Every finding on record at Lakeside Health & Rehab Center

Based on interview and record review the facility failed investigate falls and provide interventions to prevent falls on one of four residents (R2) reviewed for falls in a sample list of nine.Findings include:R2's Electronic Heath record dated 5/1/2026 documents R2 had significant diagnoses including Dementia with Agitation, Hypertension, Multiple Myeloma, Chronic Obstructive Pulmonary Disease, Depression, Chronic Kidney Disease, and Thoracic Aortic Aneurysm. R2's MDS (Minimum Data Set) dated 5/14/2026 documented impaired cognition. Fall risk assessments dated 1/3/2026, 2/10/2026, and 5/14/2026 consistently documented R2 as a high risk for falls.R2's care plan documented numerous fall risk factors and interventions, including door open at night, use of floor mat, bolsters, alarms, education on risks of placing R2's self on the floor, low air loss mattress, orientation, lighting, and encouragement to use the call light. The care plan noted R2 occasionally put (R2's self) on the floor.R2's Electronic Health Record documents R2 was admitted to the facility on [DATE], R2 passed away in the facility on 5/19/2026 at 5:00am, and R2 was a hospice patient.R2's progress note dated 5/1/2026 at 4:29 am documents Nurse observed (R2) going from the edge of the bed upright to (R2's) knees on the padded mat. (R2) reported that (R2) was Going to the bathroom. (R2) assisted back to the edge of the bed without difficulty. (R2) denies pain or discomfort. Bed raised to facilitate (R2) standing. (R2) stands up with walker, ambulates to the bathroom with one assist. (R2) reminded to use the call light for assistance. There is no investigation for 5/1/2026. On 8/4/2026, V1 Administrator, and V2 Director of Nursing confirmed there was no investigation or updated intervention noted to R2's care plan on 5/1/2026.R2's progress note dated 5/1/2026 at 5:01 am documents (R2) was noted laying on the floor mat beside (R2's) bed with a pillow beneath (R2's) head. Neurological checks within normal limits. Vital signs stable. No complaints of pain. Range of motion without difficulty, no new injuries. (R2) assisted back to bed. When asked what happened (R2) stated (R2) did not know. V12 (R2)'s Power of Attorney notified. On 8/4/2026, V1 Administrator, and V2 Director of Nursing confirmed there was no investigation or updated intervention noted to R2's care plan on 5/1/2026R2's progress note dated 5/17/2026 at 1:48 am documents Tonight certified nursing assistant witnessed (R2) sit up on the side of (R2's) bed, grab the side rails, and gently lower (R2's) self to (R2's) knees. (R2) said (R2) was trying to 'check on that crying baby'. Assisted back to bed. No concerns at this time. On 8/4/2026, V1 Administrator, and V2 Director of Nursing confirmed there was no investigation or updated intervention noted to R2's care plan on 5/17/2026R2's progress note dated 5/18/2026 at 2:06 pm documents Writer observed (R2) on the mat next to bed. (R2) able to move all extremities without difficulty. (R2) voiced complaints of 'Pain all over'. No visible injuries other than two skin tears, one on right forearm, and one on left elbow. Writer called (V30) hospice nurse with local hospice to notify of (R2) putting (R2's) self on the floor and of the skin tears.V30 stated V30 would follow up with V30's manager about possibly increasing the dose of the morphine tablet. On 8/4/2026, V1 Administrator, and V2 Director of Nursing confirmed there was no investigation or updated intervention noted to R2's care plan on 5/18/2026.On 8/5/2026 at 11:00 am V32 Licensed Practical Nurse stated that V32 recalls R2 had a bed that lowered almost to the floor. V32 stated that R2 frequently got R2's self onto the mat next to R2's bed onto R2's knees. V32 stated I do not consider it a fall if it is in the resident's care plan to get onto the mat. R2's bed is very low and R2 only had to go mattress depth to get to the mat. On 8/5/2026 at 1:40 pm V34 Registered Nurse stated I have been the nurse for (R2) before. (R2) yelled out a lot. (R2) was a hospice patient and the hospice nurse frequently visited (R2) in the facility. (R2) often got off the bed to the fall mat. (R2) had a bed alarm so when staff heard it, they would get to the room quickly. I was told (R2) preferred to be on the mat and that (R2) was care planned to be on the mat. I do not consider (R2) getting on the floor as a fall.Facility accident and incident policy dated 7/1/23 documents All accidents and incidents involving a resident will be documented in Risk Management. The nursing team will investigate the root cause, with new interventions.

Based on observation, interview, and record review, the facility failed to utilize infection control techniques in 5 of 5 residents (R3, R7, R10, R15, R28), reviewed for infection control in the sample of 29. This failure resulted in R10 having multiple UTI's (Urinary Tract Infections) with hospitalization. Findings Include: 1) On 5/20/26 at 10:40 AM, nephrostomy care was observed with V21, Wound Nurse, with the following noted: Prior to entering room, V21 donned a gown, gloves, and mask. V21 entered the room and removed the left nephrostomy dressing, dated 5/19/26, and discarded it in the regular trash can. There were no gloves available in the room, V21 exited the room and brought in a box of gloves. V21 donned the gloves with no hand hygiene completed. V21 then proceeded to clean the left nephrostomy tube injection site and flushed it with normal saline as ordered. V21 then cleaned the injection site again and removed her gloves. V21 then donned new gloves without completing hand hygiene. V21 then cleaned around the left nephrostomy tube site, took the gloves off, donned new gloves without performing hand hygiene. R10 was turned onto her left side. V21 removed right R10's nephrostomy tube dressing, dated 5/19/26, removed her gloves and donned new gloves without performing hand hygiene. V21 then cleaned the right nephrostomy tube injection site and flushed it with saline as ordered and then cleaned the injections site after injection. V21 then removed her gloves, donned new gloves without performing hand hygiene. V21 then cleaned the right nephrostomy tube site, removed her gloves and donned new gloves without performing hand hygiene. V21 then placed a clean dressing over the site. V21 stated R10 is on isolation for ESBL (Extended Spectrum Beta-Lactamase) in the urine and she has the nephrostomy tubes because she couldn't tolerate the indwelling urinary catheter. V21 did not use sterile technique or maintain a sterile environment during the observation. R2's Face Sheet, undated, documents R10 has the following diagnoses: Multiple Sclerosis, ESBL Resistance, Mechanical Complication of Other Urinary Catheter, Urinary Tract Infection, Retention of Urine, and Neuromuscular Dysfunction of the Bladder. R10's MDS (Minimum Data Set), dated, 4/1/26, documents R10 has moderate cognitive impairment and an indwelling urinary catheter. R10's Care Plan, dated 1/22/26, documents R10 has nephrostomy drain tubes related to complications of kidney stones. R10's POS (Physician Order Sheet), documents the following orders: 5/15/26 - Cefpodoxime Proxetil Tablet 200 MG (Milligrams). Give 1 tablet by mouth every 12 hours for ESBL URINE for 7 Days; 3/19/26 - change dressings to Nephrostomy tubes daily and as needed; 3/18/26 - Flush nephrostomy tubes with 10ml (milliliters) of normal saline solution, 5 mL up and 5mL down. BID (Twice Daily) and as needed. R10's Progress Note, dated 1/5/26 at 9:36 AM, documents the following: Call placed to (hospital interventional radiology (IR) department), informed nurse of Nephrostomy issues, nurse states she will call back and get a plan in place. R10's Progress Note, dated 1/5/26 at 10:10 AM, documents the following: (Hospital) IR department called with an appointment for tomorrow morning d/t (due to) nephrostomy tubes not flushing. Arrival time is 6:30 AM 1/6/2026. Resident is to be NPO (Nothing by Mouth) after midnight tonight. May have Clonazepam before transport with a sip of water. Resident will also need latest H&P (History & Physical) from primary care doctor. R10's Progress Note, dated 1/6/26 AM at 10:45 AM, documents the following: (Hospital) called and stated that they are going to admit resident for a dx (diagnosis) of UTI.R10's Progress Note, dated 1/17/26 at 12:27 AM, documents the following: Resident is presenting with temperature of 103.4, 50, 14, 84/50, skin color is ashen/dusky respirations shallow response time is slow indwelling (urinary) catheter is patent draining very small amounts 25cc (cubic centimeters) left side nephrostomy tube is not draining and the right side has approx. 150cc amber urine resident has not eaten today d/t c/o nausea PCP (Primary Care Physician) aware sending to local ER (Emergency Room) for eval POA (Power of Attorney) updated hospital preference is (outside) hospital. R10's Progress Note, dated 1/21/26 at 4:55 PM, Resident returned from hospital per ambulance. Assisted to bed per staff and EMT's (Emergency Medical Technicians). Skin check completed with multiple scattered discolorations to BUE's (Bilateral Upper Extremities), no other skin issues noted at this time. R10's Progress Note, dated 1/22/26 at 2:18 AM, documents the following was given: Meropenem Intravenous Solution Reconstituted 2GM (Grams). Use 2GM intravenously every 12 hours for sepsis inject 2GM every 12 hours for 3 days for Sepsis.R10's Progress Note, dated 2/6/26 at 1:51 PM, documents the following: Call received from RN (Registered Nurse) at outside hospital. Will fax urine culture results and NO (New Order) received for fosfomycin 3GM one time only for UTI. R10's Progress Note, dated 5/13/26 at 11:28 AM, documents the following: Resident had increased confusion this AM she is currently in bed however she believes she is in the bathroom and sitting on the toilet, unable to re-orientate. Both Nephrostomy tubes are patent and draining dark amber urine with foul odor. Nephrostomy tubes are flushing without difficulty. Notified (V24, Medical Director), waiting for response. R10's Progress Note, dated 5/13/26 at 12:04 PM, documents the following: MD (Medical Doctor) in facility. NO received to obtain UA (Urinalysis)/C&S (Culture & Sensitivity). R10's Progress Note, dated 5/15/26 at 5:50 PM, documents the following: Per V24, analysis culture reviewed, new order for resident to start cefpodoxime 200mg twice a day for seven days. R10's Hospital Records, dated 1/6/26 - 1/9/26, documents R10 was admitted with the following diagnoses: Complicated UTI, Hydronephrosis, Malfunction of Nephrostomy Tube, Nephrostomy Tube Failure with Subsequent Urinary Leak, and Septic Shock. R10's Hospital Records, dated 1/17/26 - 1/21/26, documents R10 was admitted with the following diagnoses: UTI, Sepsis, and Septic Shock. 2) On 05/19/2026 at 9:00 AM V15, Housekeeping, observed walking into R9 and R28's room and began cleaning room with no Person Protective Equipment (PPE) on. Sign outside of R9 and R28's room documents states Contact Precautions Everyone Must: clean their hands, including before entering and when leaving the room. Providers and Staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before us on another person. R9's Physician Order dated 2/11/2026 at 12:52 PM documents Contact Isolation related to Extended-Spectrum Beta-Lactamase (ESBL) of the urine. R28's Physician Order dated 4/20/2026 at 9:38 PM documents Contact Isolation related to Urinary Tract Infection (UTI), Wound. On 5/20/26 at 8:04 AM V15, Housekeeping, stated if a resident is on isolation, staff are to wear a mask, gown, and gloves while cleaning the resident's room. On 5/20/26 at 10:42 AM V12, Housekeeping, stated staff are to follow the signs that are outside of the resident's room instructing what PPE should be worn. On 5/20/26 at 10:48 AM V32, Housekeeping, stated staff are to follow the signs outside of resident rooms regarding what PPE to wear when cleaning the rooms. 3) R7's Undated Face Sheet documents R7 was admitted to the facility on [DATE] and has a medical diagnosis of Chronic Respiratory Failure with Hypoxia, Chronic Systolic Congestive Heart Failure, Hypertension, Type 2 Diabetes Mellitus, and Displaced Trimalleolar Fracture of Right Lower Leg. R7's Minimum Data Set (MDS) dated [DATE] documents R7 is cognitively intact, is dependent on staff for toileting hygiene, and is frequently incontinent of bladder. R7's Care Plan Date Initiated 2/13/2026 documents R7 needs assistance with Activities of Daily Living (ADLs) related to decreased mobility related to fracture (FX) of the Trimalleolar Fracture of the Right Lower leg. At 9:57 V13, Certified Nursing Assistant (CNA), and V14, CNA, came into R7's room with full PPE on. R7 stated she needed to have a bowel movement. V14 rolled R7 onto her side and unfastened R7's adult brief. R7's adult brief was saturated with urine. V14 then placed R7 onto the bedpan. V14 took off gloves and allowed R7 to use the bedpan. V14 performed hand hygiene and put on clean gloves. V14 assisted R7 off the bedpan and took the bedpan to R7's restroom, emptied the bedpan in the toilet, and washed out the bedpan. V14 began to clean R7 buttocks with a wet soapy washcloth and did not change her gloves or perform hand hygiene after emptying R7's bedpan that was full of stool. V14 cleansed R7's buttocks with wet soapy towel, then took a dry towel to dry R7's buttocks without changing her gloves or performing hand hygiene. V14 assisted R7 onto R7's back to provide peri-care to R7. V14 cleansed under R7's abdominal fold with a wet soapy washcloth, then cleansed with a wet washcloth, and patted dry with a towel. V14 did not perform hand hygiene or change her gloves. V14 proceeded to clean R7's vaginal area with a wet soapy washcloth, then cleansed with a wet washcloth, and patted with a dry towel without changing her gloves or performing hand hygiene. R7's abdomen, abdominal folds, and peri-area were red and excoriated. 4) On 5/19/26 at 12:02 PM V13, CNA, delivered R10's lunch tray with no PPE on. Sign outside of R10's door documents Contact Precautions Everyone Must: clean their hands, including before entering and when leaving the room. Providers and Staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before us on another person. 5) On 5/20/26 at 9:59 AM V19, Licensed Practical Nurse, (LPN), observed entering R10 and R15's room with medications without applying any PPE. Sign outside of R10 and R15's room documents Contact Precautions Everyone Must: clean their hands, including before entering and when leaving the room. Providers and Staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before us on another person. 6) On 5/20/26 at 10:13 AM V19, LPN, entered R10's room to administer R10 her medications. V19 helped R10 take her medications with no PPE on. R3's Undated Face Sheet documents R3 was admitted to the facility on [DATE] and has a medical diagnosis of Subacute Osteomyelitis Right Ankle and Foot, Non-Pressure Chronic Ulcer of Other Part of Unspecified Foot, Type 2 Diabetes Mellitus, Local Infection of the Skin and Subcutaneous Tissue, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, and Hypertension. R3's MDS dated [DATE] documents R3 is rarely/never understood and has a memory problem. R3's Physician Order dated 5/19/26 at 10:11 AM documents Cleanse wound to right lateral ankle with wound cleanser. Skin prep surrounding tissue and apply border foam every night shift every Tue, Thu, Sun for Wound care R3s Physician Order dated 5/13/26 at 2:40 PM documents Contact Isolation related to ESBL in urine, wound care every day and night shift for ESBL in urine. On 5/20/2026 at 11:31 AM V21, LPN/Wound Nurse, performed hand hygiene and put on personal protective equipment (PPE) including a gown and gloves. V21 removed R3's dressing dated 5/20/26, disposed on her gloves and performed hand hygiene. V21 applied clean gloves and cleansed R3's wound to the right ankle with gauze and wound cleanser. V21 opened package of skin prep and applied prep to R3's wound area and applied clean dressing without changing her gloves or performing hand hygiene. V21 removed gloves and gown and disposed of the gown and gloves in a plastic trash bag. No red biohazard bag or container noted in R3's room to dispose of PPE. On 5/21/26 at 10:20 AM, V3, Infection Control Preventionist, stated if a resident is on EBP, they do not need to use PPE when entering the room, only if they are providing direct care, if a resident is on contact precautions, they are to wear a gown, gloves and it is to be put on prior to entering the room. If a resident is on EBP and contact precautions, they are to follow contact precautions. V3 stated when a resident is on isolation, there should be a special isolation container kept inside the room, next to the doorway. On 5/21/26 at 10:50 AM, V2 DON (Director of Nurses), stated V2 stated when a resident is on isolation, they are to have a special trashcan inside the room next to the door. V2 stated staff are to provide hand hygiene, preferably wash their hands with soap and water, before and after care, going from a soiled to clean area, and between glove changes. V2 stated improper hand hygiene can lead to resident's developing UTIs. V2 stated when she sees a resident with a UTI, she will in-service the staff on proper perineal care and infection control. On 5/22/26 at 8:43 AM, V24, Medical Director, stated R10 has the nephrostomy tubes with recurrent kidney stones that cause the tubes to move/dislodge, because of this, R10 has frequent urine infections. R10 would be sent to the hospital, admitted for a urine infection or replacement of the nephrostomy tubes, then would be sent back to the hospital a day or two later with Sepsis. V24 stated every time R10 has to have her nephrostomy tubes changed, the urologist will order antibiotics. R10 stated not wearing the appropriate personal protective equipment when a resident is on isolation precautions along with a lack of handwashing can cause an increase in their risk for infections with possible hospitalization. The Facility's Initiating Isolation Precautions Policy dated 7/2/2023 documents When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee): d.) Determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions. (1) The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/pr instructions to see a nurse before entering the room. Ensures that an appropriate linen barrel/hamper and waste container, with appropriate liner (red bag), are placed in the resident's room. The Facility's Hand-Washing Policy dated 7/1/2023 documents This facility considers hand hygiene the primary means to prevent the spread of infections. All staff will properly wash hands after direct contact with any contaminated substance, after direct resident care, and as instructed. Employees must wash their hands for fifteen (15) to twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin. After removing gloves. After handling items potentially contaminated with blood, body fluids, or secretions. The Facility's Incontinence Care Policy dated 7/1/2023 documents All incontinent residents will receive incontinence care in order to keep skin clean, dry, and free of irritation and/or odor. Procedure: wash all soiled skin areas and dry well, especially between skin folds; changing gloves and performing hand hygiene as required to prevent cross-contamination. The Nephrostomy Tube Care Procedure, undated, documents the following, in part: The purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous nephrostomy tube. Use sterile technique for dressing changes and irrigation. Steps in the procedure: perform hand hygiene, open sterile drape and create the sterile field, open several packages of gauze pads, open several packages of provodine-iodine swabs, and open the disposable waste bag and place it away from the sterile field. Perform hand hygiene and put on clean gloves. Carefully remove the wet/soiled dressing. Discard the dressing in the disposable waste bag. Remove gloves, perform hand hygiene, and put on sterile gloves. Cleanse the nephrostomy tube site. Discard soiled swabs. Remove gloves and perform hand hygiene. For irrigation: Perform hand hygiene and put on sterile gloves.

