don't want to be here. E14 RN (Registered Nurse) told her to discuss that with social services, the DON (Director of Nursing) and the Administrator. On September 22, 2016 at 8:50 AM, E12 and E13 maintenance measured the distance from R1 ' s room (room [ROOM NUMBER]) to the nurse ' s station/TV room and said it was 148 feet one way. The distance from R1's room to the north shower room was measured by E12 and E13 as 120 feet each way. On September 21, 2016 at 8:45 AM, R5 said R1 was screaming in pain for days because she couldn't walk for a few days before she went to the hospital. On September 21, 2016 at 9:00 AM, R6 said R1 complained she could not walk and they were trying to get her to. She was on the floor in the hallway (on Saturday, September 17th) and they just put cones around her so nobody would walk on her. R1 was screaming in pain for three days when she was trying to walk and they were trying to get her out of bed. She kept complaining to staff that she hurt and they thought she was faking it, I guess. R1 did not normally scream, yell and make a fuss. She would normally walk the halls. She yelled that she was in pain and could not walk. My room is directly across from hers. R6 said they should have sent her to the hospital. They think she was putting on a show. R1 was standing on her tippy toes to walk and they used gait belt and two people. They continued to walk her even though she was in pain. On September 21, 2016 at 9:50 AM, E5 CNA (certified nursing assistant) said they started using a gait belt and two people to assist with ambulation on Friday (September 16th) because it was the only way to get her up and walk. E5 said normally R1 walked on her own and I attributed her not walking to a behavior. On September 21, 2016 at 2:25 PM, E7 CNA said (on Friday, September 16th) R1 seemed to be in pain and said she had pain. I notified the nurse (does not recall which one) of her pain and incontinence as this was not normal. On September 21, 2016 at 1:55 PM, E4 LPN (Licensed Practical Nurse) said on Sunday (September 18th) R1 was still screaming and yelling I can ' t do it .I can ' t do it. I can ' t walk. R1 fell Saturday and Sunday. On September 22, 2016 at 9:05 AM, E15 PRSC (psychiatric rehabilitation services coordinator) said if a resident complained of pain for days and was forced to walk on a broken limb for days it would not affect their mental status . E15 said R1 suddenly became dependent, like a switch flipped . E15 said she worked the weekend of September 17-18, 2016. E15 said R1 was complaining of pain and the CNA ' s (certified nursing assistants) and nurses were aware of her complaints. On September 22, 2016 at 11:35 AM, Z1 (Orthopedic surgeon) said R1 ' s continued ambulation on the fractured leg would cause unnecessary pain, suffering and had to be pure misery. The facility ' s Pain Prevention and Treatment policy revised January of 2010, defines pain as an unpleasant sensory and emotional experience associated with actual or prtenial tissue damage or described in such terms of such damage. Pain is subjective and should be documented as perceived by the resident. Pain management is defined as the assessment of pain and if appropriate, treatment in order to assure the needs of residents who experience problem with pain are met. This document, under procedure number 2 states, Assessment of pain will be completed with changes in the resident ' s condition, self reporting of pain or evidence of behavioral cues indicative of the presence of pain. The undated facility ' s policy on emergency care states the facility will strive to provide emergency care to the residents as required. Under procedure numbers 3-4, the C.N.A. or Charge nurse is to assess the resident ' s condition and extent of injury or condition and report to the charge nurse immediately. The charge nurse shall attend to the resident ' s need for emergency treatment within his/her scope of capabilities and per facility protocol to stabilize the resident ' s condition. The facility ' s policy on Notification for change in a resident ' s condition issued July 1, 2012, has as its purpose for the facility and or facility staff shall promptly notify appropriate individuals (i.e. Administrator, DON (director of nursing), Physician, Guardian, HCPOA ,etc) of changes to the medical/mental condition and or status. Under Procedure number one, the nurse supervisor/charge nurse will notify the resident ' s attending physician or on call physician when there has been any symptom , sign or apparent discomfort that is sudden in onset, (is a) marked change in relation to usual signs or symptoms and is unrelieved by measures already prescribed. The facility ' s abuse prevention program defines neglect as the failure to provide , or willful withholding of adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish or mental illness of a resident

Based on observation, interview and record review the facility failed to provide nursing services by not assessing and identifying a medical injury for a resident who suffered two known falls on September 17 and 18, 2016. This failure resulted R1 complaining of pain and having an inability to walk due to the pain. This failure also resulted in a delay in treatment, a decline in the resident ' s control of continence of bowel and bladder and an avoidance of weight bearing activities. R1 was sent to a local hospital three days after symptoms began and was diagnosed with [REDACTED]. This applies to 1 of 3 residents (R1) reviewed for pain in the sample of 7. The findings include: R1 ' s initial MDS (minimum data set) of May 15, 2016 shows independence in ambulation and locomotion. R1 has not had any falls or behaviors. R1 has clear speech and is able to be understood and understands others. R1 self performs all ADLs (activities of daily living) and has no limitations in range of motion. The MDS shows she is 51 inches tall and 192 pounds.R1 ' s MDS shows she is cognitively intact and has occasional mild pain. R1 ' s psychiatric evaluation dated July 21, 2016 shows R1 is a [AGE] year old white female with a history of MR (mental [MEDICAL CONDITION]), [MEDICAL CONDITION] disorder, and borderline disorder. The nurse ' s notes dated September 15, 2016 show R1 required 2 assistants and a gait belt for transfer, refused to walk to get her medications, non-compliant getting out of bed, was yelling she needed an ambulance as she was unable to walk and this behavior started after her home visit was cancelled. R1 ' s social service progress note shows the facility spoke with R1 ' s father and POA (Power of Attorney) who said R1 ' s claim she cannot walk, is in pain and needs help are behaviors. There is no documentation the facility noted a history of these behaviors before this time. R1 ' s Psychosocial Assessment shows no rejection of care or attention seeking behaviors. R1 ' s nurse ' s notes dated September 16, 2016 show R1 continues to yell out and say she can ' t walk but was walked to the dining room with two assistants and her gait was unsteady. R1 refused to go to lunch and was observed lying on the floor in the hallway and crawled into her room. This note shows she continues to request an ambulance and staff redirected and encouraged her numerous times. (On September 22, 2016 at 8:50 AM, E12 and E13 maintenance staff measured the distance from R1's room to the nurse's station (to receive medications)/TV room and said it was 148 feet one way. On September 22, 2016 at 9:50 AM, E12 and E13 maintenance staff measured the length of the hallway from R1's room to the north shower and said it was 120 feet one way.) The September 16, 2016 3-11 shift note shows R1 refused to get out of bed. This note shows staff told her she needs to get up out of bed and CNA ' s (certified nursing assistant) encouraged her several times. The nurse ' s note dated September 17, 2016 (11-7 shift) shows R1 was yelling down the hallway and was incontinent multiple times throughout the shift. R1 ' s September 17, 2016 nurse ' s note (7-3 shift) shows R1 was incontinent of bowel and bladder twice that shift and R1 reported she rolled out of bed. This nurse's note shows R1 was then seated in the TV room and yelled the whole time she was there. This note shows R1 fell from the chair in the TV room, refused to get off the floor and rolled around until lunch. R1 refused to eat lunch. R1 ' s nurse ' s note dated September 18, 2016 (3-11 shift) shows R1 was incontinent and was brought to the medication room being held up by two CNA ' s and a gait belt. R1 ' s September 18, 2016 7:30 PM nurse ' s note shows R1 was sitting naked on the shower floor and was lifted to a chair by the RN (Registered Nurse) and two CNA ' s. R1 was told to lift up her leg to put on her underclothes and was reluctant to do as she was told. R1 was then walked to her room almost the whole length