Based on observation, interview, and record review the facility failed to provide timely and complete incontinent care for 2 (R7 and R15) of 2 residents reviewed for Activities of Daily Living (ADL) care in a sample of 29, this failure resulted in R7 and R15 expressing feelings of worry, anxiety, and being upset.Findings Include:1.)R7's Undated Face Sheet documents R7 was admitted to the facility on [DATE] and has a medical diagnosis of Chronic Respiratory Failure with Hypoxia, Chronic Systolic Congestive Heart Failure, Hypertension, Type 2 Diabetes Mellitus, and Displaced Trimalleolar Fracture of Right Lower Leg.R7's Minimum Data Set (MDS) dated [DATE] documents R7 is cognitively intact, is dependent on staff for toileting hygiene, and is frequently incontinent of bladder. R7's Care Plan Date Initiated 2/13/2026 documents R7 needs assistance with Activities of Daily Living (ADLs) related to decreased mobility related to fracture (FX) of the Trimalleolar Fracture of the Right Lower leg. On 05/19/2026 at 9:36 AM R7 pressed call light button due to being incontinent of urine. R7 stated she is unsure how long she has been wet because she fell asleep, but she is wet now. R7 stated she is left in a wet depends for extended periods of time and has waited over 30 minutes for her call light to be answered by staff to help her.On 5/19/2026 at 9:40 AM V22, Activity Aide, walked into R7's room and asked what R7 needed. V22 walked out of R7's room leaving R7's call light on.On 5/19/2026 at 9:47 AM V14, Certified Nursing Assistant (CNA), entered R7's room and turned off R7's call light. V14 took R7's clothes out of R7's closet and turned on the water from R7's sink without saying anything to R7.On 5/19/2026 at 9:49 AM V14 walked out of R7's room and left the faucet water running, without saying anything to R7. R7 stated this is normal behavior, staff come and go. R7 stated staff do this to her all the time, they come in, ask what you need, and leave without saying anything. R7 stated you never know what staff are doing or when they will come back. R7 stated when staff leave her after coming into her room or don't answer her call light for an extended period of time, she starts to get upset, panics and has to tell her that she will be okay. On 5/19/2026 at 9:57 V13, CNA, and V14 CNA, came into R7's room to provide care.On 5/20/2026 at 7:37 AM V18, R7's Family, stated staffing and staff attitudes are a concern and R7 is left wet due to long call light times and slow staff response. V18 pulled R7's covers back and showed this surveyor R7's urine soaked depends, R7 was unable to say the last time staff have checked on her and changed her. R7's abdominal folds and peri- area were red and excoriated. R7 stated her peri-area and abdomen area are sore. 2.) R15's Undated Face Sheet documents R15 was admitted to the facility on [DATE] and has a medical diagnosis of Hypertension, Anxiety Disorder, Bipolar Disorder, Depression, and Ogilvie syndrome.R15's MDS dated [DATE] documents R15 is cognitively intact, is dependent on staff for toileting hygiene, showering/bathing, chair/bed to chair transfers, is frequently incontinent of bladder and is always incontinent of bowel. R15's Care Plan Last Reviewed 3/13/2023 documents R15 has a self-care deficit as evidenced by needs assistance with ADL's related to impaired mobility, weakness and obesity. Interventions document bathing: two person physical assistance required. Toilet use: two person physical assistance required. On 05/19/2026 at 12:03 PM R15 stated call light wait times are an issue. R15 stated she has sat in her own urine and feces for an hour before staff answered her light and cleaned her up. R15 stated the attitudes of staff are terrible and she had her call light on one night for an hour and when staff came into the room, R15 mentioned to staff that her light had been on for an hour, and that she was wet and dirty. R15 stated the staff member stated, Well how about I make you wait for the next shift then. R15 stated she had to wait another hour to be cleaned up by staff. R15 stated when staff don't want to help her it makes her want to cry. R15 stated it makes her anxious, upset, and she feels pretty bad when she has to sit in her own urine and feces while waiting on staff. R15 stated certain staff do not want to help her or answer her call light. R15 stated some staff will not let her take a shower and make her take a bed bath because she has to use the mechanical lift and staff do not want to lift her into her wheelchair and then lift her into the shower chair. R15 stated she wants to cry when staff do not want to assist her in the shower chair and does not understand why staff will do things for other residents and not for her. On 5/22/2026 at 8:43 AM V24, Medical Director, stated it is possible for a resident to feel a lack of dignity and sadness when being left in urine and feces for extended periods of time.On 5/22/26 at 1:00 PM V2, Director of Nursing, stated she expects residents to be cleaned up as soon as staff are made aware. V2 stated she hopes call lights are answered immediately but expects them to be answered within 2-3 minutes because there is enough staff in the facility to answer the lights and report back to the appropriate department. V2 stated she expects staff to treat all residents with dignity and respect and treat residents how they would want themselves and their family to be treated. The Facility's Resident Council minutes and Grievances were reviewed. The Facility's Resident Council Minutes dated 4/1/26 documents Nursing: Certified Nursing Assistants (CNA's) not answering call lights in timely manner.The Facility's Grievance Summaries dated 3/4/26 documents residents in resident council meeting stated their call light stays on for long periods of time without being answered. The Facility's Grievance Summaries dated 4/1/26 documents residents in resident council meeting stated that call lights are not being answered in a timely manner.The Facility's Call Light Guidance Policy dated 7/1/2023 documents Resident call light shall be responded to within a reasonable amount of time. It is the responsibility of all staff to respond to call lights.The Facility's Incontinence Care Policy dated 7/1/23 documents All incontinent residents will receive incontinence care in order to keep skin clean, dry, and free of irritation and/or odor.The Facility's ADL Support Policy dated 7/1/23 documents Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing grooming, and oral care), mobility (transfer and ambulation, including walking), elimination (toileting), dining (meals and snacks), and communication (speech, language, and any functional communication systems.)The Facility's Resident Rights Policy dated 7/2/2023 documents Employees shall treat all residents with kindness, respect, and dignity.

Based on interview and record review, the Facility failed to provide timely emergency room (ER) transport for 1 of 1 residents (R61) reviewed for quality of care in the sample of 29. This failure resulted in R61 not being sent to the ER for more than eight hours after receiving the physician order. R61 decompensated later that day and required oral intubation.Findings include: 1-R61's Face Sheet documents R61 was admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV), toxoplasma meningoencephalitis, cryptococcosis, and streptococcal pneumonia. R61's Minimum Data Set (MDS) dated [DATE] documented R61 was cognitively intact and required partial assistance with bed mobility and transfer. 05/20/2026 10:03 AM, R61 was sitting up in his bed. He was very thin with orbital wasting. He stated he did not receive his IV medications in the Facility for a couple of days on admission and ended up in the ICU (Intensive Care Unit). R61's Physician Order dated 4/23/26 documents Ganciclovir Sodium Intravenous Solution (Ganciclovir Sodium), use 7 milliliters (mL) IV every 12 hours for four weeks related to pneumonia. On 4/24/26 at 4:25 PM, The Facility's (Secure Messaging System) documents V24, Medical Director, was notified that the pharmacy could not deliver R61's IV Ganciclovir Sodium medication to the Facility due to stability issues. On 4/24/26 at 9:43 PM, The Facility's (Secure Messaging System) documents V24 ordered to send R61 to the ER if the Facility cannot obtain the medication. On 4/25/26 at 6:09 AM, The Facility's (Secure Messaging System) documents R61 had not yet been sent to the ER. R61's Progress Note dated 4/25/26 at 9:07 AM documents R61 was not sent to the ER until 6:45 AM. R61's Hospital Records dated 4/25/26 document R61 was admitted to the hospital and later decompensated, requiring transfer to ICU and intubation. On 5/21/2026 at 10:20 AM, V3, Infection Preventionist, stated if the provider gives an order to send a resident to the ER, she would do it immediately unless the provider specified it was a non-emergent transport. On 5/21/2026 at 10:45 AM, V11, Licensed Practical Nurse (LPN), stated if the physician gives an order to send a resident to the ER, she would send them immediately. On 5/21/2026 at 11:05 AM, V9, LPN, stated if the physician wanted a resident to be sent to the ER, she would send them immediately or as soon as possible. On 5/21/2026 at 10:50 AM, V2, Director of Nursing (DON), stated if the physician wants a resident to be sent out to the hospital, they should be sent immediately. On 5/22/26 at 8:41 AM, V24 stated R61 was a very sick, complex patient, so he wanted him to be sent to the hospital if the Facility could not provide the IV Gencyclovir. The Facility's Undated Change of Condition Protocol documents if it is decided that care or observation cannot reasonably be provided in the Facility, the physician will authorize transfer to an acute hospital, ER or another appropriate setting.

Based on observation, interview, and record review, the facility failed to provide appropriate nephrostomy care to prevent infections in 1 of 2 residents (R10), reviewed for bowel/bladder incontinence, catheters, and UTIs (Urinary Tract Infections) in the sample of 29. This failure resulted in R10 having multiple UTIs with hospitalization. Finding Include:On 5/20/26 at 10:40 AM, nephrostomy care was observed with V21, Wound Nurse, with the following noted: Prior to entering room, V21 donned a gown, gloves, and mask. V21 entered the room and removed the left nephrostomy dressing, dated 5/19/26, and discarded it in the regular trash can. There were no gloves available in the room, V21 exited the room and brought in a box of gloves. V21 donned the gloves with no hand hygiene completed. V21 then proceeded to clean the nephrostomy tube on the left injection site and flushed it with normal saline as ordered. V21 then cleaned the injection site again and removed her gloves. V21 then donned new gloves without completing hand hygiene. V21 then cleaned around the left nephrostomy tube site, took the gloves off, donned new gloves without performing hand hygiene. R10 was turned onto her left side. V21 removed R10'sright nephrostomy tube dressing, dated 5/19/26, removed her gloves and donned new gloves without performing hand hygiene. V21 then cleaned the right nephrostomy tube injection site and flushed it with saline as ordered and then cleaned the injections site after injection. V21 then removed her gloves, donned new gloves without performing hand hygiene. V21 then cleaned the right nephrostomy tube site, removed her gloves and donned new gloves without performing hand hygiene. V21 then placed a clean dressing over the site. V21 stated R10 is on isolation for ESBL (Extended Spectrum Beta-Lactamase) in the urine and she has the nephrostomy tubes because she couldn't tolerate the indwelling urinary catheter. V21 did not use sterile technique or maintain a sterile environment during the observation.R2's Face Sheet, undated, documents R10 has the following diagnoses: Multiple Sclerosis, ESBL Resistance, Mechanical Complication of Other Urinary Catheter, Urinary Tract Infection, Retention of Urine, and Neuromuscular Dysfunction of the Bladder.R10's MDS (Minimum Data Set), dated, 4/1/26, documents R10 has moderate cognitive impairment and an indwelling urinary catheter.R10's Care Plan, dated 1/22/26, documents R10 has nephrostomy drain tubes related to complications of kidney stones. R10's POS (Physician Order Sheet), documents the following orders: 5/15/26 - Cefpodoxime Proxetil Tablet 200 MG (Milligrams). Give 1 tablet by mouth every 12 hours for ESBL URINE for 7 Days; 3/19/26 - change dressings to Nephrostomy tubes daily and as needed; 3/18/26 - Flush nephrostomy tubes with 10ml (milliliters) of normal saline solution, 5 mL up and 5mL down. BID (Twice Daily) and as needed.R10's Progress Note, dated 1/5/26 at 9:36 AM, documents the following: Call placed to (hospital interventional radiology (IR) department), informed nurse of Nephrostomy issues, nurse states she will call back and get a plan in place.R10's Progress Note, dated 1/5/26 at 10:10 AM, documents the following: (Hospital) IR department called with an appointment for tomorrow morning d/t (due to) nephrostomy tubes not flushing. Arrival time is 6:30 AM 1/6/2026. Resident is to be NPO (Nothing by Mouth) after midnight tonight. May have Clonazepam before transport with a sip of water. Resident will also need latest H&P (History & Physical) from primary care doctor.R10's Progress Note, dated 1/6/26 AM at 10:45 AM, documents the following: (Hospital) called and stated that they are going to admit resident for a dx (diagnosis) of UTI.R10's Progress Note, dated 1/17/26 at 12:27 AM, documents the following: Resident is presenting with temperature of 103.4, 50, 14, 84/50, skin color is ashen/dusky respirations shallow response time is slow indwelling (urinary) catheter is patent draining very small amounts 25cc (cubic centimeters) left side nephrostomy tube is not draining and the right side has approx. 150cc amber urine resident has not eaten today d/t c/o nausea PCP (Primary Care Physician) aware sending to local ER (Emergency Room) for eval POA (Power of Attorney) updated hospital preference is (outside) hospital.R10's Progress Note, dated 1/21/26 at 4:55 PM, Resident returned from hospital per ambulance. Assisted to bed per staff and EMT's (Emergency Medical Technicians). Skin check completed with multiple scattered discolorations to BUE's (Bilateral Upper Extremities), no other skin issues noted at this time.R10's Progress Note, dated 1/22/26 at 2:18 AM, documents the following was given: Meropenem Intravenous Solution Reconstituted 2GM (Grams). Use 2GM intravenously every 12 hours for sepsis inject 2GM every 12 hours for 3 days for Sepsis.R10's Progress Note, dated 2/6/26 at 1:51 PM, documents the following: Call received from RN (Registered Nurse) at outside hospital. Will fax urine culture results and NO (New Order) received for fosfomycin 3GM one time only for UTI.R10's Progress Note, dated 5/13/26 at 11:28 AM, documents the following: Resident had increased confusion this AM she is currently in bed however she believes she is in the bathroom and sitting on the toilet, unable to re-orientate. Both Nephrostomy tubes are patent and draining dark amber urine with foul odor. Nephrostomy tubes are flushing without difficulty. Notified (V24, Medical Director), waiting for response.R10's Progress Note, dated 5/13/26 at 12:04 PM, documents the following: MD (Medical Doctor) in facility. NO received to obtain UA (Urinalysis)/C&S (Culture & Sensitivity).R10's Progress Note, dated 5/15/26 at 5:50 PM, documents the following: Per V24, analysis culture reviewed, new order for resident to start cefpodoxime 200mg twice a day for seven days.R10's Hospital Records, dated 1/6/26 - 1/9/26, documents R10 was admitted with the following diagnoses: Complicated UTI, Hydronephrosis, Malfunction of Nephrostomy Tube, Nephrostomy Tube Failure with Subsequent Urinary Leak, and Septic Shock. R10's Hospital Records, dated 1/17/26 - 1/21/26, documents R10 was admitted with the following diagnoses: UTI, Sepsis, and Septic Shock. On 5/21/26 at 10:50 AM, V2 DON (Director of Nurses), stated V2 stated when a resident is on isolation, they are to have a special trashcan inside the room next to the door. V2 stated staff are to provide hand hygiene, preferably wash their hands with soap and water, before and after care, going from a soiled to clean area, and between glove changes. V2 stated improper hand hygiene can lead to resident's developing UTIs. V2 stated when she sees a resident with a UTI, she will in-service the staff on proper perineal care and infection control. On 5/22/26 at 8:43 AM, V24, Medical Director, stated R10 has the nephrostomy tubes with recurrent kidney stones that cause the tubes to move/dislodge, because of this, R10 has frequent urine infections. R10 would be sent to the hospital, admitted for a urine infection or replacement of the nephrostomy tubes, then would be sent back to the hospital a day or two later with Sepsis. V24 stated every time R10 has to have her nephrostomy tubes changed, the urologist will order antibiotics. R10 stated not wearing the appropriate personal protective equipment when a resident is on isolation precautions along with a lack of handwashing can cause an increase in their risk for infections with possible hospitalization. The Nephrostomy Tube Care Procedure, undated, documents the following, in part: The purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous nephrostomy tube. Use sterile technique for dressing changes and irrigation. Steps in the procedure: perform hand hygiene, open sterile drape and create the sterile field, open several packages of gauze pads, open several packages of provodine-iodine swabs, and open the disposable waste bag and place it away from the sterile field. Perform hand hygiene and put on clean gloves. Carefully remove the wet/soiled dressing. Discard the dressing in the disposable waste bag. Remove gloves, perform hand hygiene, and put on sterile gloves. Cleanse the nephrostomy tube site. Discard soiled swabs. Remove gloves and perform hand hygiene. For irrigation: Perform hand hygiene and put on sterile gloves.

Based on observation, interview, and record review, the facility failed to provide a sufficient number of CNAs (Certified Nursing Assistants) to provide timely care to the residents in the sample of 29, when reviewed for sufficient staffing. This failure has the potential to affect all 54 residents residing in the facility.Findings Include:On 5 /19/26 at 9:36 AM, R7 pressed the call light button due to being incontinent of urine. R7 stated she is unsure how long she was been wet because she fell asleep, but she is wet now. R7 stated she is left in a wet depends for extended periods of time and has waited over 30 minutes for her call light to be answered by staff to help her. On 5/19/26 at 9:40 AM, V22, Activity Aide, walked into R7's room and asked what R7 needed. V22 walked out of R7's room with R7's call light still on.On 5/19/26 at 9:47 AM, V14, CNA, entered R7's room and turned off the call light. V14 took R7's clothes out of R7's closet and turned on the water from R7's sink.On 5/19/26 at 9:49 AM, V14 walked out of R7's room and left the faucet water running. R7 stated this is normal, staff comes and go. R7 stated staff do this all the time, they come in, ask what you need, and leave. R7 stated you never know what staff are doing or when they will come back. R7 stated when staff leave her after coming into her room or don't answer her call light after it has been on for a while, she starts to panic and has to tell herself that she will be okay. R7 stated they need more staff and that is why they don't answer her call light or provide her care timely.On 5/19/26 at 9:57 AM, V13, CNA, and V14 CNA, came into R7's room. V14 rolled R7 onto her side and unfastened R7's adult diaper. R7's adult diaper was saturated with urine. R7's abdomen and abdominal folds were red and excoriated. On 5/19/26 at 11:43 AM, V3, ICP (Infection Control Preventionist)/Nurse Manager, stated they are currently utilizing agency staff and are always recruiting for CNAs and nurses. On 5/19/26 at 12:03 PM, R15 stated call light wait times are an issue. R15 stated she has waited over an hour for her call light to be answered because they don't have enough staff. R15 stated she has sat in her own urine and feces for an hour before staff answered her light and cleaned her up. R15 stated the attitudes of staff are terrible and she had her call light on one night for an hour and when staff came into the room. On 5/19/26 at 1:30 PM, during the resident council meeting, R18, R21 and R55, stated there are not enough staff. R21 stated at night, call lights take forever. R55 stated at night they are putting people to bed which makes the call lights take longer. R18 stated when you have to go to the bathroom, she has to use bedpan because they can't get back to me quickly enough, it comes on me right away and they have to change the sheets. R21 stated they have had to use the bed pan because of this too.On 5/20/26 at 8:00 AM R9 stated they need more staff, often times they only have one or two CNAs on her hall and they need at least three on days and two on nights. R9 stated there are a lot of people on her hallway that need care, they don't have a voice, but she does. On 5/20/26 at 7:37 AM V18, R7's Family, stated staffing in the facility is a concern and R7 is left wet due to long call light times and slow staff response. V18 stated the facility has had a terrible urine odor and believes it is due to resident's being left in wet depends and not changed timely. V18 pulled R7's covers back and showed this surveyor R7's urine soaked depends, R7 unable to say the last time staff have checked on her and changed her. On 5/20/26 11:37 AM V1, Administrator, stated they base their staffing numbers off of their census. On 5/21/26 at 10:05 AM V13, CNA, stated everybody needs more staff, but we make do with what we have. On 5/21/26 at 10:20 AM, V3 stated they try to get to the residents in a timely manner, they do their due diligence. On 5/21/26 at 10:45 AM, V11, LPN (Licensed Practical Nurse), stated they could use more CNAs sometimes, it varies. On 5/21/26 at 10:50 AM V2, DON (Director of Nurses), stated they are utilizing agency staff, have hired staff, and she has four interviews today. V2 stated the managers help out on the floor a lot too. The Daily Staffing Sheets, dated 5/3/26 through 5/19/26, documents there are 4 CNAs working 6:00 AM to 6:00 PM and 3 CNAs working 6:00 AM to 6:00 PM. The Facility Assessment, dated 4/20/26, documents, in part, daily staffing is determined by nursing administration and administrative leadership utilizing various reports to analyze the number of patients, velocity of expected admissions and discharges, diagnosis, the types of tasks and services required of nursing, nursing assistants, and other ancillary personnel. The total number of FTE (Full Time Equivalence) of nursing aides on average or range is 7. The Staffing Policy, dated 7/1/23, documents, in part, the facility has developed and assigned duty hours for the nursing services department, based on state/federal requirements utilizing the staffing calculator. Nursing service is provided twenty-four hours per day, seven days per week. Departmental work schedules may be revised by the Director of Nursing Services when deemed necessary and appropriate to ensure that each resident's needs are met. The CMS (Centers for Medicare and Medicaid Services), form 671, dated 5/19/26, documents there are 54 residents residing in the facility.

Based on interview and record review, the Facility failed to obtain and properly administer prescribed medications for 2 of 3 residents (R15, R61) reviewed for pharmacy services in the sample of 29. This failure resulted in R61 missing three doses of a prescribed intravenous (IV) medication and being transported to the hospital where he required intubation.Findings include: 1-R61's Face Sheet documents R61 was admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV), toxoplasma meningoencephalitis, cryptococcosis, and streptococcal pneumonia. R61's Minimum Data Set (MDS) dated [DATE] documented R61 was cognitively intact and required partial assistance with bed mobility and transfer. On 5/20/2026 at 10:03 AM, R61 stated he did not get his IV medications for a couple days when he was admitted to the Facility and ended up in the ICU (Intensive Care Unit). R61's Hospital Discharge Paperwork dated 4/23/25 documents R61 received a dose of Ganciclovir 7 milliliter (mL) IV piggyback that morning and should continue to take it twice daily for at least four weeks upon discharge. The Facility's Physician Order for R61 dated 4/23/26 documents Ganciclovir Sodium Intravenous Solution (Ganciclovir Sodium), use 7 mL IV every 12 hours for four weeks related to pneumonia. On 5/20/26 at 9:30 AM, V1, Administrator, stated when R61 was admitted to the Facility our pharmacy did not have R61's IV medication on hand. R61's Medication Administration Record (MAR) documents the numeral 7 for all three scheduled doses of IV Ganciclovir on 4/23/26 and 4/24/26. On 5/20/26 at 10:32 AM, V1 provided a reference sheet for the MAR codes and stated the numeral 7 on the MAR means Refer to Progress Note. She stated she was not sure why there was no documentation regarding R61's IV medications in his Progress Notes on those dates. On 5/20/26 at 12:45 PM, V23, Pharmacist, stated the purpose of Ganciclovir is to prevent or treat CMV (Cytomegalovirus). If a resident does not receive the medication, it can cause the virus to replicate. R61's order for Ganciclovir was faxed to the pharmacy after they had already closed for the day, but the Facility did not contact the backup pharmacy to see if they could get it there. They also could have tried to obtain the medication from the hospital. The Facility's (Secure Messaging System) documents V24, Medical Director, was notified on 4/24/26 that R61's IV Ganciclovir Sodium medication was not stable enough for the pharmacy to deliver to the Facility. The Facility's (Secure Messaging System) documents V24 responded on 4/24/26 that R61 would need to be sent to the ER if the Facility cannot get the medication. On 5/22/26 at 8:41 AM, V24, Medical Director, stated R61 did not receive the Gancyclovir due to stability issues with the delivery. He sent R61 to the hospital because he was already a very sick, complex patient and did not want him to go the entire weekend without the medication. On 5/22/26 at 1:00 PM, V2, Director of Nursing (DON), stated the Facility should have checked to see if IV Gancyclovir was available before admission. Also, R61's admitting nurse should have immediately called the pharmacy to see if the medication was available or if there was another way we could obtain the medication or a similar medication. Then she should have contacted the doctor for further instructions. 2.) R15's Undated Face Sheet documents R15 was admitted to the facility on [DATE] and has a medical diagnosis of Hypertension, Anxiety Disorder, Bipolar Disorder, Depression, and Ogilvie syndrome. R15's MDS dated [DATE] documents R15 is cognitively intact. On 5/20/26 at 9:59 AM V19, Licensed Practical Nurse (LPN), observed entering R15's room with medications in a medication up. V19 observed handing R15 the medication cup and exiting R15's room. On 5/20/26 at 10:03 AM R15 observed with medications spread over bedside table. R15 stated some nursing staff do not watch her take her medications and will leave them on her table. On 5/20/26 at 10:05 AM R15 observed V19 in the hallway and called V19 into room. R15 informed V19 she was missing a medication and V19 stated she would check on the medication. V19 instructed R15 to take her medications that were on her table since she was now in the room. V19 stated she left the room after giving R15 her medication cup because she had to go check on another resident. On 5/21/2026 at 10:45 AM V11, LPN, stated nurses are to stay with the residents when administering medications. On 5/21/2026 at 10:50 AM V2, Director of Nursing, stated the nurses are to stay with the residents when administering medications until all have been taken. V2 stated they only have one resident that is allowed to have medication at bedside, and it is his nose spray. On 5/21/2026 at 11:05 AM V9, LPN, stated that when administering medications, the nurse is to stay with the resident until all medications are taken. The Facility's Medication Administration Policy initiated 7/1/23 documents, Medications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe, following the recommended administration method and will be documented as required. It is the responsibility of all licensed nursing staff to safely administer medications to residents. Ensure medication has been swallowed before leaving.

Based on interviews, observations, and record review, the facility failed to report a fall timely, follow fall incident procedures, and use gait belts during transfers for 3 of 5 residents (R1, R2, R3); reviewed for Quality of Care in a sample of 6. This failure resulted in R2 being moved before a nurse's assessment and delayed treatment for that R2 succumbed multiple pelvic fractures from later requiring surgery. Findings include:1.R2's Facesheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, atrial fibrillation, anemia, and age-related osteoporosis prior to her fall.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact and required substantial/maximal assistance for toilet transfers and going from sitting to standing.Care Plan initiated 1/14/26 documented R2 was at risk for falls and included the following intervention, in part, for staff to encourage call light usage.R2's Fall Incident Investigation documented her fall occurred on 2/10/26 at 9:00 AM. The investigation included a Corrective Action/Termination Form dated 2/11/26 that documented V8 Certified Nursing Assistant (CNA) received a final warning for not following safety procedures and unsatisfactory job performance. The Corrective Action Form documented details of the incident included R2 reported to V8 that she had fallen and V8 stated I won't tell if you don't. V8 didn't report the fall to the nurse until after R2 began complaints of pain. R2's Incident Report dated 2/10/26 documented that she fell and was sent out by ambulance to the hospital at 10:40 AM with injuries to pelvis that included a reddened area on right side upon initial assessment. The report continued to document R2 stated, I fell when I tried to get up and transfer myself and I told the CNA I did not want him to tell anyone that I fell because I am fine and my family is dealing with enough right now. R2's Progress Note dated 2/10/26 at 2:17 PM documented V20 (Prior Director of Nursing/DON) stated, Writer was notified that resident had experienced a fall in her bathroom when transferring without assistance leading to R hip pain. Upon assessment area appears slightly red. Resident states that it hurts to move her right leg or put weight on her right leg. Granddaughter at bedside upon this RN entering room.R2's Hospital Records dated 2/10/26 documented R2 was diagnosed with minimally displaced fractures involving the right superior and inferior pubic rami from falling.R2's Orthopedic Clinic notes dated 2/13/26 documented R2 had 2 (possible 3) pelvic fractures. The notes continued to document recommendation of surgery for an implant in the pelvis to stabilize her pelvic fractures. R2's Hospital Records dated 2/19/26-2/25/26 documented R2 was hospitalized for her pelvic fracture.On 4/13/26 at 10:20 AM, R2 stated she was helped to the restroom the day she fell by a male CNA and told to pull the string when she was done. R2 stated she waited for a while and no one came so she wasn't sure if she was supposed to pull it and go back to bed or just wait. R2 stated the CNA didn't tell her not to get up and she didn't know what to do. R2 stated while she was waiting, she started to get uncomfortable and having pain so she deciding to get up herself and she made it just right outside the bathroom door when she fell. R2 stated the male CNA found her and helped her back to bed but what really bothered her was that he told her not to tell anybody what happened. R2 stated she thinks he wasn't supposed to leave her alone on the toilet and got scared maybe. R2 stated she doesn't blame the CNA though, they are so understaffed. R2 stated she ended up going to the hospital with pelvic fractures and required surgery to correct it. R2 stated it's been a rough recovery and has been getting therapy and they say it's one of the most painful breaks to deal with. R2 was sitting in her wheelchair, her call light was not in reach. R2 stated when the CNA came to tell her she would be back to help her shower earlier, she left her call light somewhere and couldn't find it; she didn't make sure I had it before she left. R2's call light was buried under sheets in her bed on the opposite side of where R2 was sitting in her wheelchair.On 4/13/26 at 9:09 AM, V4 (R2's Family) stated R2 told her that she was taken to the bathroom by staff and left. V4 stated at the time of her fall R2 wasn't doing anything on her own, needed help with transfers. V4 stated R2 told her she waited for staff to come back to help her off the toilet for a long time and was starting to have pain in her back, so she decided to get up herself and fell. V4 stated R2 told her the male CNA found her on the ground and told her not to tell anyone, and he didn't report it. V4 stated V9 (R2's Family) visited R2 later that morning and that's when R2 told V9 she had fallen, and she was in pain. V4 stated V9 told the nurse who didn't know anything and then the DON overheard it all and came to assess. V4 stated V9 told her the DON sent her to the hospital to be assessed and that's when she was notified. V4 stated R2 sustained 3 pelvic fractures and later required surgery to correct. On 4/13/26 at 12:14 PM, V8 (CNA) stated he found R2 on the floor when he was walking by her room that morning, no call light was going off and the last time he saw her was in the dining room for breakfast. V8 stated R2 is able to wheel herself around independently. V8 stated he went to help R2 and she wanted him to help her up but not to tell anyone because she was doing so good in therapy, so he did that. V8 stated at the time R2 was a pivot and one assist for transfers. V8 stated R2 did not use her call light to get help at that time. V8 stated he was the only CNA working that hall at the time. V8 stated he was not trying to neglect her in any way; she was laughing and didn't complain of pain at the time. V8 stated when R2 pressed her call light about an hour later though she told him she was in pain and that's when he decided to report it to the nurse. V8 stated R2 was usually really good about using her call light prior to her fall and was known to use it. V8 stated R2 told him she felt silly it happened.On 4/13/26 at 1:41 PM, V9 (R2's Family) stated she came to visit R2 around 10:00 AM that morning and she was lying in bed. V9 stated she asked how R2 was doing, and she told her not good, she had a fall after using the toilet. V9 stated R2 told her she waited for a long time and decided to get up herself then fell. V9 stated R2 told her that the CNA told her not to tell anyone, and she didn't until she saw me. V9 stated she told the nurse who knew nothing about a fall and the DON came over to find out what happened. V9 stated R2 was in a lot of pain when she got there. V9 stated R2 didn't want the CNA to get in trouble. V9 stated R2 had had falls at home and would use her call light for assistance but it wouldn't surprise her if she sometimes doesn't.On 4/13/26 at 2:00 PM, R2 stated she was in a lot of pain when she fell, it was at least a ten out of ten on a pain scale and she was crying when the CNA found her.On 4/14/26 at 10:49 AM, V15 Licensed Practical Nurse (LPN) stated she was R2's nurse the day she fell. V15 stated she was first notified by V8 (CNA) that she had fallen. V15 stated she couldn't remember if V8 stated he had gotten R2 up already or not. V15 stated she immediately told V20 (Prior Administrator) to go look at R2 since she had pills out on her cart. V15 stated she did not go see R2 right away but later did see her in her bed.On 4/14/26 at 12:47 PM, V19 (Medical Director) stated he expects a fall to be reported at the time it occurs and the resident should not be moved ideally before a nurse assesses them in case of head or neck injury. V19 stated R2 did have fractures and required surgery. V19 stated he does not consider R2 was neglected. V19 stated he expects staff to be following the facility's Incident/Accident Policy.2.R1's Facesheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, dementia, type two diabetes mellitus, and heart failure.R1's MDS dated [DATE] documented R1 was cognitively intact. R1's Care Plan dated 4/3/24 documented she was at risk for falls and injuries. R2's fall care plan included the following interventions, in part, observe for unsteady gait and balance on 4/3/24.Facility incident reports documented R1 fell 3/7/26, 3/11/26, two times on 4/6/26, and on 4/13/26.R1's Fall Risk assessment dated [DATE] documented she was at high risk for falls, having three or more falls in the past three months and requires assistive devices for gait/balance.On 4/13/26 at 9:51 AM, V5 (CNA) stated she was going to assist R1 to the restroom, she's a standby assist and has had a couple falls lately. V5 placed R1's walker in front of her while she sat in her wheelchair and stood by to assist her without applying a gait belt. R1 walked with her walker to the restroom, was unsteady throughout the process but corrected herself as she walked very slowly. V5 assisted R1 with pulling her brief down at the toilet, R1 stood without her hands holding anything for several seconds before finally using her right hand to grab the side bar on the wall next to the toilet and lowering herself down.3.R3's Facesheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, surgical aftercare following surgery on the digestive system, hypertension, and atrial fibrillation. R3's MDS dated [DATE] documented she was moderately cognitively impaired and was not assessed for toileting transfers or sit to stand transfers due to health conditions or safety concerns.R3's Care Plan dated 1/28/26 documented she was at risk for falls and injuries.On 4/13/26 at 9:58 AM, R3's call light was lighting up red and was sitting in her wheelchair waiting in the bathroom for assistance to use the toilet. At 10:10 AM, V5 (CNA) entered R3's room. V5 brought R3 outside of the bathroom and put her walker in front of her, then assisted her to a standing position by holding the back of her pants (did not apply a gait belt) the entire way to the toilet.On 4/13/26 at 8:21 AM, in a joint interview with V16 Certified Occupational Therapy Assistant (COTA) and V17 (COTA) both stated a transfer with one assist should have a gait belt used. Both stated R1 and R3 should have had a gait belt used during their transfers. V16 stated recently R1 had a decline, and she was independent but now is not and that is why we picked her up in therapy. V17 stated R3 is a one assist and a gait belt should have been used. V17 stated we will educate the staff today on transfers. On 4/14/26 at 10:49 AM, V15 (LPN) stated a gait belt should absolutely be used if indicated. V15 stated call lights should be left in reach for safety measures. V15 stated falls should be reported immediately and residents should not be moved until the nurse has assessed them in case they have injuries.On 4/14/26 at 11:55 AM, V1 stated V5 (CNA) is the lead CNA at the facility. V1 stated falls are to be reported immediately to the nurse and residents not to be moved before the nurse assesses them to prevent further injury. V1 stated she would absolutely expect gait belts to be used during transfers. V1 stated call lights should be left in reach at all times for residents to be able to alert staff for need of assistance. V1 stated she is not aware of any neglect or reports of neglect at this time. V1 stated V8 definitely did not have good intentions, it was definitely a delay in treatment though.On 4/14/26 at 12:00 PM, V2 (DON) stated she expects falls to be reported immediately, and the resident is not to be moved prior to a nurse assessing them to make sure it's safe to move them. V2 stated she expects gait belts to be used when indicated. V2 stated V8 (CNA) should not have moved R2 at all after she fell, that's not okay in any way.The facility's Accidents and Incidents policy dated 7/1/23 documented accidents and incidents, including injuries of an unknown origin, must be reported to the department supervisor, and an Accident/ Incident Report should be completed on the shift that the accident or incident occurred. The policy continued to document, Render immediate assistance. DO NOT move the victim until he/she has been examined for possible injuries. If assistance is needed, summon help. If you cannot leave the victim, ask someone to report to the nurse's station that help is needed, or if possible, use the call system located in the resident's room to summon help.The facility's Transfer policy dated 7/1/23 documented gait belts, full body mechanical lifts, and/or sit to stand/partial body mechanical lifts will be used, unless otherwise specified and it is the responsibility of all nursing staff to ensure the use of safe transfer techniques when transferring a resident. The policy continued to document the transfer technique used for the resident will be evaluated and determined by the nurse or directed by therapy.

Based on interview and record review, the facility failed to provide a safe transfer for 1 of 1 resident (R6) reviewed for accidents in the sample of 16. Findings include:R6's admission Record, print date of 10/2/25, documents R6 was admitted on [DATE] and has diagnoses of Alzheimer and Dementia.R6's Minimum Data Set, dated [DATE], documents R6 is severely cognitively impaired, uses wheelchair, is dependent on staff for toileting, showers, lower body dressing, personal hygiene, and all mobility except rolling in bed.R6's Care Plan, dated 12/12/23, documents, (R6) has a Self-Care Deficit As Evidenced by: Needs assistance with ADLs (Activities of Daily Living) related to dx (diagnosis): ALZHEIMER'S DISEASE, UNSPECIFIED, HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE. Intervention: Transfer: Two person physical assistance required Date Initiated: 12/13/2024.R6's Therapy to Nursing Recommendations, dated 8/21/25, documents R6 transfers with assist of 2 with a wheeled walker.R6's Health Status Note, dated 9/3/2025 08:53, documents, Residents daughter/POA (Power of Attorney) (V16) approached nurses station to report that resident had redness discoloration/bruising noted to the top of both hands this AM and a small skin tear present to the top of her left hand. Upon assessment this nurse noted that resident does have reddish discoloration/bruising present to the top of both hands and wrist area. ROM (range of motion) appears to be unaffected, and resident denies pain/ discomfort at this time. Does have a small skin tear present to the top of her left hand with absence of any drainage or discharge from open area. MD (Medical Doctor), DON (Director of Nurses) and Administrator notified of incident. Skin tear cleaned with wound cleanser and steri-strips applied as ordered.R6's Health Status Note, dated 9/3/25, documents, Made (V17) office aware of skin tear and reddish discoloration/bruising to bilateral hand and wrist. Made aware of skin tear to top of left hand and treatment started.R6's Health Status Note, dated 9/6/24, documents, Discoloration continues to bilateral wrists, s/sx (signs and symptoms) of tenderness noted to discoloration. Two steri strips to left hand intact, no s/sx infection noted. Resident continues scheduled tylenol.R6's Health Status Note, dated 9/7/25, documents, Discoloration continues to bilateral wrists, no s/sx of tenderness noted to discoloration. Two steri strips to left hand intact, no s/sx infection noted. Resident continues scheduled tylenol.R6's Health Status Note, dated 9/7/25, documents, Discoloration continues to bilateral wrists, no s/sx of tenderness noted to discoloration. Two steri strips to left hand intact, no s/sx infection noted. Resident continues scheduled tylenol.R6's Health Status Note, dated 9/8/25, documents, Discoloration continues to bilateral wrists, no s/sx of tenderness noted to discoloration. Two steri strips to left hand intact, no s/sx infection noted. Resident continues scheduled tylenol.R6's Health Status Note, dated 9/20/25, documents, Bruises to Lt (left) wrist and arm are resolved. continue monitoring Rt (right) wrist and arm.R6's QA (quality assurance) report, dated 9/3/25, documents, General Information Type: Skin Issue. Incident Location unknown Prior caregiver (V18, Certified Nurse Aide (CNA)), other treatments: steri strips and wound cleanse to top of left hand. Details: Skin Issue Type Bruise. Wound Description Base Color red Wound description: resident has reddish bruising / discoloration noted to bilateral hands with small skin tear present on top of left hand. Injuries Type Bruise Location Left Hand Date / Time 9/3/25 7:00 AM Details red discoloration / bruising noted with small skin tear on top of left hand. Bruise location Right Hand Date / Time 9/3/25 7:00 AM Details red bruising / discoloration present to top of hand. Investigate. Conclusion: investigation reveals that CNA likely transferred the resident with one instead of 2. CNA denies. CNA working her last shift at (facility) on this day and no longer works her. Marked in her file that she is ineligible for re-hire.On 9/29/25 at 3:13 PM, V19, R16's Husband, stated he comes every day and sits with R6 all day. He stated that when he came in this morning R6's elbow was bleeding a little bit, and he let the facility know. He said she must have bumped it. V19 was questioned if he had concerns about abuse or R6's safety, V19 stated no but about a month ago both of her wrists were bruised it looked like she was pulled. I am not sure what they did about that.On 10/2/25 at 9:29 AM, V2, Director of Nurses, stated I did do an investigation into R6's hands. I determined the CNA V18 transferred R6 by herself. R6 requires 2 staff members and a gait belt for a safe transfer. This happened on V18's last night shift. She had already turned in her notice of quitting. The bruising was reported to me at 7:00 AM after V18 had already clocked out and went home. I let V16 know that it V18 did not work her anymore because when she clocked out at 6:00 AM her employment was finished.On 10/2/25 at 10:45 AM, V6, CNA, stated R6 transfers with 2 staff members and a gait belt.On 10/2/25 at 1:05 PM, V20, Licensed Practical Nurse, stated I was told about R6's wrists and hands. They were just kind of red, the left had a skin tear, and I think the right wrist was the worse one. She was not complaining of pain and there was no swelling. I let V2 and V17 know about it.The transfer Policy, dated 7/1/23, documents, Procedure: 1. Explain to resident what task you are going to be performing. Enlist his / her assistance with the task if he / she can prove it. 2. The transfer technique used for the resident will be evaluated and determined by the nurse or directed by therapy. It continues, 7. Follow Plan of Care to ensure the use of proper transfer technique.