of the hall (as documented by the RN) with a gait belt and three staff supporting most of her weight. This note shows R1 said she doesn ' t want to be here and the RN told R1 to discuss that with social services, the DON (Director of Nursing) and the Administrator. R1 ' s nurses note dated September 18, 2016 (11-7 shift) shows R1 yelled throughout the shift, refused to ambulate to the bathroom and was incontinent of urine and feces multiple times. R1 ' s nurse ' s notes dated September 18, 2016 (7-3shift) show R1 received a sponge bath and was assisted by two staff and use of a gait belt to get morning medications. The September 19, 2016 10:30 AM emergency room note by Z4 (Nurse Practitioner) shows R1 told a staff person she fell on [DATE]. This note also shows there was a 3 cm (centimeter) bruise to R1's right groin and bruising to the outer aspect of the right knee. R1 also complained of pain with range of motion to the right hip. R1 ' s September 19, 2016 10:00AM nurse ' s note shows R1 was sent to a hospital. The facility transfer form for R1 ' s shows the reason for transfer was behaviors: refusing to ambulate, states she cannot walk, screams when staff attempt to ambulate and refusing meals. This transfer form shows the resident ' s symptoms began September 16, 2016 and R1 is usually continent of bowel and bladder and now is lying in bed incontinent. R1 ' s September 19, 2016 9:00 AM nurse ' s note shows R1 continues to refuse breakfast, to ambulate and be non-compliant. R1 ' s September 19, 2016 2:50 PM, case management progress note from a local hospital shows she was sent the emergency room to be evaluated for refusing to ambulate, states she cannot walk, refuses meals and screams when staff attempt to ambulate. This note shows the LTC (long term care) facility felt she was acting out because her father did not visit and there was a history of a recent fall. The food and fluid intake sheet for September 2016 shows R1 refused 10 of 13 meals (that require walking to the dining room) from September 15-19, 2016. R1 ' s Orthopedic physician consultation dated September 19, 2016, shows R1 was sent to the hospital for evaluation of unwillingness to eat, dehydration, refusing to walk for several days resulting in R1 defecating on herself and having to be cared for in bed. This physician consultation shows R1 had a right displaced femoral neck fracture, and she reported she fell in the shower three days ago. The physician history and physical shows the resident told the facility she had right hip pain but they thought she was depressed because her father did not visit. R1 ' s physical exam on this history and physical showed it was painful to move the right lower extremity. On September 20, 2016 at 2:50 PM, Z2 (hospital case manager) said there was concern R1 could not walk for three days and nobody realized it was a mechanical injury and not a behavior. R1 was in pain, immobile, had new incontinence and it went untreated. On September 20, 2016 at 2:00 PM, E11 CNA (certified nursing assistant) said R1 was usually up walking in the hall. E11 said this past weekend she was not up at all. E11 said R1 is a good historian and able to verbalize her needs. On September 21, 2016 at 9:20 AM, E8, CNA said he did not see R1 walk on her own Friday. E8 said he had to use a gait belt because R1 told him it hurt to walk. E8 said when he returned to work on Monday (September 19, 2016-two days later) R1 was still complaining of pain, still incontinent and still saying she could not walk. On September 21, 2016 at 9:50 AM, E5 CNA said R1 is able to verbalize her needs and did not normally complain of pain. E5 said Friday afternoon (September 16, 2016), R1 started being incontinent. E5 said when we wanted her to walk to get her meds she would complain. I attributed all of this to a behavior. On September 21, 2016 at 10:05 AM, E6 CNA said she was told in report by the night shift (on September 17, 2016) R1 had been incontinent and refused to get out of bed. This was unusual as she normally walked by herself. We were told to redirect her to do as much for herself as possible and were not made aware of any injury. E6 said beginning on Saturday, R1 required two assistants and a gait belt to walk On September 21, 2016 at 12:35 PM, R1 was lying supine in her hospital bed. Her speech was clear and she was oriented to person, place and time. R1 had good eye contact and showed no objective signs