Based on observation, interview, and record review, the facility failed to assess, monitor, and provide interventions to prevent decannulation for a resident with known behaviors of self-decannulation; and failed to ensure that staff were provided tracheostomy recannulation education for extubation for 1 of 2 residents (R3) reviewed for tracheostomy in the sample of 2. The failure resulted in R3's self-decannulation of her tracheostomy which compromised R3's health status. R3 required emergency transfer to the local hospital on [DATE] and required two attempts at reinsertion of the tracheostomy and arterial line placement. After reinsertion of R3's tracheostomy by an ENT physician, R3 became hypoxic with oxygen saturation in the 80's and had increased work for breathing. R3's hospital records document R3 ultimately died on [DATE] with clinical impression of tracheostomy complications, cardiopulmonary arrest and heart block. R3's death certificate is pending investigation. This failure has the potential to affect all residents with tracheostomy medical needs.The Immediate Jeopardy began on [DATE], when R3 was admitted to the facility with a tracheostomy tube. R3's Infectious Disease Progress Note dated [DATE] documents R3 had a history of tracheostomy tube decannulation prior to being admitted to the facility. R3's care plan dated [DATE] had no documented interventions to prevent R3 from self-decannulating tracheostomy tube. R3 self-decannulated her tracheostomy tube at the facility on [DATE] and she was transferred to the emergency room and readmitted to the facility the same day. No interventions were added to R3's care plan to prevent her from decannulating the tracheostomy again. On [DATE] staff documented R3 removed her tracheostomy again and was transferred to the emergency room. R3's clinical impressions included tracheostomy complications, cardiopulmonary arrest and heart block. On [DATE] at 9:26 AM PM V1, Administrator, V2 DON and V28 Regional Nurse were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on [DATE], but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R3's Infectious Disease Physician Progress Note, dated [DATE] documents R3 pulled out her tracheostomy tube 3 weeks prior.On [DATE] at 2:00 PM V2, DON provided a timeline of R3's health status. The timeline documented R3 had a history of decannulating her tracheostomy tube prior to being admitted to the facility. R3's Undated Face Sheet documents she was initially admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, tracheostomy, pneumonia, colostomy, gastrostomy and high blood pressure. R3's admission Nurse Assessment, dated [DATE] documents reason for admission: pneumonia, peg-tube and IV (intravenous) ABT (antibiotics.) No behaviors documented. No documentation R3 had a tracheostomy tube upon admission. R3's Physician's Order Sheet (POS), dated [DATE] documents oxygen humified at 6 LPM via trach collar continuous two times a day for shortness of breath. R3's Comprehensive Care Plan, dated [DATE] documents R3 has the presence of a tracheostomy at this time r/t (related to) DX (diagnosis) of acute respiratory failure. Goal: R3 will have no complications r/t tracheostomy through next review date. Interventions: all orders r/t tracheostomy will be followed, and MD (physician) updated with any concerns. No documentation of interventions to prevent R3 from decannulating her tracheostomy tube. R3's Nurse Progress Notes dated [DATE] through [DATE] no documentation R3 was agitated, restless or behaviors of pulling on tracheostomy tube or collar. R3's admission Minimum Data Set (MDS) dated [DATE] documents R3 is cognitively impaired, had no behaviors exhibited, a tracheostomy and a diagnosis of respiratory failure. R3's Nurse Progress Note dated [DATE] documents at 6:19 AM, writer entered resident's room at 5:15 AM to administer morning medication and discovered trach dislodged. R3 was transferred to the emergency room. R3's Health Status Note, dated [DATE] at 5:15 PM, documents resident returned to facility from the ER (emergency room) following a trach tube replacement. Trach was replaced due to dislodgement. R3's Comprehensive Care Plan has no documentation of interventions to prevent R3 from decannulating her tracheostomy tube after removing it on [DATE] documented. R3's form dated [DATE] through [DATE] documents follow up question: Did resident display change in mood? [DATE] through [DATE] documents No change. [DATE] at 2:02 PM, Other documented.R3's Health Status Notes, dated [DATE] through [DATE], no documentation of R3 being agitated, restless or having behaviors of pulling on tracheostomy tube. R3's Nurse Progress Note dated [DATE] at 1:25 PM V12, RN documented Res noted to be restless and pulled bag off colostomy and trach out. MD notified and orders to send to ER, POA notified. R3's Emergency Medical Services (EMS) Run Report, dated [DATE] documents the primary complaint is that the trachea tube pulled out, with an estimated onset time of 11:00 AM on [DATE] and a duration of 3 days. The patient's level of distress is mild. The primary impression is muscle weakness signs, and the secondary impression is shortness of breath.On [DATE] at 12:05 PM V16, CNA stated he was familiar with R3 and her care. V16 stated prior to [DATE] he observed R3 pull on her trach, G-tube and colostomy but he wasn't aware R3 had pulled her trach out before this day. V16 stated [DATE] day shift and he recalled R3 had a tracheostomy tube, G-Tube and colostomy bag and exhibited behaviors of pulling on all of them in the past. V16 stated the morning of [DATE] he recalled R3 was anxious and pulled her colostomy bag off and he let V12, RN know, and she assist R3 to get the colostomy bag back on. V16 stated he didn't know R3 had a history of taking her trach out and didn't know of any interventions in place to prevent R3 from pulling it out again. On [DATE] at 11:30 AM V12, RN stated she was assigned to R3 on [DATE] from 6:00 AM to 6:00 PM and she suctioned R3 2-3 times that shift and recalled R3 pulled her colostomy bag off, so she had to replace it in the morning and R3 was also pulling on her g-tube as well. V12 stated she didn't notify R3's physician of the behavior of pulling on everything, she looked at R3's POS but there were no medications for anxiety to administer. V12 stated she wasn't aware that R3 had a history of pulling her trach out and if she did, she would have notified the physician of the pulling behavior to try to prevent R3 from pulling it out. R3's trach collar was on, and the trach was in place when she administered R3's morning medications via G-Tube. At one-point V16, CNA notified her R3 pulled her colostomy bag off again and when she entered R3's room she noted her trach was on her bed. She didn't know what to do so she got V11, LPN to assist her and V11 told her to call R3's physician the physician stated to send the resident to the emergency room to get the trach replaced. V12 stated V11 assisted her to suction R3 as well that day because she was new to trach's and wanted to ensure she was doing it properly and she suctioned R3 2-3 times that day but V12 stated she doesn't recall if she documented she suctioned R3 on her MAR or not. V12 called 911 and R3 was transferred to the local emergency room for trach replacement. V11 told V12 that they do not attempt to put a trach cannula back in at the facility so neither her or V11 attempted to put R3's trach back in and there was no trauma to R3's trach area. V12 stated she works at the facility PRN and hasn't received training on re inserting a trach and didn't feel comfortable doing that. V12 stated staff took R3's vital signs and noted her oxygen saturation was in the low 90's and that was another reason R3 was transferred to the emergency room.On [DATE] at 11:45 AM V11, LPN stated she worked on [DATE] 6:00 AM to 6:00 PM and recalled V12 asked her to assist her in suctioning R3 a few times that morning and she went and R3's trach collar was on and intact. After lunch V12 reported to her that R3's trach cannula was on her bed, she told her to call R3's physician and find out what they want to do, she called, and they called 911 to transfer R3 to the emergency room for trach placement. V11 stated she assisted R3 onto the stretcher when EMS arrived at the facility, and she didn't assess any trauma to R3's trach area. V11 stated R3's oxygen saturation was around 93% after she pulled her trach out. V11 stated she's new to working at the facility and she didn't know if there was an emergency trach available and she wasn't trained on how to re insert a trach either. V11 stated she is an LPN, and she doesn't think it's in her scope of nursing practice to re insert a trach and she thought that reinserting the trach would be an emergency room procedure. On [DATE] 3:45 PM V20, LPN/MDS/Care Plan Coordinator stated R3 had a G-Tube, colostomy and a trach and she was considered a high acuity resident. V20 stated staff did frequent checks on R3 from admission because she was so high acuity. At the end of [DATE] R3 pulled her trach out and R3 was readmitted to the facility the same day and the trach was reinserted in the emergency room. V20 stated staff did frequent checks on R3 after she pulled her trach out at the end of [DATE] but didn't know of any new interventions the facility put in place to prevent R3 from pulling out her trach again. V20 stated she hadn't received tracheostomy reinsertion training at the facility and wouldn't feel comfortable attempting to reinsert a tracheostomy tube, she'd just call 911 and send the resident to the emergency room. On [DATE] at 8:45 AM V5, CNA stated she was assigned to R3 often and she recalled R3 was always fidgety, pulling on her colostomy bag, G-Tube and trach area. V5 stated she wasn't working when R3 pulled her trach out either time and no staff said anything about new interventions to prevent R3 from pulling the trach out again after she pulled it out the first time. On [DATE] at 3:40 PM, V9 PTA and V10 Director of Therapy stated they provided therapy to R3 prior to her pulling her tracheostomy tube out at the end of [DATE] and during the therapy session V9 and V10 stated they recalled R3 pulled on her tracheostomy collar often and they redirected her not to pull on it multiple times during the therapy sessions. V10 stated she reported R3 pulling on her tracheostomy collar to the nurse (name unknown) when it occurred. On [DATE] at 3:30 PM V18, LPN stated R3 had behaviors of pulling on her colostomy, G-Tube and tracheostomy collar. V18 stated she didn't know R3 had a history of decannulating her tracheostomy tube prior to doing it the first time at the facility at the end of [DATE] and she didn't know of any new interventions that were put in place after R3 was readmitted to the facility after pulling her tracheostomy tube out. V18 stated she had not received training on reinserting a tracheostomy tube and wouldn't be comfortable reinserting a tracheostomy tube in an emergency. On [DATE] at 1:05 PM V3, RN/Assistant Director of Nurses (ADON) stated she is new working at the facility, but she hasn't been trained on re inserting a trach and wouldn't feel comfortable doing so. On [DATE] at 1:15 PM V25, RN stated she works night shift and has worked 2 shifts at the facility and is still on orientation and hasn't been trained on trach re insertion and wouldn't feel comfortable with reinserting a trach. On [DATE] at 1:58 PM V2, DON stated she hasn't been trained on trach decannulation and she wouldn't feel comfortable reinserting a trach after it came out. V2 stated V15 LPN, V20 LPN, V22 LPN, V24 LPN, V26 LPN and V27 LPN have received tracheostomy tube reinsertion in case of an emergency. On [DATE] at 2:00 PM V15, LPN stated she received emergency tracheostomy reinsertion training but would only feel comfortable attempting to reinsert a resident's tracheostomy tube if she had assistance of another nurse to ensure she was doing it correctly. On [DATE] at 2:05 PM V7, LPN stated she received emergency tracheostomy reinsertion training, but she couldn't recall what facility trained her and she would only feel comfortable reinserting a tracheostomy tube with the assist of another knowledgeable nurse assisting her. On [DATE] at 2:09 PM V24, LPN stated she has not received emergency tracheostomy reinsertion training at the facility and wouldn't feel comfortable reinserting a tracheostomy tube. On [DATE] at 9:30 AM V2, Director of Nurses (DON) stated R3 was initially admitted to the facility with a tracheostomy tube, G-Tube and a colostomy so she was considered to be a high acuity resident, and staff did frequent checks on her from admission. V2 stated R3 had chronic respiratory failure and that's why she had the tracheostomy tube which had a physician's order for continuous humidified oxygen to her trach collar at 6 liters. V2 stated R3's family took the oxygen off R3's tracheostomy tube for up to 30 minutes at a time and R3's oxygen saturation stayed stable. V2 stated R3 pulled her tracheostomy tube out at the end of [DATE], and she was sent to the emergency room and readmitted to the facility. V2 stated she would have to look into R3's medical records and see what interventions the facility documented they put in place to ensure R3 didn't pull her tracheostomy tube out again but that she knew staff were doing frequent checks and they had the tracheostomy tube tied to the collar to prevent it from coming out. V2 stated she reviewed R3's medical record and no staff documented she was restless until she pulled her tracheostomy tube out the second time at the facility on [DATE]. V2 stated the nurse assessed R3, notified her physician that the tracheostomy tube was removed and sent R3 to the emergency room per physician's orders. V2 stated she spoke to the nurses who assessed R3 after she removed the tracheostomy tube on [DATE] and they stated R3 wasn't in respiratory distress at that time and she expected the assessment to be documented in R3's nurse progress notes, including her vital signs. V2 stated R3 was transferred to the hospital on [DATE] where she was diagnosed with pneumonia and when R3 was readmitted to the facility her family abruptly discontinued her Hydralazine and Adamine and V2 stated she looked into it and that abrupt discontinuation of those medications could cause agitation, delirium and restlessness which could occur within hours to days after the discontinuation. R2 stated no staff reported to her that R3 was ever restless or having behaviors of pulling on her tracheostomy tube and there is no documentation of that in R3's medical record either, until [DATE]. On [DATE] at 2:39 PM V2, DON stated she can't find staff education documentation that shows staff were educated on recanalization of a tracheostomy tube and she probably won't be able to.On [DATE] at 2:00 PM V1, Administrator went through the facility's tracheostomy policy and stated it doesn't address reinsertion of a tracheostomy in an emergency situation. V1 stated he would have V2 add it to the policy and reinservice nurses to ensure they are properly trained on how to reinsert it in an emergency situation. On [DATE] at 8:45 AM V28, Regional Nurse stated she understood the facility's tracheostomy policy that was given to IDPH on [DATE] didn't address reinsertion of a tracheostomy in an emergency situation and that she added that to the facility's tracheostomy policy and had inserviced nurses so they were educated on this topic. Reviewed hospital emergency room records dated [DATE]. They document due to resident decannulated tracheostomy which required two attempts at reinsertion of the tracheostomy and arterial line placement. After reinsertion of R3's tracheostomy by an ENT physician, R3 became hypoxic with oxygen saturation in the 80's and had increased work for breathing. R3's hospital records document R3 ultimately died on [DATE] with clinical impression of tracheostomy complications, cardiopulmonary arrest and heart block.On [DATE] at 9:56 AM V21, R3's Physician stated R3 had a lengthy hospitalization in 2025 for acute respiratory failure where she was intubated for a long period of time. R3 had a physician's order for humidified oxygen to the trach collar and that was to keep the trach moisturized not to prevent hypoxia. V21 stated you can't restrain residents in long term care so when R3 was readmitted to the facility after pulling her tracheostomy tube out the first time, he expected staff to remind the resident to not pull out her tracheostomy tube and to do frequent checks on the resident. V21 stated if R3 was restless or having behaviors of pulling on her tracheostomy tube/collar he would have expected staff to notify him so he could review her medications. V21 stated he wasn't aware R3's family removed the oxygen from the trach, but he was OK with it as long as R3's oxygen saturation level was OK. The tracheostomy tube was medically necessary because R3 was intubated for so long she needed to be slowly downgraded from being intubated. V21 stated the tracheostomy tube should not be removed abruptly because it could cause hypoxia which could lead to cardiac arrest which if not corrected could lead to death. V21 stated when R3 was observed to have removed her tracheostomy tube the second time at the facility nurses assessed her, notified him and R3 was transferred to the emergency room to be assessed and have the tracheostomy tube reinserted.The Facility Assessment Updated [DATE], documents they accept 1-2 tracheostomy residents a year with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Asthma, Chronic Lung Disease and Respiratory Failure.The Facility's Undated Tracheostomy Care Procedure documents the purpose of this procedure is to guide tracheostomy care and the cleaning of resuable tracheostomy cannulas. The Immediate Jeopardy that began on [DATE] was removed on [DATE], when the facility took the following actions to remove the immediacy:Immediate Jeopardy Removal Plan: On, [DATE] R3 admitted to the facility with a HX of decannulation. On [DATE] resident decannulated her trach. Facility nursing staff attempted to re-insert her Trach without success and was sent to local Hospital for re-insertion of the Trach. Resident returned to the facility on the same day. On [DATE] resident decannulated her trach, no respiratory distress and O2 saturation WNL, PCP notified and gave orders to send to ED for reinsertion of trach. Facility called EMS for transfer to hospital for reinsertion of trach. Staff were in-serviced/trained on tracheostomy recannulation by the RNC. Education will be ongoing. Staff on vacation or FMLA will be in serviced before returning to work by Administrator/DON, nurse management. Administration will monitor for compliance. [DATE] and Ongoing. New hires will be trained on tracheostomy recannulation as part of their general orientation before starting by DON or nurse management. [DATE] and Ongoing. DON in serviced by RNC on tracheostomy recannulation and respiratory assessment and care planning. [DATE] and Ongoing. Resident respiratory assessments for all residents that require Trach care will be completed each shift. Any resident in the facility that requires trach care will have individualized interventions to prevent decannulation. This will be reviewed and updated accordingly by the IDT team. Trach care plans reviewed and updated by the IDT team. Trach care and suction assessments and care plans will be reviewed by IDT at least quarterly and after any incident or resident change in behavior. [DATE] and Ongoing. Tracheostomy recannulation drill was performed on [DATE] by DON/RNC and will be performed weekly for one month and monthly thereafter for 6 months. Staff will be re-in-serviced on tracheostomy recannulation and upon annual review of annual policy by DON, nurse management, and administration. New hires will be in serviced on during their general orientation. [DATE] and Ongoing. Recanalization supplies are in each resident area for those that have tracheostomies. [DATE] and Ongoing. QAPI review with Medical Director to review tracheostomy recanalization incident and plan of action. Action plan will be reviewed monthly at QAPI meeting. Medical Director approved of plan with no further recommendations. [DATE] and Ongoing. Medical Director notified of incident on [DATE] in the facility by the Administrator and reviewed the facility's immediate action plan. He agreed with immediate action plan. [DATE]. R3 no longer resides in the facility. [DATE].

Based on observation, interview and record review the Facility failed to maintain residents' well-being and dignity by accommodating preference for 4 of 5 residents (R1, R2, R4, and R5) reviewed for accommodation of needs in the sample of 6. Findings include: On 6/6/2025 at 9:14 AM, R4 stated, the facility runs out of towels, pads and sheets all the time. I think they need to order more. They are always running out. It happens a lot, too much. I have my own briefs that I keep at my bedside, but staff had come in here and taken mine. I get cold sometimes and they do not have enough blankets and when I ask, they say they do not have any more. On 6/6/2025 at 9:18 AM, R2 stated the Facility at night runs out of adult briefs and pull ups at least two or three times a month. On 6/6/2025 at 9:28 AM, R5 stated the Facility has run out of (adult diapers) and staff made her stay in her room when she did not want to because they did not have anything to put on her. On 6/6/2025 at 10:29 AM, V8, Certified Nursing Assistant (CNA) stated, I started working in the Facility as a housekeeper and then I became a CNA. She stated the facility was always running out of supplies. We are always running out of gloves, adult briefs, adult diapers, linens, pads, sheets. We run out of linen and blankets especially at night. I have residents that get cold, and I have no blankets to give them. (V11, CNA) had to purchase snacks out of her own money and was working the night shift and she had to buy the bigger depends on the other night because we ran out. I heard them tell everyone at a morning meeting they if they bought anything they could give them a receipt and they would be reimbursed. But really one should not have to purchase any supplies to begin with. The supplies should be restocked and supplied so staff don't have to buy anything out of their own pocket. I don't think it is right, and it's not a one-time thing, it is constantly happening. There are times that we run out and when that happens, we have to keep residents in their rooms, in their beds, and it's not right. On 6/6/2026 at 1:24 PM, V11, CNA, stated she had been working in the Facility for six years. She usually works 6 AM to 6 PM. V11 stated It is not uncommon for us to run out of stuff especially on nights. We run out of linens, adult briefs, and this is not a one-time thing, this has been happening for months now. Management is aware, but nothing really changes. Last week we ran out of stuff and the agency staff walked out. When we run out, we try and look in other places to find something, and then we have to leave residents in their bed, in their room. There are times when residents just had to lay in bed because there were not enough incontinent supplies. On 6/6/2025 at 3:09 PM, V10, CNA stated, This cart is not full. It's not uncommon for us to run out of slings, towels, sheets, adult briefs, pull ups, blankets. When it happens, I will try and find a replacement, but sometimes we just don't have any in the building. It is hit and miss and not uncommon for me to run out of supplies. If I can't find one, then I put the resident to bed with pads and do frequent checks on them because there is not much else that I can do even though the pad is saturated. On 6/6/2025 at 3:10 PM, the clean supply room on the 100-hall had only two opened packages of xl (extra-large) pull ups with only 4 left, and 2 adult diapers. There were no small pulls ups and/or medium pull ups. This rack was almost bare. On 6/6/2026 at 3:14 PM, R2 was in a bariatric bed. R2 stated she wears adult pull ups, but the large bariatric size and they have run out of her size several times and when it happens, they put her in a pull up that is too small and is very uncomfortable especially when she has a sore area on her butt. This has happened 2-3x times in the last month, and she feels it is not good for her to wear a smaller size with that area on her bottom. On 6/6/2026 at 3;20 PM, V13, CNA stated, We have good days and bad days when it comes to supplies. It's not uncommon for us not to have enough supplies. They keep telling us they are on a budget. We used to have housekeeping at nights but no more. There have been 2-3 times in the last two months when I did not have any diapers and/or pull ups for my residents. When that happens, I clean them up and put them on bed pans. Some of the residents are not happy about that. I understand that. I do the best I can do with what I have and sometimes I need more stuff, you know what I mean. On 6/8/2025 at 9:17 PM, V14, CNA stated, We do not have enough supplies. We are always running out of gloves, blankets, pull ups and adult briefs. It's really bad at nights. We just need more supplies. We run out of stuff and when it happens, we have to try and keep the residents in bed, in their rooms and constantly check on them. I have had some residents complaining to me tonight that they are cold, and I do not have one blanket to give them tonight. On 6/9/9/2025 at 9:19 PM, R1 stated via telephone when he was at the facility, they were always running out of his size of pull ups, and he would either be squeezed into a smaller size or not have anything. It was really bad at night. R1's Grievance Incident date 4/20/2025 document, Not having the right size pull up. He has been told we do not have his size, and they are awaiting a shipment. On 6/9/2025 at 9:25 PM, tour of the facility for supplies was conducted and there were only two clean blankets in storage in all four clean linen closets and none on the carts on each hall. The Resident Right Policy with a revision date of 7/2/2023 documents, To provide guidance to facility staff on resident rights. The resident rights to dignified existence, be treated with respect, kindness and dignity.

Based on Observation, Interview, and Record Review the facility failed to implement preventative measures to reduce the development of and worsening of pressure injuries in 2 of 7(R55, R39) residents in the sample of 31. This failure resulted in R55's skin on 1/7/25 documented as mid buttocks maceration to a developed and documented sacrum pressure ulcer stage 3 on 1/16/25; and other in house developed pressure wounds. R39 also developed several in-house pressure injuries. Findings include: 1. R55's Face sheet documents an admitted [DATE]. Diagnosis include Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Dysphagia, Type 2 Diabetes, Congestive Heart Failure. R55's Minimum Data Set, MDS, dated [DATE] documents R55 is moderately cognitively impaired. R55 is dependent for rolling left to right and chair to bed transfers. R55 is at risk for pressure injuries and has unhealed pressure injuries. R55's care plan updated 3/4/2025 documents Actual Pressure Ulcer; Site(s): unstageable of sacrum. Requires assist with turning and positioning, present on admission. Provide off loading for ulcer site. R55 has an arterial ulcer of the right lateral ankle, arterial of right lateral foot. Heels up device as tolerated in bed. R55's admission nursing assessment dated [DATE] documents mid buttocks maceration. R55's Braden Scale for predicting pressure sore risk documents R55 is at moderate risk of developing pressure ulcers. R55's progress notes dated 1/7/2025 at 6:25PM documents Skin is unremarkable but there is maceration to buttocks, zinc is ordered for this. R55's wound notes dated 1/16/2025 documents sacrum pressure ulcer stage 3. Measurements 6.5 cm x 1.5 cm x .10cm. R55's wound notes dated 1/23/2025 documents Sacrum unstageable pressure wound. Measurements 5.5 cm x 1.2 cm x .20 cm. New in-house facility acquired right lateral ankle wound. Measurements 2cm x 1.5cm x .10cm. R55's wound notes dated 2/13/2025 documents Sacrum pressure wound stage 3. Measurements 2 cm x .8 cm x .2 cm. Right lateral ankle arterial ulcer full thickness 2.5 cm x 2.5 cm x .10cm. New facility acquired right lateral foot. Measurements .70 cm x .50cm. R55's wound notes dated 3/20/2025 documents sacrum pressure wound stage 3. Measurements 1.5 cm x .7 cm x .7 cm. Right lateral foot new facility acquired. Measurements 1.5cm x 1cm x .10cm. Right lateral ankle arterial ulcer full thickness 3.5 cm x 3.3 cm x .3cm. R55's Skin and Wound note dated 2/27/2025 documents stage 3 pressure injury to the sacrum and an arterial wound to his right lateral ankle and right lateral foot. Patient was placed on PO Augmentin by PCP for his right lateral ankle, he had a wound culture after he finished this antibiotic, and it was positive for MRSA. He was placed on doxycycline and finished this antibiotic 1-2 days ago per wound nurse. Preventative Measures: R55 has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit. Float heels while in bed with use of heel boots. On 3/27/2025 at 10:45AM R55 lying flat in bed. No heel protectors on in bed. Heels to the mattress. On 3/27/2025 at 12:15PM R55 up in geriatric chair sitting straight up with feet directly on bottom of chair. Heels not floated. On 3/27/2025 at 3:15PM R55 remains up in geriatric chair with feet to bottom of chair. Heels not floated. On 3/27/2025 at 10:30AM V3, Wound Nurse, stated when R55 came to us the Nurse Practitioner called the redness to his sacrum maceration. The wound kind of deteriorated into a stage 3. R39's Face sheet documents an admitted [DATE]. Diagnosis includes Encephalopathy, Sepsis, Acute Cystitis, Paroxysmal Atrial Fib, Chronic Kidney Disease, Hyperlipidemia. 2. R39's MDS dated [DATE] documents R39 is severely cognitively impaired and is dependent for bed mobility and transfers. R39 is at risk for pressure ulcers and has unhealed pressure ulcers. R39's care plan dated 2/24/2025 documents Actual Pressure Ulcer; Site(s): unstageable sacrum unstageable Left heel stage 3. Requires assist with turning and repositioning. Interventions include Encourage to Float heels. R39's Braden scale for pressure ulcer development dated 11/26/2024 documents R39 is at risk for pressure ulcer development. R39's Admission assessment dated [DATE] documents wound to left buttock. R39's Skin/Wound visit dated 1/16/2025 at 2:57 PM documents Wound # 1 left heel Pressure ulcer. The patient has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit. R39's wound notes dated 1/16/2025 documents new facility acquired wound to left heel. Measurements 3.5cm x 2cm. R39's wound notes dated l/23/2025 document left heel. Measurements 2.5cm x 2.5cm. R39's wound notes dated 1/30/2025 document left heel. Measurements 3.5cm x 3.0cm. R39's wound notes dated 2/6/2025 document left heel. Measurements 2.5cm x 3.0cm. R39's wound notes dated 2/20/2025 document sacrum new facility acquired. Measurements 6.5 cm x 7cm x .10 cm. Left heel 1.5cm x .75cm. R39's wound notes dated 2/27/2025 document sacrum 7cm x 4.5cm. Left heel 1.5cm x .5cm. R39's wound notes dated 3/20/2025 documents sacrum 5.5cm x 4.5cm. R39's order sheet dated 3/17/2025 documents Heel protectors as tolerated two times a day. On 3/26/2025 at 10:00AM R39 lying in bed with no float heels on. Heels on mattress. On 3/27/2025 at 12:55PM V8, CNA, stated R39 is able to roll on side by himself. On 3/27/2025 at 1:00PM V8, CNA, and V20, CNA, provided incontinent care to R39. R39 unable to roll self from left to right or right to left without max assist. Float heels not on. Heels on mattress. On 3/27/2025 at 3:00PM V2, Director of Nursing, DON, stated her expectation is for residents to be turned and repositioned every 2 hours and heels floated as the resident will tolerate. Facility policy with a revision date of 10/16/2023 states Prevention program including Turning and Positioning, will be utilized for all residents who have been identified of being at risk for developing pressure ulcers. The facility will initiate an aggressive treatment program for those residents who have pressure ulcers. A pressure ulcer is defined as any lesion caused by unrelieved pressure those results in damage to underlying tissue. Pressure ulcers usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed.

Based on interview, observation, and record review the facility failed to provide progressive interventions and to prevent multiple falls for 1 of 5 (R47) residents investigated for accidents in a sample of 31. The failure resulted in R47 sustaining a right hip fracture and then sustaining a right hip surgical incision dehiscence requiring a return to the hospital for sutures and antibiotics. Findings include: R47's EMR (Electronic Medical Record) undated documents that the resident was readmitted to the facility after right hip surgery on 12/04/24. R47's EMR dated 4/25/24 documents a diagnosis of unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; unspecified osteoarthritis, unspecified site; and age-related osteoporosis without current pathological fracture. R47's MDS (Minimum Data Set) dated 3/11/25 documents a BIMS (Brief Interview for Mental Status) score of 4 out of 15. The MDS documents that the resident requires substantial/maximal assistance for roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer. R47's Care Plan dated 7/25/24 documents (R47) is at potential risk for falls and injuries r/t (related to) use of hypoglycemic medications and diagnosis of Type II DM (Diabetes Mellitus), PVD (Peripheral Vascular Disease), Dementia, Chronic Ischemic Heart Disease, and HTN (Hypertension). R47's Health Status note dated 10/09/24 at 6:58 PM documents Resident had a witnessed noninjury fall at approx. 0830- did not hit head. Vitals 110/62, 69 pulse, 16 resp, 97.4T 96% RA (room air). Resident had c/o (complaint of) of dizziness and pain to LUQ (left upper quadrant) prior to fall. (V17), Medical Director's office notified and POA (Power of Attorney) aware. NNOR (no new order) at this time. No intervention noted for fall on 10/09/24. R47's Health Status Note dated 10/10/24 at 4:08 PM documents Writer called to resident's room by CNA (Certified Nursing Assistant) staff. Resident was observed laying on the floor on the right side of the bed near the door. Floor was dry and free of debris. Resident's legs extended outward. CNA at bedside sitting on floor with resident. CNA (V8) stated I seen (sic) her just roll out of the bed and on to the floor. She didn't hit her head. I just couldn't get to her quick enough to stop her from rolling out of the bed. Resident assessed by writer and assisted to standing position without difficulty. Nursing staff assisted resident back into bed per her request and call light placed in reach. Resident bed was placed in the lowest position and turned towards the wall. Intervention for fall on 10/10/24 is bed to be against the wall. R47's Health Status note dated 10/17/24 at 2:11 AM documents This writer was sitting at the nurse's station when a hospice CNA stated that someone had fell on the floor. Upon entering room resident was noted to be on right side with left hand on the floor in front of her. The second drawer to her nightstand was open. On the floor by her head was a yellow bead. Resident had proper fitting shoes on bilateral feet. Resident was assisted up to her bed. Resident has complaints of her left wrist hurting. Resident stated her bracelet had broken, she was trying to find a string, and that she slipped on the bead. This writer cleaned the floor of all objects and took all beads out of room. POA, DON (Director of Nursing), and (V17) notified. New orders received for x-ray to left wrist. No intervention noted for fall on 10/17/24. R47's Health Status Note dated 10/26/24 at 3:55 PM documents Resident inside therapy room and fell , complaints of pain to right hip. Called (V18) NP (Nurse Practitioner) to report fall. Pain level keeps increasing, NP states to send to ER (emergency room ) for eval. 911 called for non-emergency transfer to (local hospital), (V19) POA called to report fall and orders from NP. No rotation or shortening noted, resident is able to put weight on Right hip but has pain with pressure. EMT (Emergency Medical Technician) arrived x 2 to transport, report called into (local hospital) ER, will update with results. R47's Health Status Note dated 10/29/24 at 11:33 PM documents Called (local hospital) and spoke with (hospital staff) RN, transferring resident to Metropolitan hospital) for fractured right hip. Resident did not have an intervention for the fall prior to this fall with an injury. Intervention for fall on 10/26/24 is for PT/OT (Physical Therapy/Occupational Therapy) to eval and treat, as needed. R47's Health Status Note dated 11/20/24 at 5:26 PM documents Resident fell at approx. 1645, unwitnessed. Surgical wound to R hip dehiscence. Resident found laying (sic) on her left hip in the doorway/hallway with pants to knees. Puddle of blood next to bed. Staff applied pressure to site. 911 called, paperwork gathered. Returned with ABD (Abdominal) pads. Ambulance arrived-- applied pressure dressing. Transferred to stretcher without complications. V17(Medical Director), DON and POA notified. R47's Health Status Note dated 11/20/24 at 10:40 PM documents (V18), NP for (R47), notified of resident's return and of sutures and of ABT (antibiotic) order. No intervention noted for fall on 11/20/24. R47's Health Status Note dated 11/30/24 at 8:35 PM documents called to resident's room. noted this resident sitting in doorway of room to hallway only wearing shirt. sitting on buttocks with knees bent. noted urine beside bed. alarm on bed on but not sounding. PROM (Passive Range of Motion) is wnl (within normal limits) for this resident. surgical site to right hip is intact. neuro checks started and are wnl. assist of 2 to get in chair. resident cleaned and put to bed per CNA. VS (vital signs) 97.8, 73, 18, 84/53. sp02 (oxygen saturation) 91% r/a. No intervention noted for fall on 11/30/24. R47's Health Status note dated 1/10/25 at 4:25 PM documents resident had unwitnessed fall, resulting in a lump to the right side of the back of her head, range of motion completed, vitals WNL, resident responds appropriately per her baseline. MD (Medical Director) made aware, calls POA, no VM (voice mail) set up. poc (plan of care) ongoing. Intervention for fall of 1/10/25 is pressure pad alarm placed. R47's Health Status Note dated 2/18/25 at 11:15 PM documents called to resident's room for resident sitting on floor at FOB (foot of bed) on buttocks pulling on catheter. ROM and PROM without resistance or c/o pain/discomfort. neuro checks initiated and are wnl. assist of 2 to get back in bed. Noted large purple bruise to right hip area, resident able to move hip joint without c/o or resistance. MD notified. son(V19), notified. No intervention noted for fall on 2/18/25. R47's Health Status Note dated 2/24/25 at 7:40 PM documents called to oakwood hall for resident on floor. noted resident sitting on floor on buttocks in oakwood DR (dining room) with back against corner. resident unable to say what she was doing d/t (due to) usual confusion. c/o some pain to right leg with PROM but no resistance noted. assist to w/c (wheelchair) with 2 assists. neuro checks initiated and are wnl. VS 98.4, 91, 20, 94/57. sp02 96% r/a. Intervention for fall on 2/24/25 is anti-roll backs applied to w/c. R47's Health Status Note dated 3/12/25 at 8:00 PM documents Resident observed sitting on legs on floor in front of w/c. Barefoot (Removed socks per self). No c/o pain. Able to move extremities without difficulty. No noted injuries. Resident does not remember what was doing. VS: 124/71 97.7 69 20. SPO2 96% RA. Assisted to w/c. Alarm turned on and placed in w/c. Neuro-checks attempted. Resident refuses to participate. Closes eyes. Resident remains in area with staff. Intervention for fall on 3/12/25 is dycem (anti slip cushion) to w/c, gripper socks as tolerated. On 3/27/25 at 10:59 AM, V4, RN (Registered Nurse) stated that today is her second day working at this facility. She stated that she would add interventions to a resident's care plan after a resident has fallen. On 3/27/25 at 11:01 AM, V8, CNA stated that (R47) has a pressure alarm on her bed and wheelchair. She stated that R47 likes to stay busy, so they keep her busy to keep from falling. On 3/27/25 at 11:02 AM, V9, LPN (Licensed Practical Nurse) stated that today is her second day working at the facility. She stated that she thinks that it's the MDS person's job to add interventions to the care plans. On 3/27/25 at 11:03 AM, V5, LPN stated that it is the MDS, DON, and V3 the QA (Quality Assurance) nurse's job to add interventions to the care plans. On 3/27/25 at 2:19 PM, V21, MDS Coordinator/LPN stated that she just started as the MDS coordinator in December. She stated that it is her job to add interventions to the care plans after a resident falls. She stated that when she took over the MDS, it was a mess and care plans were not up to date. Facility's policy Accidents & Incidents dated 7/01/23 documents All accidents/incidents involving a resident will be documented in Risk Management. The nursing team will complete an investigation with the root cause and new interventions. Facility's policy Fall Prevention Program/Protocol dated 7/01/23 documents Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview, and record review, the facility failed to date two opened multi-dose vials of Tuberculin Serum when reviewed for medication storage and labeling. This failure has the potential to affect all 62 residents residing in the facility. Findings include: On 3/25/25 at 1:39 PM, the medication storage room refrigerator was observed with two multi-dose vials of Tuberculin Serum, opened and undated. The Tuberculin Product Information, dated October 2021, documents a vial of Tubersol (Tuberculin) which has been entered (opened) and in use for 30 days should be discarded. The Medication Storage Policy, dated 7/1/23, documents the facility stores all drugs and biologicals in a safe, secure, and orderly manner and in accordance with state and federal regulations. Medications shall be administered prior to the manufacture's expiration date. On 3/26/25 at 3:21 PM, V2, Director of Nurses, stated if the Tuberculin Serum is a multi-dose vial, it is used on multiple residents and should be dated when opened. The CMS (Centers for Medicare and Medicaid Services) for 671, dated 3/25/25, documents there are 62 residents residing in the facility.