of pain (had hip surgery the day before). R1 said it made me feel like crap that I was in pain and they made me walk on my leg. I tried to keep walking on it. They said it would make me feel better. I never got good pain relief. They should have called the ambulance sooner. They said it was all a behavior and wouldn't listen to me when I told them it wasn't. It hurt. On September 21, 2016 at 10:35 AM E9 CNA said R1 started complaining on Friday she could not walk because her leg hurt. E9 said on Saturday R1 walked to the bathroom with moderate assistance and R1 leaned and put weight on E9 to walk. E9 said this was unusual as R1 is usually independent with care and does not require any staff assistance. E9 said R1 ' s incontinence started Saturday or Sunday and R1 looked like she was in pain. E9 said at first R1 walked and complained of pain (it seemed to get worse) then R1 started refusing to get out of bed for meals. E9 said E3 LPN (Licensed Practical Nurse) and E4 LPN knew R1 was complaining of pain, could not get out of bed and was incontinent over the weekend. On September 21, 2016 at 12:35 PM, R1 said it made me feel like crap that I was in pain and they made me walk. I tried to keep walking on it; they said it would make me feel better. I never got good pain relief. They should have called the ambulance sooner. They said it was all a behavior and they wouldn ' t listen when I told them it wasn ' t, it hurt. On September 21, 2016 at 1:30 PM E3 LPN said she was told that R1 ' s Dad said R1 claims she cannot care for herself when she is upset. I heard on Saturday R1 rolled out of bed. E3 said she would do a physical assessment to rule out medical symptoms of pain versus behavioral symptoms. E3 said R1 usually walks up and down hall unassisted. R1 ' s behavior tracking from July, August and September 2016 does not identify refusal of care, refusing to ambulate or incontinence as behaviors. On September 21, 2016 at 1:55 PM, E4 LPN said two weeks ago R1 was up walking by herself and on Friday (11PM-11 AM shift) R1 was a completely different person. On Saturday (September 17, 2016), R1 required two assistants to walk, was yelling and screaming down the halls saying I can ' t walk and bring me my meds. R1 said she did not want to get up so E4 said they sat R1 up in her bed to take her medications. E4 said R1 was incontinent of bowel and bladder and E4 told R1 this was totally inappropriate and unhealthy for her. E4 said she encouraged R1 to get up but R1 was incontinent two more times during the shift. E4 said on Sunday R1 required two CNA ' s to assist her to walk down the hall and R1 was yelling and screaming I can ' t do it, I can ' t walk. E4 said she was told R1 rolled out of bed on Saturday. On Sunday E4 said she had the CNA ' s put R1 in a chair in the TV room and encouraged her to get up and get her own water. E4 said R1 then fell out of the chair in the TV room on Sunday. On September 21, 2016 at 2:25 PM, E7 CNA on Friday R1 had refused care, refused to get out of bed, go to meals and get her medication (which required walking). E7 said this was not normal for R1 and she seemed to be having pain. E7 said she had never seen these behaviors prior to Friday and R1 ' s father said these were behaviors. On September 21, 2016 at 2:45 PM, E10 CNA said R1 is normally very compliant and does not exhibit behaviors. R1 is usually fully independent for care. E10 said R1 did not want to walk beginning on Friday because she was in pain. E10 said on Saturday R1 would not get up to go to the bathroom, take her medications or come to meals. E10 said on Sunday she had lunch because they made her get up . E10 said R1 began soiling the bed on Saturday and said R1 didn ' t want to get up because it hurt. E10 said the nurse ' s knew R1 was in pain. On September 22, 2016 at 8:42 AM, E1 Administrator said R1 had not exhibited behaviors before and R1 put herself on the floor twice over the weekend. E1 said R1 was sent to the hospital on Monday to be evaluated for her behaviors . E1 said R1 ' s incontinence; complaints of pain and not getting out of bed were believed to be behavioral. On September 22, 2016 at 9:05 AM E15 PRSC (psychiatric rehabilitation service coordinator) said if a resident had pain for days and was forced to walk on a broken limb it would not effect their mental status. On September 22, 2016 at 11:35 AM, Z1 (Orthopedic surgeon) said R1 suffered a right displaced femoral