Based on interview and record review, the facility failed provide sufficient nursing staff to meet the needs of the residents residing in the facility when reviewed for Sufficient Staffing in the sample of 31. This failure has the potential to affect all 62 residents residing in the facility. Findings include: 1. On 3/25/25 at 12:20 PM, R4 stated they need more CNAs (Certified Nursing Assistants) everyday, all day. R4 stated the CNAs are leaving and not staying. R4 stated she is constantly having to wait for her call light to be answered and care provided. R4 stated she has had to sit in her urine for long periods of time and she is tired of it and is trying to move to another facility. R4's MDS (Minimum Data Set), dated 2/5/25, documents R4 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R4 is cognitively intact and is dependent with toileting. 2. On 3/25/25 at 9:35 AM, R2 stated there were only 2 CNAs on 3/22/25 during the night for the entire building. R2 stated it is harder to get care when there is less staff. R2 stated he takes a water pill and when he has to go, he has to go. R2 stated he will put his call light on, the staff will tell him they will be right back, but they don't, and he has an accident. R2's MDS, dated [DATE], documents R2 has a BIMS score of 15, indicating R2 is cognitively intact and dependent upon staff for toileting. 3. On 3/27/25 at 10:30 AM, during the resident council meeting, R18, stated they do not have enough CNAs to provide timely care. R18's MDS, dated [DATE], documents R18 has a BIMS score of 15, indicating R18 is cognitively intact and is dependent with toileting. 4. On 3/27/25 at 10:30 AM, during the resident council meeting, R21 stated they do not have enough CNAs to provide timely care. R21's MDS, dated [DATE], documents R21 has a BIMS score of 10, indicating R21 has moderate cognitive impairment and requires partial/moderate assist with toileting. 5. On 3/27/25 at 10:30 AM, during the resident council meeting, R31 stated they do not have enough CNAs to provide timely care. R31's MDS, dated [DATE], documents R31 has a BIMS score of 15, indicating R31 is cognitively intact and is dependent with toileting. 6. On 3/27/25 at 10:30 AM, during the resident council meeting, R37 stated they do not have enough CNAs to provide timely care. R37's MDS, dated [DATE], documents R37 has a BIMS score of 15, indicating R37 is cognitively intact and is dependent with toileting. The Resident Council Minutes, dated July 2024 and January 2025, documents under concerns that there are not enough nurses. The CMS (Centers for Medicare & Medicaid Services, Payroll Based Journal Report, for fiscal year quarter one 2025 (October 1 - December 31), documents the facility has a one star staff rating. The Facility Assessment, undated, documents it is the facility practice to provide sufficient staff with the appropriate competencies and skill sets to provide care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnosis of the facility problem. On 3/26/25 at 8:05 AM, V5, Licensed Practical Nurse, stated she would like to see more CNAs during the day, their acuity is higher and when they are short, it makes for a long, hard day. On 3/27/25 at 12:49 PM V1, Administrator, stated they use a staffing calculator based off of the state's ratios when scheduling CNAs and Nurses. The CMS form 671, dated 3/25/25, documents there are 62 residents residing in the facility.

Based on interview, observation, and record review, the Facility failed to ensure enteral feeding was administered in a manner that prevents foodborne illness for 1 of 4 residents (R10) reviewed for nutrition in the sample of 31. Findings include: R10's Face Sheet documents R10 was admitted to the facility on [DATE] with diagnoses including brain stem stroke, functional quadriplegia, dysphagia (difficulty swallowing), and gastrostomy (feeding tube) status. R10's Minimum Data Set (MDS) dated [DATE] documented R10 was moderately cognitively impaired, dependent with mobility, and had a feeding tube. R10's Care Plan initiated 7/29/21 documents R10's nutrition must be provided via feeding tube due to history of stroke with dysphagia. R10's 3/13/25 Diet Order documents NPO (nothing by mouth). R10's Physician Orders dated 3/17/25 documents Jevity 1.2 per PEG (percutaneous endoscopic gastrostomy) via pump rate of 65 mL (milliliters) per hour with 150 mL water flush every 4 hours. On 3/25/25 at 9:15 AM, R10 was sleeping in bed in her room. Jevity 1.2 was infusing at 65 mL per hour via infusion pump. The Jevity 1.2 container was not dated or timed. On 3/25/25 at 9:17 AM, V5, Licensed Practical Nurse (LPN), stated if there is no date on the tube feeding bottle she will discard it for resident safety. She would also discard the formula if the date was more than 24 hours ago. On 3/25/25 at 2:20 PM, R10 was sleeping in bed in her room. Jevity 1.2 was infusing at 65 mL per hour via pump. There was no date or time on the tube feeding carton. On 3/26/25 at 8:38 AM, R10 was sleeping in bed in her room. Jevity 1.2 was infusing at 65 mL/hr via pump. The carton of tube feeding was labeled 3/25 and 13:17 (1:17 PM). On 3/26/25 at 3:15 PM, R10's tube feeding was infusing at 65 mL/hr via pump. The Jevity 1.2 carton still read 3/25 and 13:17. On 3/26/25 at 3:17 PM, V4 stated tube feedings can only hang for 24 hours after being spiked. V4 was notified that R10s tube feeding label was greater than 24 hours ago. On 3/26/25 at 3:40 PM, R10's Jevity 1.2 with the labels 3/25 and 13:17 was still infusing at 65 mL/hr via pump. On 3/27/25 at 10:18 AM, V2, Director of Nursing (DON), stated tube feedings should be dated and timed and discarded after 24 hours. The Facility's Undated Enteral Tube Feeding via Continuous Pump Procedure documents, On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order.

Based on interview and record review, the facility opened a package belonging to a resident without their permission for 1 of 3 residents (R2) reviewed for Communication with Privacy in the sample of 31. Findings include: On 3/25/25 at 9:35 AM, R2 stated he had ordered a wireless charger and when it came, staff (unknown) opened the package prior to giving it to him without his permission because they thought it was medication. R2 stated he tells the staff when he has ordered something, so they don't open it and he does not order his medication anymore, the facility does. R2's Minimum Data Set, dated dated [DATE], documents R2 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R2 is cognitively intact. R2's Admission Contract, dated 12/20/24, documents R2 declined authorization for the facility to inspect and open official correspondence. On 3/26/25 at 8:58 AM, V1, Administrator, stated V1 the resident's mail/packages are not opened by staff. On 3/26/25 at 3:21 PM, V2, Director of Nurses, stated they do not have a policy on resident mail.

Based on interview and record review, the Facility failed to report an injury of unknown origin for 1 of 1 resident (R265) reviewed for abuse in the sample of 31. Findings include: R265's Face Sheet documents R265 was admitted to the facility on [DATE] with diagnoses including unspecified dementia and metabolic encephalopathy. R265's Minimum Data Set (MDS) dated [DATE] documented R265 was severely cognitively impaired and dependent with mobility. R265's Care Plan does not address risk of abuse and neglect. R265's Weekly Skin Inspection dated 3/13/25 did not document any skin impairments. R265's Progress Note by V15, Registered Nurse (RN), on 3/14/25 at 11:45 AM documents, At 11:30 a.m. activities personnel brought resident to the nurse's station and showed this nurse a skin tear to resident's right arm. Skin tear 5 cm (centimeters) x 3 cm x 0 cm noted to resident's right arm. Resident unable to explain how she sustained the skin tear. R265's Progress Note by V15 on 3/14/25 at 2:16 PM documents, New order per (V17, Medical Director): Monitor (sterile strips), applied TAO (triple antibiotic ointment), non adherent pad, wrap with (cotton gauze bandage), secure with paper tape. On 3/26/25 at 11:28 AM, V15 stated R265 got a skin tear on 3/14/25 and could not tell me how she got it. On 3/27/25 at 12:30 PM, V16, CNA, stated he took R265 to the dining room, and she did not have a skin tear at that time. Soon after that, R265 was at the nurse's station with a skin tear. V16 does not know how it happened. On 3/26/25 at 11:00 AM, V14, Activities Assistant, stated she noticed R265 was bleeding when she came down to the dining room, so she took her back to her nurse. V14 did not know how the injury occurred. On 3/26/25 at 12:52 PM, R265 was sitting in wheelchair in her room with two bandages on her right forearm. R265 was unable to explain what happened to her arm. On 3/26/25 at 10:50 AM, V2, Director of Nursing (DON), stated the skin tear was not reported to IDPH. The Facility's Abuse Policy revised 1/9/24 documents, The administrator and/or designee is the facility abuse coordinator for the facility. It is the responsibility of all facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. It is all staff responsibility to report any allegation or witnessed abuse Immediately to the Administrator (Abuse Coordinator). The facility will report all allegations of abuse immediately to the Administrator and timely to the proper authorities to include IDPH, Ombudsman, Local P.D. (Police Department), POA (Power of Attorney), M.D. (Medical Doctor) in a timely manner.

Based on interview and record review, the Facility failed to investigate an injury of unknown origin in a timely manner for 1 of 1 resident (R265) reviewed for abuse in the sample of 31. Findings include: R265's Face Sheet documents R265 was admitted to the facility on [DATE] with diagnoses including unspecified dementia and metabolic encephalopathy. R265's Minimum Data Set (MDS) dated [DATE] documented R265 was severely cognitively impaired and dependent with mobility. R265's Care Plan does not address risk of abuse and neglect. R265's Weekly Skin Inspection dated 3/13/25 did not document any skin impairments. R265's Progress Note by V15, Registered Nurse (RN), on 3/14/25 at 11:45 AM documents, At 11:30 a.m. activities personnel brought resident to the nurse's station and showed this nurse a skin tear to resident's right arm. Skin tear 5 cm (centimeters) x 3 cm x 0 cm noted to resident's right arm. Resident unable to explain how she sustained the skin tear. R265's Progress Note by V15 on 3/14/25 at 2:16 PM documents, New order per (V17, Medical Director): Monitor (sterile strips), applied TAO (triple antibiotic ointment), non adherent pad, wrap with (cotton gauze bandage), secure with paper tape. On 3/26/25 at 10:50 AM, V2, Director of Nursing (DON), provided an undated investigation documenting, On 3/14/25 (R265) had a skin tear on right forearm. Upon talking to the activity assistant, the CNA (Certified Nursing Assistant) had brought resident down from activities and she noticed a skin tear to right arm. She brought resident back to the nurse's station for it to be addressed. Speaking with nurse (V5) Resident was wheeling self to (room) and was close to the guard rail. It is believed that she bumped her arm off of the guard rail on Rosemont hallway due to blood being noted on the side rail. The document was signed by V3, Licensed Practical Nurse (LPN), and documents V5, LPN, V14, Activities Assistant, and V16, CNA, were interviewed. On 3/26/25 at 10:55 AM, V5 stated she was not R265's nurse on 3/14/25 but remembers hearing about R265 sustaining a skin tear on her arm. She did not see R265's arm or the handrail that day. On 3/27/25 at 12:30 PM, V16 stated he took R265 to get weighed, then he took her to the dining room. She did not have a skin tear at that time. Soon after that, she was sitting at the nurse's station with a skin tear. V16 stated he did not know how it happened and did not see any blood on the railing, and V3 just called to ask him about it one day this week. On 3/26/25 at 11:00 AM, V14, Activities Assistant, stated she noticed R265 was bleeding when she came down to the dining room, so she took her back to her nurse. V14 did not know how it happened and was not interviewed about it until V3 asked her about it today. On 3/26/25 at 11:28 AM, V15, Registered Nurse (RN), stated she remembers the Activities person bringing R265 down to her and saying she had a skin tear. R265 could not tell me how she got it, and V15 did not see the handrail in question. On 3/26/25 at 12:52 PM, R265 was sitting in wheelchair in her room with two thin bandages on her right forearm. She was unable to explain what happened to her arm. On 3/26/25 at 11:03 AM, V3 stated she just began the investigation today and did not interview R265's nurse from 3/14/25. The Facility's Abuse Policy revised 1/9/24 documents, The administrator and/or designee is the facility abuse coordinator for the facility. It is the responsibility of all facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. It is all staff responsibility report any allegation or witnessed abuse Immediately to the Administrator (Abuse Coordinator). The facility immediately and thoroughly investigates all allegations of abuse to include by not limited to interview or residents and staff, visitors, Vendors.

Based on interview and record review, the facility failed to identify resident specific behaviors and develop a behavioral care plan with individualized interventions for residents with behavioral health needs for 3 of 6 residents (R2, R3, R8) reviewed for behavioral health services in the sample of 10. Findings include: 1. R2's Face Sheet, undated, documents R2 has diagnoses of Anxiety Disorder and Major Depressive Disorder. R2's Minimum Data Set, MDS, dated [DATE], documents R2 has a BIMS (Brief Interview for Mental Status) score of 14, indicating R2 is cognitively intact. R2's MDS goes on to document that R2 has verbal behaviors directed towards others and rejects care. R2's Care Plan, dated 1/14/25, fails to identify R2's verbal behaviors or rejection of care, therefore no resident specific interventions were implemented. R2's Care Plan does not address R2's diagnoses of Anxiety Disorder and Major Depressive Disorder or interventions to address this. R2's Progress Note, dated 2/8/25 at 8:39 AM, documents the following: After eating breakfast resident attempted to incite a riot about cigarette smoking was trying to encourage all residents on his hall that smoke to get cigarettes to go smoke when that was not effective became verbal aggressive stating that he was leaving and going home AMA (against medical advice) required multiple interventions with different approaches. R2's Progress Note, dated 2/10/25 at 5:52 AM, documents the following: Resident c/o (complaining of) feeling depressed & states he's 'going nuts' in his own mind. Mentioned his wife's death and back when he was in the hospital 'clarified brain dead'. He states he would like something for depression. Currently on duloxetine 60 mg (milligrams) daily. Faxed MD (Medical Doctor). R2's Progress Note, dated 2/18/25 at 6:26 PM, documents the following: Resident seen 3 times by writer pacing the Oakdale hall, the third time writer was walking behind him and (R3) as they were rolling back towards the nurse's station and heard them discussing a female resident and checking/ looking into her room to see where she was. Writer informed DON (Director of Nurses) of them lurking the hall for this specific resident. Writer also seen that they were looking/assessing the service doors on that hallway, writer advised that is not an area for residents and they had moved on down the hall as requested. POC (Plan of Care) ongoing. There was no behavior monitoring identified in R2's record that the facility was monitoring for any behaviors. On 3/7/25 at 8:05 AM, V8, Certified Nursing Assistant, CNA, stated R2 would follow around female residents and staff and make inappropriate comments to them. V8 stated one time, R2 told her he was going to take her out to Ponderosa and grope her. V8 stated it was reported to management and the female staff were not allowed to provide care to R2 without another staff member present, including during smoke times, there would have to be two staff present. V8 stated she isn't sure if they talked to R2 about his behaviors. 2. R3's Face Sheet, undated, documents R3 has a diagnosis of Anxiety Disorder. R3's CHIRP (Criminal History Report, dated 2/21/25, documents R3 has a criminal history with conviction including but not limited to: aggravated criminal sexual assault, aggravated kidnapping, aggravated battery, and unlawful restraint. R3's MDS, dated [DATE], documents R3 has a BIMS score of 15, indicating R3 is cognitively intact. R3's Care Plan, dated 1/7/25, fails to identify resident's diagnosis of Anxiety or any behaviors related to his criminal history, therefore no resident specific interventions were implemented. R3's Progress Note, dated 2/18/25 at 6:31 PM, documents the following: Resident seen 3 times by writer pacing the Oakdale hall, the third time writer was walking behind him and (R2) as they were rolling back towards the nurse's station and heard them discussing a female resident and checking/ looking into her room to see where she was. Writer informed DON of them lurking the hall for this specific resident. Writer also seen that they were looking/assessing the service doors on that hallway, writer advised that is not an area for residents and they had moved on down the hall as requested. POC ongoing. There was no behavior monitoring identified in R3's records that the facility was monitoring for behaviors. On 3/6/25 at 1:00 PM, V6, LPN (Licensed Practical Nurse), stated she observed R2 and R3 on the Oakdale hallway, in their wheelchairs by the service exit, which was unusual for both of them, normally they stayed on their own hallway or was by the exit to go smoke. V6 stated she told R2 and R3 not to go out the service exit door, the alarm would sound, and they would be considered exit seeking. V6 stated she asked both residents to move away from the doors and both did and as they were propelling themselves down the hallway, they stopped in front of R10's door and were peeping in, asking each other where R10 was. V6 stated R10 was in her room, in bed with the lights off sleeping and she didn't think it was appropriate that they were outside her room looking in on her, so she asked them what they were doing and R3 stumbled on his words but said they weren't doing anything so V6 asked them to move away from R10's room and both complied and left R10's hallway and went to the nurse's station and didn't return down that hallway or to R10's room. V6 stated that R2 and R3 were aware that R10 had a relative that worked at the facility and felt as though R10 got special treatment with smoking and was allowed to go out more often. V6 stated all residents were required to follow the smoking policy including R10. V6 stated on that particular day, it was below 30 degrees outside so facility management had made the decision not to allow the residents to go out and smoke, and she feels that they didn't see R10 in bed and thought that she had been taken out to smoke. V6 stated that due to R2 and R3's history and R10 being a female, she reported the occurrence and documented it in their charts. V6 stated she hadn't witnessed R2 or R3 being sexually inappropriate with any of the residents. There was an occurrence where she had taken R2 and R10 outside to smoke, it was nice out and she (V4) had made the comment that it was nice outside and couldn't wait for warmer weather and R2 stated that he couldn't wait to take his boat out and would take V6 and she could ride in it with a bikini on. V6 stated she told R2 that she couldn't do that and changed the subject. V6 stated after that she received a friend request from R2 on social media and sent her a message that he had been thinking of her all night long, so she reported it to management, and they tried to keep her from being assigned to R2's hallway. V6 stated if she did have to work on his hallway, she always had another staff member with her during interactions with R2. V6 stated then because R2 and R3 were making sexual comments to other staff, unsure of whom, they initiated cares in pairs and two staff members would go in and assist R2 and R3 together. V6 stated when she did have to care for R2 or R3, she was cordial with them but always had another staff member with her or nearby. V6 stated they had an SSD (Social Services Director) that didn't have full knowledge of that role, so there weren't interventions or safety measures in place to address R2 or R3's behaviors. V6 stated once the facility received the CHIRP results on R2 and R3, they placed them both on one-on-one observation and placed them in a room together at the end of the hallway. On 3/7/25 at 8:00 AM, R10 stated R3 would ask her things, inappropriate things (would not give further details) and it made her feel very uncomfortable. V10 stated she told V2, Director of Nursing, DON. R10 stated she didn't feel that it was abuse, but inappropriate. R10 stated it happened when they would go outside to smoke or sometimes, he would be on her hallway or outside her room and she would tell him to get off of her hallway or away from her room. R10 stated she felt safe in the facility then and now, it just made her very uncomfortable. R10 stated she isn't sure what V2 did after she told her but R3 stopped so she assumes V2 took care of it. R10 stated she hasn't had any further problems like this with the other residents. On 3/7/25 at 10:20 AM, V1, Administrator, stated staff reported that R2 and R3 were making sexually inappropriate comments to them. They interviewed all the female residents and neither R2 nor R3 were making those comments to them, only the female staff. V1 stated they placed R2 and R3 on one-on-one observation and moved them into a room together until they discharged from the facility. V1 stated R10 had reported to V2, DON, who is also R10's daughter, that R2 and R3 would ask R10 to talk V2 into letting them go out to smoke at times other than on the smoke schedule or when it was too cold. V1 stated if a resident has behaviors, it will be documented on their care plan and the progress notes with interventions specific to their behaviors in the care plan. 3. R8's Face Sheet, undated, documents R8 has diagnoses of Dementia and PTSD (Post Traumatic Stress Disorder). R8's CHIRP, dated 10/22/24, documents R8 has a criminal history with conviction of criminal sexual assault and is an identified sex offender. R8's MDS, dated [DATE], has a BIMS score of 3, indicating R2 has severe cognitive impairment. R8's Care Plan, dated 10/22/24, fails to identify resident specific interventions related to his diagnosis of PTSD and R8's criminal history. R8's Behavior Monitoring, dated 2/20/25, fails to identify resident specific behaviors or interventions. R8's Progress Note, dated 12/16/24 at 12:03 PM, documents the following: Social Service Note - Attended phone meeting today with State of Illinois referred psychiatrist. Dr. (doctor) stated that (R8) will now be considered very low risk and the only recommendations he will have is that (R8) will not be allowed to be unsupervised with minors while in the facility. R8's Progress Note, dated 1/21/25 at 11:50 AM, documents the following: Received notes from NP (Nurse Practitioner) to add dx (diagnosis) of PTSD to chart and start Sertraline 50 mg PO (by mouth) Q HS (every bedtime) from recent visit on 1/17/25. Resident is own person and made aware of orders. R8's Progress Note, dated 2/2/2025 at 6:00 AM, documents the following: Reminders needed to stay out of lady resident's rooms. Had to be redirected during night x 2 back to his room. On 3/6/25 at 8:40 AM, V3, Wound Nurse, stated they do have identified offenders including one sex offender, R8. V3 stated R8 does have dementia and hasn't displayed any sexual behaviors towards the staff or other residents. V3 stated any resident with behaviors have interventions in place and they can be found on their behavior care plan. The Behavioral Health Services Policy, dated 7/1/23, documents the facility will provide and the residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The Behavior Monitoring Policy, dated 10/3/20, documents the facility will ensure residents experiencing behaviors are monitored and interventions are appropriate to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview and record review the facility failed to prevent injury to R2's right second toe during transport to the facility from the hospital. This failure resulted in R2's right toe striking the plate at the bottom of door, causing a wound to the second toe of right foot and toenail being removed. Findings include: On 1/29/2025 at 12:40PM V13, Certified Nursing Assistant (CNA) removed socks from R2's feet. R2's second toe of right foot, toenail is off and area dried blood. No dressing in place as verified by V13. On 1/29/2025 at 10:55AM V14, facility transport stated she provided transport for R2 from hospital in (town name) to the facility on [DATE]. V14 stated when pushing R2 into the facility R2's foot hit the plate at the bottom of the door. V14 stated it was bleeding and she notified the nurse. On 1/29/2025 at 12:50PM V8 Licensed Practical Nurse (LPN) stated she was on duty when R2 arrived at the facility on 1/15/2025. V8 stated R2's toenail was off and bleeding. V8, LPN stated they cleansed wound and applied dressing. R2's face sheet dated 1/29/2025 documents in part a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R2's Minimum Data Set (MDS) dated [DATE] documents unable to interview for Cognition. R2's MDS documents R2 is dependent on staff locomotion with wheelchair. R2's Physician Orders (PO) dated 1/15/2025 documents refer to wound care for consult as needed. R2's skin and wound note dated 1/16/2025 by wound care documents right second toe full thickness abrasion. R2's Care Plan dated 1/18/2025 documents R2 has an actual impairment to skin integrity of the right second toe related to abrasion. R2's care plan documents the following interventions dated 1/18/2025; use caution during transfers and bed mobility to prevent striking arms, legs and hands against any hard surfaces, monitor/document location, size and treatment of skin injury at least weekly. Report abnormalities, failure to heal, signs and symptoms of infection, maceration to physician. On 1/29/2025 at 1:33PM V18 wound nurse stated she would expect residents to be provided safe assistance during transport from the hospital by the facility transport staff. On 1/29/2025 at 3:00PM V19, Regional nurse stated the facility does not have a policy on facility transport.