neck fracture, a [MEDICAL CONDITION]. Z1 said R1 told him she fell in the shower three days prior and R1's injury is consistent with this type of fall. Z1 said he would expect a person with this type of injury to exhibit pain, inability to walk, pain with toileting and transfer. Z1 said he would expect a nurse to be able to assess this injury and know something was wrong, in fact , the majority of the time it is a lay person who presents to the emergency room and can identify something as abnormal. Z1 said R1 ' s injury was acute and was several days old based on his surgical findings. Z1 would expect to see limited ROM (range of motion), a shortened extremity, an externally rotated extremity and severe pain with movement with this type of injury and all of these symptoms were present when he examined R1. Z1 said behaviors may have clouded the picture in this case but a physical assessment would have revealed the medical problem. Z1 said making R1 walk on the [MEDICAL CONDITION] would cause unnecessary pain, suffering and had to be pure misery. This also put R1 at risk for additional falls and could have broken her other hip. On September 22, 2016 at 12:40 PM, E2 DON (Director of Nursing) said R1 has had no physical behaviors since admission. E2 said on Friday (September 16, 2016) R1 said she couldn ' t walk, was crying but would walk with encouragement. E2 said R1 rolled out of bed on Saturday (September 17, 2016), R1 requested to be sent to the emergency room and her behaviors continued i.e.; didn ' t want to get up, eat and became incontinent. E2 said on Sunday R1 was ambulating with the aid of a gait belt and on Monday she was sent to the emergency room because her behaviors did not improve. E2 said R1 was alert and oriented to person, place and time and able to express her needs. R1 would normally do a lot of walking. E2 said the facility determined R1 was exhibiting behaviors based on what they were told by the family.

Based on observation, interview and record review the facility failed to: Identify resident's risk factors to prevent the development of pressure ulcers/blisters, Develop an individualized care plan to address these risk factors, Completely assess the wound characteristics and measurements of newly developed pressure ulcers/blisters, Perform ongoing monitoring and assessments of pressure ulcers, Notify the physician and obtain wound treatment orders for a newly discovered blood blister (Stage II) on R14's right foot, Identify 2 other pressure ulcers (blisters) on R14's right foot prior to sending R14 to the podiatrist for treatment of [REDACTED]. These failures resulted in R14 developing 3 stage II pressure ulcers to his right foot. This applies to 3 of 3 residents reviewed for pressure ulcers in a sample of 15 (R14, R4 and R10) The findings include: 1. The physician's orders [REDACTED]. R14's skin assessment dated [DATE] shows that R14 scored a 1. (0-10= low risk) The Nurses Notes (NN) dated 6/2/11 state, "To (Podiatrist)- ulcers healed." NN dated 6/26/11 state, " Resident complained that Right Great Toe has a dark blister. Nurse noted an almost quarter sized (a quarter measures approximately 2.5 cm) raised blood blister. Poked holes in blister with sterile needle and drained blood. Triple antibiotic Ointment and a bandage applied. Will monitor." NN of 6/27/11 state, "Blister on outer aspect of Right great toe 1/2 x 1 cm. " No other measurements of the documented wounds could be found in R14's medical record. The Podiatry Note dated 6/29/11 shows that R14 has a pressure ulcer to his right 2nd toe and blisters to the ball of his right foot and the outer right great toe. The note states, 'Blister- improper fitting shoes." The Podiatry Note dated 7/21/11 states,"4 x 4 x 2 mm ([MEDICATION NAME] tissue) pressure ulcer midline Right First Toe. 10 x 3 x 3 mm ( Dermal tissue) pressure ulcer distal end of 2nd right toe. The patient has been walking in his stocking feet without his shoes therefore has no protection to help stop the ulcer formations noted today." The Podiatry note dated 7/28/11 shows that R14 required surgical debridement of the distal end of 2nd right toe and midline right 1st toe. On 8/3/11 at 10:30 AM, R14 removed his right shoe and sock so blisters could be assessed. R14 had 3 affected areas. His outer great toe was about half covered with an adhesive bandage and a patch of dry yellowish skin could be seen at the bottom portion of the adhesive bandage. The 2nd toe was covered completely with an adhesive bandage and the area to the ball of R14's foot showed a dry, yellowish area about nickle size that was not covered. R14 required assistance to put the sock and shoe back on his right foot. On 8/3/11 at 2:45PM, E2 (DON) stated, " He has had those (blisters) forever. I just looked at them last week and there was nothing there. (R14) is a picker. He picks everything. He is a high risk (for pressure ulcers) because he is a picker. He won't leave things alone." R14's most recent care plan dated 8/31/2010 does not address R14's behaviors of picking at his wounds or R14's development of pressure ulcers. 2. The Physician order [REDACTED]. The Minimum Data Set of 6/6/11 assessed R4 to have occasional incontinence. R4's care plan nursing interventions dated 3/22/11 for incontinence includes reminding R4 to use the bathroom every 2 hours, and to shower R4 after each incontinence. A skin breakdown risk assessment was not completed. The nurses' notes on 04/30/11 on 7-3 shift states, "Incontinent 1 time this shift. Buttocks x 2 tiny open areas, inner Right buttock and inner Left buttock. 2 - 1/8" - 1/4" open red areas noted." The next skin documentation in the nurses' notes on 5/10/11 states, "R4 has open area starting. Left (2) on crack of buttock and 1 Right crack of buttock." The next skin documentation is on 5/24/11 on the 3-11 shift states, "Dressing applied to the coccyx." There was no corresponding physician order [REDACTED]." On 6/20/11 the nurses' notes states, "Two open areas on Right buttock appears to be getting worse. Dressing applied. B & B every hour initiated." The physician was not notifed until 6/21/11 of R4's wounds on the buttocks. R4's shower sheets from 6/1/11 through 7/18/11 show open areas on the buttocks were documented each time a shower was given. There are no wound assessments by the nurse of the noted open areas by the CNA on shower days for R4. R4's care plan dated 6/3/11 stated R4 had "Open area on Buttocks". The risk factors and contributing causes were not identified on the plan. The nursing approaches were not individualized to address the specific cause of the skin breakdown. The goal listed was not measurable and time specific. The report for R4 on the first wound clinic visit on 6/27/11 documents Wound number (#)1 was found on the left superior buttock measuring 1.1 cm x 0.8 cm, 0.1 cm. Wound #2 on the Left interior buttock measured 0.6 cm x 0.6 cm x 0.1 cm. The wound clinic instructions included to wash the area with soap and water, rinse with saline then apply ([MEDICATION NAME] agent) to the wound twice daily. Instructions also included to reposition the resident off their bottom every 2 hours, use a chair cushion and apply a low air flow mattress to R4's bed. On 8/3/11 at 10:05 AM, R4 was ambulated to the toilet room with the assistance of 1 Certified Nursing Assistant (CNA). R4's incontinence brief was dry. A healed scar was observed on the left buttock approx 2-3 cm in size and on the right buttocks a healed scar approx 1 cm in size was observed. R4's groin area was reddened. On 8/3/11 at 10:10 AM, E2 (Director of Nurses) confirmed that all wound assessments are documented in the nurses' notes. E2 stated, "It was difficult to treat the sores because he is constantly wet. He dribbles (urine) all the time." The facility policy, Pressure Ulcers/Skin breakdown - Clinical Protocol, October 2010 states, "The nurse shall assess and document/report the following: Full assessment of pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue.... The physician will authorize pertinent orders related to wound treatments, including...wound cleansing and debridement approaches, dressings and application of topical agents." The facility policy Pressure Ulcer Risk Assessment, October 2010 states, "A pressure risk assessment will be completed upon admission, with each additional assessment; quarterly, annually and with significant changes. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Staff will maintain a skin alert, performing routine skin inspections daily or every other day as needed. Nurses are to be notified to inspect the skin if skin changes are identified. Nurses will conduct skin assessments at least weekly to identify changes". The facility policy dated October 2010, Prevention of Pressure Ulcers states, "Risk factor - Bowel/Bladder Incontinence: Check resident for incontinence at least every 2 hours and clean skin when soiled. If moisture cannot be controlled use absorbent pads and/or briefs with a quick-drying surface and protect skin the moisture barrier." 