Based on interview, observation, and record review, the facility failed to prevent, identify, assess, monitor, implement progressive interventions, and to handle soiled pressure ulcer dressings appropriately to prevent pressure ulcers and encourage healing for 2 of 3 residents (R2, R3) reviewed for pressure ulcers in the sample of 6. This failure resulted in R2 going for 9 days without a treatment in place for a left heel pressure ulcer and R3 having one pressure ulcer on the left medial foot that was unknown by staff, one pressure ulcer on the left great toe that did not receive treatment or a full assessment for 9 days and R3 developing osteomyelitis requiring Intravenous Antibiotics. Findings include: 1. On 9/3/24 at 8:41 AM, V7, Certified Nurse's Aide (CNA) and V8 CNA are in R3's room in the middle of cleaning her up. R3 is lying on her left side. R3 has a visible sacrum pressure ulcer approximately 4 inches (in) by (x) 3 in x 2.5 in deep. The old dressing has yellow brown drainage on it. The dressing is on the bed near R3's mid back. The dressing is dated 9/3/24. The pressure ulcer has packing that has come out of the pressure ulcer that is lying on the bed. V8 removed all of the dressing packing, crumpled into her gloved hand, placed it back into the pressure ulcer wound bed, and reapplied the old dressing. R3 did not have pressure relieving boots on her feet. On 9/3/24 at 8:49 AM, V7 and V8 were questioned how long R3 has had the pressure ulcer, V7 stated, She has had it for a while. It requires multiple changes a day because it drains so much. On 9/3/24 at 9:27 AM, V4, Wound Nurse, stated, I helped for 4 weeks (as wound nurse) and then I asked to step down. This morning, I have accepted to take on the role again. I have not seen the wound recently. She has been seen by Infectious Disease (ID) and Plastics for debridement. The last time I saw it, it was full of slough, so it was hard to tell how deep it was. V4 removed the old dressing and packing, cleansed the wound bed with wound cleanser, packed the wound bed with gauze soaked in normal saline, and covered it with an abdominal pad. The periwound has an extended area around the wound bed that is light red with splotchy darker red areas. V4 stated, I think that (reddened periwound) was caused by the previous dressing we were using. The wound bed is light red with a minimal amount of slough. V4 was questioned if she thought the pressure ulcer was approximately 4 in (10.16 centimeters (cm)) x 3 in. (7.62 cm) x 2.5 in. (6.35 cm), V4 agreed to the approximate size. On 9/3/24 at 9:45 AM, V4, stated, (V8) should have not removed the packing or put the old dressing back on. On 9/3/24 at 1:31 PM, V2, Interim Director of Nurses, was questioned if she could go to R3's room so R3's feet could be observed. R3 was lying on her right side, there is a pillow between her knees, her right lateral foot and left medial foot are lying directly on the mattress. R3's left Great toe on the medial side has a necrotic pressure ulcer approximately 1 cm by 0.5 cm and the left medial foot below the toe has a necrotic pressure ulcer approximately 0.5 cm x 0.5 cm. The 2 pressure ulcers did not have any dressings on them. R3 was not wearing any pressure relieving boots on her feet. On 9/3/24 at 3:10 PM, V7, CNA, was questioned how long R3 had pressure ulcers on her left foot, V7 stated, It's been a while. I lose track of my days, but she has had them for a while. They come and go. V7 pointed out that the right foot has red blotches on them, V7 stated, They get worse the more contracted she becomes. On 9/3/24 at 3:29 PM, V3, Licensed Practical Nurse / Minimum Data Set Nurse (LPN/MDS), stated, (R3's) pressure ulcer started out on the left ischial tuberosity. It was almost healed. I was off for the weekend and when I came back it had opened back up and had gotten progressively worse. It started out small and turned into a larger area and that is when we started calling it a sacrum wound. I believe the wound doctor was seeing her the entire time. We had a team of nurses come from (a sister facility) and do a house wide sweep of resident's skin on 8/14/24. I was given a list of residents that had pressure ulcers that were not identified previously. She was on that list with a pressure ulcer on her left foot. I was not in charge of pressure ulcers at the time (V4) was. I was told just to enter the information into her chart and did not follow up. On 8/16/24 I got an email telling me that (V4) had stepped down from the position of wound nurse. On 8/19/24, I was told that I was put back in charge of wounds. I just never followed up on her foot pressure ulcer. V3 further stated that R3 did see ID (Infectious Disease) doctor last Tuesday (8/27/24) for her pressure ulcer and then she went to Plastics for a debridement the same day. On 9/5/24 at 2:00 PM, V2 and V11 Director of Clinical Operations both stated that all wounds should be charted on and measured when they are found and both R2 and R3 should have pressure relieving devices on their feet. V11 stated that CNAs should not be doing any treatment to the pressure ulcers. They should only let the nurse know that a dressing is off, or it needs to be replaced. R3's Admission Profile, print date of 9/3/24, documents that R3 was admitted on [DATE] with diagnoses of paralytic syndrome following a stroke, Chronic Respiratory Failure, Dementia, Tracheostomy Status, and Gastrostomy Status. R3's Minimum Data Set (MDS), dated [DATE], documents that R3 is severely cognitively impaired, is dependent on staff for mobility and activities of daily living, has an indwelling urinary catheter, and is always incontinent of bowel. R3's Care Plan, dated 5/13/24, documents, (R3) has an unstageable pressure ulcer to left buttock. I require assistance with turning and repositioning. Interventions: 5/13/24 Monitor for pain indicators. 5/13/24 Check dressing placement q (every) shift. 5/13/24 Low Air Loss Mattress. 5/13/24 Monitor for s/s (signs and symptoms) of infection daily increased warmth of surrounding tissue, redness, swelling, pain, purulent drainage, foul odor. Notify MD if identified. 5/13/24 Notify MD as needed if ulcer fails to show progress in healing. 5/13/24 Pain medication prior to wound care if indicated. 5/13/24 Provide offloading of ulcer site. 5/13/24 Daily skin checks. R3's Order Summary Report, dated 9/3/24, documents, Cleanse coccyx wound with soap and water daily. Apply wet to moist dressing with normal saline to wound bed, cover with ABD (abdominal) pad, and secure with tape BID (twice a day) and PRN (as needed). two times a day. Start date of 8/27/24. Vancomycin HCl Intravenous Solution (Vancomycin HCl) Use 1 gram intravenously one time a day related to OTHER ACUTE OSTEOMYELITIS Start date of 8/20/24. Monitor reddened, blanchable area to left medial foot, daily until resolved in the evening. Start date of 6/1/24. Monitor redness to left great outer toe daily, until resolved in the evening for Redness. Start date of 6/1/24. Skin prep to area on left medial foot, daily, in the evening for DTI (deep tissue injury) area. Start date of 6/1/24. R3's Wound Doctor Wound Assessment and Plan, dated 7/29/24, documents that R3 has a Left Buttock Unstageable Pressure Ulcer, that is declining with an onset date of 5/13/24, that measures 5.5 cm x 8 cm x a depth that is unable to be determined. The wound bed is 5% granulation, 80% slough, and 15% eschar with serosanguineous drainage. R3's Wound Doctor Wound Assessment and Plan, dated 8/5/24, documents that R3 has a Left Buttock Unstageable Pressure Ulcer, that is declining with an onset date of 5/13/24, that measures 10 cm x 8 cm x a depth that is unable to be determined. The wound bed is 85% slough, and 15% eschar with a large amount of serosanguineous drainage. This Assessment also documents, Initially started as wound on patients' buttock, but mostly involving the coccyx - rapid onset of this. Irregular / butterfly shape. R3's Wound Doctor Wound Assessment and Plan, dated 8/12/24, documents that R3 has a Left Buttock Unstageable Pressure Ulcer, that is declining with an onset date of 5/13/24, that measures 6.5 cm x 9.5 cm x a depth that is unable to be determined. The wound bed is 85% slough, and 15% eschar. The wound bed is showing signs of infection with a large amount of exudate which has an odor. This Assessment also documents, Comments: Ordering wound culture, along with x-ray of sacrum / coccyx. R3's Wound culture, collection date of 8/13/24, documents,Org (organism) 1: E. (Escherichia) coli ESBL (extended spectrum beat lactase). Org 2: Proteus mirabilis. Org 3: MRSA (Methicillin resistant Staphylococcus aureus). R3's Skin Inspection Assessment, dated 8/13/24, documents that R3 has a Stage 3 pressure ulcer on her left great toe. This Skin Inspection fails to document the size or appearance of the Stage 3 Pressure ulcer. R3's Radiology Report, dated 8/14/24, documents, MRI (magnetic resonance imaging) left hip, MRI of pelvis, and MRI right hip. Impression: Large sacral decubitus ulcer extending down to bone with small focus of increased signal and enhancement involving the S6 segment. Findings may represent acute osteomyelitis. 6.5 x 7 cm region of nonenhancing soft tissue overlying the sacrum may represent nonviable tissue with surrounding cellulitis. R3's Wound Doctor Wound Assessment and Plan, dated 8/19/24, documents that R3 has a Left Buttock Unstageable Pressure Ulcer, that is stable with an onset date of 5/13/24, that measures 6.5 cm x 9.5 cm x a depth that is unable to be determined. The wound bed is 10% Granulation / 80% slough, and 10% eschar with undermining at 11 to 1 o'clock 2 cm. The wound bed is showing signs of infection with a large amount of exudate which has an odor. This Assessment also documents, Comments: X-ray of sacrum / coccyx ordered last week showed findings concerning for acute osteomyelitis of distal sacrum and coccyx. PCP (Primary care Provider) ordered MRI, which reportedly showed evidence of acute osteomyelitis. Has plans to establish with infectious disease next week. It continues: Wound healing / course likely complicated by frequency / completion of dressing changes as well. R3's Wound Doctor Wound Assessment and Plan, dated 8/26/24, documents that R3 has a Left Buttock Unstageable Pressure Ulcer, that is stable with an onset date of 5/13/24, that measures 7 cm x 9 cm x a depth that is unable to be determined. The wound bed is 20% Granulation, 80% slough, with undermining at 11 to 1 o'clock 2 cm. The peri wound is macerated and there is a large amount of exudate. This Assessment also documents, Comments: MRI showed evidence of acute osteomyelitis. Currently on IV antibiotics per ID. R3's Infectious Disease Report, dated 8/27/24, documents, Assessment: 1. Pressure ulcer, buttock 2. Sacral Osteomyelitis 4. Chronic wound. Plan consult: [AGE] year old female who presents to (hospital) infectious disease clinic for further evaluation and management of concerns for new onset acute osteomyelitis to a chronic sacral wound as well as ESBL E coli urinary tract infection (UTI) with a (indwelling catheter) in place. It continues, Plan: we will refer to plastics as able to evaluate the patient today for possible debridement of the area. It continues, for now we will continue broad spectrum antibiotics therapy. R3's Plastic Surgeon Report, dated 8/27/24, documents, History of present Illness: This is an [AGE] year old female presenting with stage 4 sacral pressure sore with underlying osteomyelitis demonstrated on MRI presenting to establish care. It continues, Skin: Stage 4 sacral pressure sore with exposed bone and fibrinous debris along the lateral aspect encompassing approximately 25% of the wound. Wound measures approximately 6.5 x 5.5 x 3.5 cm. Procedure: Given the extensive fibrinous debris within the stage 4 sacral pressure sore and necrotic tissue burden was recommended that the patient undergo sharp excisional debridement of the fibrinous debris. An Iris scissor and pickups were then utilized to debride skin and subcutaneous tissue from the sacral pressure sore. Total area of debridement was approximately 3.5 x 2 x 2 cm. R3's Wound Evaluation, dated 9/4/24, documents, R3 has a Stage 3 Pressure Ulcer to the coccyx measuring 4.82 cm x 4.13 cm no depth noted. R3's Wound Evaluation, dated 9/4/24, documents that R3 has a Pressure Ulcer Stage 1 to the left dorsum (top) 1st digit (hallux), measuring 0.67 cm x .48 cm, and the wound bed is scabbed. R3's Electronic Medical Record (EMR) fails to document a full assessment or treatment for R3's left medial Great toe pressure ulcer before 9/3/24. R3's EMR fails to document a full assessment for R3's left medial foot. R3's Health Status Note, dated 9/4/24 at 11:00 AM, documents, This writer drew blood from midline to Rt (right) upper arm for labs that were ordered. Resident laying in bed, s(sic) labored and uneven, resident felt warm, tympanic temperature 101.9. Staff nurse reported that resident had large amount of green/gray sputum earlier this AM. Blood obtained for labs. Reviewed resident with IDT (Interdisciplinary) members. R3's Health Status Note, dated 9/4/24 at 11:14 AM, documents, Call placed to (V13 R3's Power of Attorney (POA)). Updated on elevated temp (temperature) and copious amounts of thick green/gray sputum. Updated (V13) of nursing judgement to be sent to ER (emergency room ) for evaluation and treatment. (V13) in agreement. R3's Health Status Note, dated 9/4/24 at 5:19 PM, documents, This writer called for an update on resident. She has sepsis that they believe is from her wound. She has a UTI, but they do not believe that it is bad enough to cause sepsis. Her temperature is down, and she is waiting on placement at a higher acute care hospital. R3's Health Status Note, dated 9/11/24, documents, Resident arrived back to facility at 330p per our transport. R3's Hospital Discharge Summary, dated 9/11/24, documents, I was in the hospital because: I was unresponsive with fevers. The medical term for this is: Sepsis, osteomyelitis. On 9/16/24 at 12:30 PM, V2, was questioned as to why the observation of R3's sacrum pressure ulcer size on 9/3/24 was so different than the measurements documented on the Wound Evaluation of 9/4/24, V2 stated our pressure ulcer documentation is that the nurse will put a sticker near the ulcer and then take a picture. The system then does all the measurements, so the nurses do not do any measuring it is all calculated in the computer system. V2 further stated that every pressure ulcer should be measured and described when found and then again weekly. On 9/17/24 at 11:55 AM, V4, Wound Nurse, was questioned why R3 did not have an assessment for her left medial foot pressure ulcer, V4 stated that she did not realize that she did not and that she would put one in. V4 stated that the left medial foot pressure ulcers should have been identified and treated sooner. V4 stated that R3 should have had pressure reducing foot boots on. V4 also stated that she is still learning the computer system for wounds and how to get the camera to take good measurements. V4 did agree that what you see is not what is being charted because of the computer system. V4 was questioned about R3's sacral pressure ulcer and it's decline, V4 stated that she believes she has so many bodily fluids that would contaminate the dressing and the wound and R3 was just not cleaned up timely or the dressing changed timely, and the infection set in, and the pressure ulcer deteriorated. 2. R2's Transfer Discharge Report, print date of 9/3/24, documents that R2 was admitted on [DATE] with diagnoses of Heart Failure, Parkinson's Disease, and Dementia. R2's MDS, dated [DATE], documents that R2 is severely cognitively impaired and requires moderate assistance for transfers. R2's Skin Inspection Assessment, dated 8/14/24, documents that R3 has an In House Acquired Left Heel Stage 3 Pressure Ulcer which measures 1.6 cm x 1.3 cm. This assessment fails to document appearance of the pressure ulcer. R2's Health Status Note, dated 8/15/2024 12:15, documents, Note Text: vm (voicemail) left to update POA on wounds to L (left) heel stage 3, abrasion to right toe and sacrum - unstageable noted during wound rounds yesterday. POC (plan of care) ONGOING MD (Medical Doctor) short form filled out for review. will continue current treatments as advised pending MD response. R2's Skin & Wound Evaluation V7.0, dated 8/21/24, documents that R2 has an In house Acquired Stage 3 Pressure Ulcer measuring 1.2 cm x 1.7 cm x 0.1 cm to the left heel, has serosanguineous drainage, and was discovered on 8/13/24. R2's Physician Order, dated 8/22/24, documents, Cleanse wound to left heel with normal saline. Apply calcium alginate to wound bed. Cover with dry dressing daily and PRN. R2's Physician Order, dated 8/30/24, documents, Float heels every shift for wound care Encourage resident to float heels as often as resident will allow. R2's Treatment Administration Record, dated 9/2024, documents, Cleanse wound to left heel with normal saline. Apply calcium alginate to wound bed. Cover with dry dressing daily and PRN. Start date of 8/22/24. R3's EMR fails to document any treatment orders for R3's heel before 8/22/24. R2's Skin & Wound Evaluation V7.0, dated 9/3/24, documents that R2 has a In house Acquired Stage 3 Pressure Ulcer measuring 1.5 cm x 1.3 cm x 0.1 cm to the left heel. R2's EMR fails to document any assessment of the left heel pressure ulcer before 8/21/24 and between 8/21/24 and 9/3/24. On 9/3/24 at 8:51 AM, R2 is sleeping in her bed. R2 has her left foot hanging of the side of the bed. R2 is not wearing any pressure relieving boots on her feet. On 9/3/24 at 10:05 AM, V4, Wound Nurse, stated that R2 has a blister on her left heel that is getting skin prep to it. R2 is sitting up in her wheelchair. R2 is wearing gripper socks. V4 removed her sock and examined the left heel. The left heel did not have a dressing on it. V4 stated that it is not a blister anymore and she needs to go and reread the treatment orders. R2's left heel has a pressure ulcer approximately the size of a quarter, the wound bed is brown in color, and the periwound is red. V4 returns to the room and stated that the area is cleansed with wound cleanser, calcium alginate applied to the wound bed, and covered with a dressing. V4 performed the treatment with no concerns. V4 placed R2's gripper socks back on her. On 9/3/24 at 3:40 PM, V3, LPN/MDS, stated that a team from the sister facility came in to do a house wide sweep of resident's skin, and also identified the pressure ulcer on R2's foot. V3 stated that R2 does not see the wound clinic and that her primary physician ordered the treatment for her pressure ulcer. On 9/3/24 at 4:00 PM, R2 was observed sitting in her wheelchair with no pressure relieving boots on. On 9/17/24 at 11:55 AM, V4, Wound Nurse, was questioned why R2 did not have a pressure reducing device on her left foot, V4 stated that the supply company does not like to use the heel boots, but they like to use a foot elevator which is an elevated surface that sits at the end of the bed and the foot rest's on it while the resident is in bed. V4 was questioned what is done during the day since she sits in the wheelchair most of the day, V4 stated, Your right. I didn't think about that. The policy Pressure Ulcer Prevention, Identification & Treatment, dated 10/16/23, documents, Procedure: 3. When a pressure ulcer is identified whether in-house, or upon a resident's admission, the area will be assessed using the Skin & Wound assessment and initial treatment started per physician's orders. 4. The physician is to be notified when A) pressure ulcer develops, B) when there is a noted lack of improvement after a reasonable amount of time, C) and / or signs of deterioration. 5. If Pressure Ulcer is found initiate a treatment sheet and complete the skin inspections assessment in PCC (Point Click Care (computer program). It continues, Documentation of the pressure ulcer must occur upon identification and at least once a week until healed. Assessment is to include: a. Characteristics: (i.e. (for example)) size, depth, color, drainage) b. presence of granulation tissue, necrotic tissue. c. Treatment and response to treatment. d. Prevention technique (i.e. turning and positioning, skin care, protective devices) e. Update MD and resident / POA of any regression in wound.