3. The Physician order [REDACTED]. The Minimum Data Set of 4/23/11 states R10 is able to recall repeated words accurately without prompting, does not have any short or long term memory problems and does not have any unhealed or previous pressure ulcers. On 8/1/11 at 2:30 PM, R10 and his wife and daughter were interviewed. R10 stated he had increased the amount of walking he was doing to get more exercise. R10 stated subsequently he had developed blisters on both feet. R10 stated he was not aware of the blisters and that some of them had already popped when they discovered them when he took a shower. R10 felt his shoes were probably too tight and with the increased walking he developed the blisters. R10 stated now he walks very little because his feet are painful. R10's shower sheets on 7/17/11 show there were no concerns to his feet. The next shower sheet dated 7/29/11 shows R10 has blisters and both feet are calloused. On 8/3/11 at 10:35 AM, E7 (Registered Nurse - RN) removed the dressings from R10's feet. On the right foot, the great toe had a healed scar from a previous amputation. The right 2nd toe had peeling skin, and several dark areas in the tissue at the tip of the toe. The tip of the 3rd toe was pale with peeling skin. The center of the peeling skin on the tip of the toe was a deep red color. R10 stated the sores started as blisters and then they scabbed over. The left foot great toe had an opening approximately 5 cm x 3 cm in size, the tissue was peeling and and had deep red and dark areas. A small blister/callous was on the inside of the 4th toe. E7 did not cleanse the wounds prior to reapplying the treatment cream and gauze dressings. On 8/2/11 at 3:15 PM, E2 (Director of Nurses - DON) stated, "R10 picks. He had a blister on the bottom of the foot and the toe opened. R10 will be going to the foot doctor this week. New shoes have been ordered, but they are not here yet. Treatment is in progress, and the progress records are in the chart. I am not sure if the wounds have been measured yet." The podiatrist notes on 7/25/11 documents "Ulceration Left Hallus, (great toe) plantar aspect and 2nd and 3rd toes." The nurses' notes show the following information regarding the left foot: On 6/17/11, blood blister noted on left foot. (no additional comments or assessments recorded). The next skin assessment was recorded on 7/22/11 (no time) stated, "MD (physician) check left great toe broken blister site clear no signs of infection." On 7/30/11 (7-3), "Left great toe lite shade of red and swollen, bottom portion toe raw and outer aspect area raw." Review of the nurses' notes show the following information regarding the right foot: On 7/23/11 (7-3) "Right great toe entire bottom of toe blister, skin loose hanging shreds removed." (No corresponding physician order [REDACTED].) On 7/24/11 (7-3) "Right Great toe no signs of infection, skin bottom toe granulating looks good." On 7/25/11 (no time) "Right great toes noted today, light red with swelling. Message left at doctor office." At 1:50 PM on 7/25/11. "MD called back, requested to see R10 now in office." At 4:20 PM on 7/25/11, R10 returned to the facility with MD orders for oral antibiotic for 10 days, wound treatment and to use orthopedic boots in place of R10's shoes. Initial or ongoing wound assessments for R10's feet were not recorded. The care plan for R10 initiated on 7/22/11 states R10 has "Open areas on toes". The risk factors, contributing factors, or specific interventions to address assessment and treatment of [REDACTED]. On 8/4/11 at 9:30 AM, E2 confirmed the facility would not order the new shoes for R10 until the wounds are healed. E2 also confirmed the record did not have an initial wound or ongoing wound assessments for R10. On 8/3/11 at 3:15 PM, E2 (DON) presented the facility policy for pressure ulcers. E2 stated, "This is a brand new policy, we have had it about 2 weeks and haven't had time to start it." The facility policy for Prevention of Pressure Ulcers, October 2010 states, "Risk Factor - Friction and Shear. Shoes need to be monitored for proper fit to avoid development of blisters, corns and calloused areas. The facility policy for Pressure Ulcer treatment, Stage II protocol states, treatment of [REDACTED].