Based on interview and record review, the facility failed to follow Physician's hospital discharge orders for a high-risk anticoagulant medication for 1 of 2 residents (R49) reviewed for anticoagulant medications in the sample of 27. This failure resulted in R49 receiving double the ordered dose of Eliquis for three days and being hospitalized for 11 days with the diagnosis of Severe Blood Loss Anemia, Acute on Chronic with a differential diagnosis of GI (Gastrointestinal) Bleed, AAA (Abdominal Aortic Aneurysm), and Autolysis. Findings include: R49's Face Sheet documents, R49 was admitted to the facility on [DATE], with the diagnoses to include: Embolism and Thrombosis of Lower Extremities, Other Long Term (Current) Drug Therapy, Anemia, and Paroxysmal Atrial Fibrillation. R49's Hospital Discharge Orders dated 02/24/23 documents, the following order: Eliquis 2.5 mg, (milligram), give 5 mg every 12 hours. R49's Facility Physician Order Summary Report, dated 02/24/23 documents, the order dated 02/24/23: Apixaban (Eliquis) Give 10 mg by mouth every 12 hours, related to Embolism and Thrombosis of Arteries of the Lower Extremities. This Physician order summary also, documents the order dated 02/24/23: All medications to be reviewed/confirmed by Physician. R49's Hospital Progress Notes dated 02/28/23 document, he was admitted to the hospital with the diagnoses of Acute Blood Loss Anemia, Severe Anemia, Acute on Chronic, and lists R49's differential diagnoses as GI (Gastrointestinal) Bleed, AAA (Abdominal Aortic Aneurysm), and Autolysis. The hospital progress notes document, Of note, SNF, (Skilled Nursing Facility), had placed, (R49), back on 10 mg Eliquis BID, (twice a day), instead of 5 mg BID dosing sent back to Skilled Nursing Facility. It is unclear why the increase back to 10 mg. The facility's Occurrence Report for R49's medication error dated 02/27/23 documents, Resident admitted on [DATE]. All orders checked by DON, (Director of Nursing), and noted error with medication. Resident was being monitored for decreased HGB (hemoglobin), related to use of Eliquis in hospital. It was noted that medication was entered in (Electronic Medical Record) incorrectly. Resident was to be receiving Eliquis 5 mg BID and had received 10 mg Eliquis BID x 6 doses. HGB noted at 6.8 (low). Order to send to ER (emergency room ) obtained. Resident remained at hospital for observation and to receive 1-unit PRBCs, (Packed Red Blood Cells). POA (Power of Attorney), PCP (Primary Care Physician), and Pharmacy all made aware of med error. Hospital made aware of doses received x 6 doses. Medication updated with correct dose. On 04/12/2023 at 10:42 AM, V2 Director of Nursing (DON), stated, the med error was caught when she was checking all the orders for admission from R49 returning from the hospital. V2 stated, the nurses were given him Eliquis 10mg twice daily and he was given six doses of the wrong dose, he was supposed to be getting 5 mg of Eliquis instead of 10mg. The nurses put the orders in the system upon new admission. V2 stated, a red flag immediately when she reviewed the discharge orders from the hospital. V2 stated, he was admitted back to the facility on a Friday afternoon, and she didn't check the orders till she returned back to the facility after having the weekend off. On 04/12/23 at 10:52 AM, V2 DON stated, her expectations are all nurses should be double checking any orders on new admissions or readmission. She said, the dose of Eliquis is much higher than the normal dose of Eliquis. V2 stated, the nurses should be calling the Primary Physician, or on call Physician to confirm medication orders. On 04/13/2023 at 1:45 PM, V12 Registered Nurse, (RN), stated, she did not confirm R49's Eliquis orders when he was admitted on [DATE]. She stated, if the admissions are after hours, they normally call the Physician. She stated, she did not call. She stated, she faxed the orders over to the Physician's office around 2:30 PM but, did not hear back from the Physician on the fax. V12 stated, she put the medication order of Eliquis 10mg in the computer wrong and that's the cause of R49 having to go to ER at the local hospital. She said she was not in the facility when he had a change of condition and had to go to ER. On 04/14/2023 at 10:27 AM, V22, R49's Physician stated, that 10mg Eliquis is a significant higher dose of the normal dose of Eliquis and giving Eliquis 10mg would only be in an acute care setting like the hospital. Eliquis 10 mg is out of range to be given in the facility. V22 stated he would expect the nurses to call him to question an order for Eliquis 10mg and he expects the discharge orders to be followed as ordered by the physician. V22 stated, that giving 10mg of Eliquis could cause the bleed in that excessive dose that was given. The facility's policy, Anticoagulant Policy, and Procedure dated 4/2009 documents, It is the policy of this facility to treat and monitor residents receiving anticoagulant therapy by following physician's orders, assessing changes in resident's condition, and reporting changes to the resident's physician for further testing if needed. Procedure: Give medication per orders following best practices.

Based on interview and record review, the facility failed to provide supervision and effective fall interventions for 1 of 4 residents (R2) reviewed for supervision/falls in the sample of 4. This failure resulted in R2 falling twice in less than a 24-hour period. R2 was hospitalized with a displaced a nasal bone fracture on both sides with a soft tissue injury resulting in bruising and swelling to forehead, face and left eye, a fracture to the upper spine and multiple right sided rib fractures. Finding includes: R2's Admission Record, print date of 4/14/22, documented an admitted [DATE] and medical diagnoses of unspecified dementia with behavior disturbance, [CONDITION(S)] with delusion, anxiety, major depressive disorder, [CONDITION(S)] and [CONDITION(S)]. R2's Minimum Data Set, dated dated [DATE], documented R2 had moderately impaired mental cognition. R2's Fall Risk Assessment, dated 1/18/22, documented R2 was at high risk for falls due to R2 has a normal gait and a mental status to, overestimates or forgets limits and history of falling. R2's Care Plan, with initiated date of 12/1/21, documented, Fall/Safety: I am at risk for falls. I have diagnoses of dementia, hypertension, anxiety, depression, [CONDITION(S)], [CONDITION(S)], delusions, arthritis, hypocholesteremia, cervicalgia. I have poor safety awareness due to impaired cognition. I ambulate in my room without assistance and frequently forget to use my walker. I do not understand the use of the call light and I do not ask for assist. I require staff assist with ADL's (activity of daily living). I am incontinent at times. I am ambulatory with use of walker, and I do not always use it. I at times require use of wheelchair. I have adequate vision with use of eyeglasses. I have adequate hearing. I receive medication that may increase my risk for falls (antidepressant, antipsychotic, antianxiety, narcotic pain medication. R2's Care Plan Interventions, dated 12/1/21 are as follows: Make sure call light is in reach, reminders to use walker, and assist to keep non-skid footwear on at all times. R2's Fall Care Plan, revision date of 2/24/22, documents May have a mattress on the floor. The same Care Plan documented, Behavior/Mood(R2) has dementia, anxiety a delusion disorder, displays behavior of rummaging through her belongings, frequent crying, refusing care, yelling out and [CONDITION(S)]. These interventions are documented with initiation date of 12/8/21. R2's, Progress Notes, for the following dates in March 2022, documented: On 3/21/22 R2 was standing at bedside with confusion talking to staff. On 3/22/22 R2 was slightly agitated, does not know what to do. On 3/25/22 R2 observed in her room screaming and had pulled all of her clothes out of the closet. Clothes were on floor, bed and bedside table. R2 yelling, she does not know what to do. On 3/29/22, R2 was yelling due to the placement of personal items, R2 crying and I don't know what to do. and R2 stripping bed linens. On 3/29/22, R2 was observed to have clothing from her closet stacked on wheeled walker and was placed in hallway, R2 stating she denies these are her clothes and threw on the floor. On 3/30/22 R2's Physician and Nurse Practitioner were notified of R2's increased behaviors, order received to increase R2's [MEDICATION(S)] to 50 mg (milligrams) po (by mouth) BID (two times a day) with a start date of 4/3/22 for Dementia with Behavioral disturbance. R2's Progress Note, dated 4/4/22 at 3:24 PM, documented a physician's orders received to transfer R2 to the local Emergency Department, regarding R2's statements of yelling and wanting to kill herself. The note documented R2 was transferred out at 3:55 PM. R2's Progress Note, dated 4/4/22 at 9:09 PM, documented R2 returned to facility with [MEDICATION(S)] 0.5mg (milligrams) IM (intramuscular) received at hospital. R2's 15 Minute Visual Check Sheet, dated 4/4/22, documented R2 had received 15-minute checks starting at 9:20 PM, every 15-minutes that ended on 4/5/22 at 2:20 AM. The 15-minute entries documented the following on 4/5/22 from 1:35 AM until 2:50 AM: 4/5/22 1:35 AM sitting up on bed 4/5/22 1:50 AM sitting up on bed 4/5/22 2:05 AM in bathroom-screaming 4/5/22 2:20 AM in bed, screaming, yelling, crying There were no entries after this documenting how the staff addressed R2's behaviors to ensure she was safe. R2's Post Fall Investigation, dated 4/5/22 at 2:30 AM, documented, R2 found on floor, in room, barefoot, confused, and trying to get out of bed. This Post Fall Investigation did not document a fall mat/mattress was in place at the time of R2's fall. R2's Hospital Discharge instructions, date of service on 4/5/22 at 3:41 AM, documented R2 was treated for a head injury with contusion of the right side of the chest and right hip. R2's, Progress Note, dated 4/5/22, at 7:08 AM, documented R2 returned from the hospital, placed in bed with call light and personal items in reach and 15-minute safety checks continues. The Note documented R2 was educated on using call light and waiting for assistance for all transfers. R2's 15-minute visual check sheet for 4/5/22, which documented at 7:05 AM, returned per ambulance assisted to bed. There are no other 15-minute visual times documented after this entry. R2's Progress Note, dated 4/5/22 at 7:26 AM, R2 found on the floor in her room, yelling for help. The Note documented R2 was found lying on her left hip with copious amount of blood that appears to be coming from her nose and a hematoma forming in the middle of her forehead and complaining of neck and left shoulder pain. R2's Progress Note documented R2 was transported out on 4/5/22 at 7:47 AM, to the emergency room for evaluation and treatment. This Progress Note did not document there was a fall mat/mattress in place at the time of this fall. R2's, Hospital Emergency Department Radiology Report, dated 4/5/22, documented R2 with the following injuries: Acute variable-displaced left 9th-11th right rib fractures, bilateral acute slightly rightward-displaced nasal bone fractures with soft tissue swelling about the bridge of the nose, acute fracture of the T1 (thoracic) vertebral (base of neck area). R2's Trauma History and Physical, Acute Care Surgery Service, dated 4/5/22 at 1:33 PM, documented R2 was transferred from outlying facility for evaluation and treatment due to a fall at nursing facility with hospital diagnoses: Bilateral Nasal bone fracture, fall, thoracic fracture, multiple right sided rib fractures, Dementia. R2 was then admitted . R2 returned to facility on 4/11/22 at 5:40PM. There was no documentation in R2's medical record that the staff implemented any other interventions to prevent R2 from future falls after she returned from the hospital. R2's Care Plan was not revised after R2 returned to the facility on [DATE] with progressive interventions to address R2's high risk for falls and need for supervision. R2's Progress Note, dated 4/12/2022 at 10:03AM, documented, At approx (approximately) 0800, (R2) called out that she was on the floor. Activity Director entered the room to observe (R2) sitting on the floor beside her bed. There was no documentation in this Progress Note that R2 was receiving one-to-one supervision when this fall occurred. On 4/18/22 at 9:00 AM, V1, Administrator stated R2's one on one supervision began when R2 returned to facility on 4/11/22, when R2's son could not provide the one on one for his mother. V1stated the facility has tried with Psychological evaluation which were unsuccessful, offered activities, provided a roommate change, none of these interventions had worked regarding R2's falls. V1 stated I don't know what to do to keep (R2) safe. On 4/14/22 at 3:05 PM, V5, Certified Nurse Aide, (CNA) stated before R2 had a room change, R2 had resided down the 400-hall. V5 stated R2's bed was near the window. V5 stated R2 would only play with her call light, she could not use it. V5 stated R2 had signs posted to 'Call Don't Fall', but she didn't follow or understand the meaning and she did not have fall floor mats. V5 stated that 15-minute visual checks are when you check on the resident, but not sit in the resident's room. On 4/14/22 at 3:10 PM, V6, Licensed Practical Nurse (LPN), stated she cared for R2. V6 stated R2 was constantly getting up without assistance, walking in her room, re-direction was provided but was not affective. On 4/18/22 at 8:20 AM, V4 CNA, stated she had cared for R2 before her fall and R2 did not know how to use the call light, one time pulled it out of the wall. V4 stated R2 never slept, up walking in her room, agitated, pulling clothes out of her closet and drawers and would throw them on the floor. V4 stated she knows if 15-minute checks need to be done for a resident, you make visual contact and return in 15 minutes. On 4/18/22 at 9:00AM, V3, Registered Nurse, stated, I know R2's new Fall interventions for 4/4/22 and 4/5/22 are documented in the Care Plan. V3 continued to state. So how do you place new fall interventions, when she (R2) fell two times back-to-back and didn't return until 4/11/22? The Facility's Policy and Procedure, entitle, Fall Assessment and Management, dated 4/2019, documented, It is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned.

Based on interview and record review, the facility failed to provide interventions for poor fluid intake for 1 of 4 residents (R4) reviewed for hydration in the sample of 11. This failure resulted in R4 hospitalization with dehydration and acute renal failure. Findings include: R4's Admission Record, print date of 8/10/21, documents R4 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Minimum Data Set (MDS), dated [DATE], documents R4 was severely cognitively impaired and required extensive assist of 1 staff member for eating. On 8/12/21 at 9:50 AM, V5, Licensed Practical Nurse (LPN), stated, Upon admit, (R4) was a peg tube feeder. She was alert to self only and responded to tactile stimuli. Her left side was flaccid and required extensive assistance with all of her Activities of Daily Living (ADL's). She was getting Occupational Therapy, Speech Therapy and Physical Therapy. She improved. She started taking ice chips then pureed pudding thick liquids. She got to were she was able to feed herself with verbal cues and supervision. She became more alert to self and could hold down conversions with yes no answers. We were able to decrease her feeding tube and we were able to remove the tube. She was maintaining her weight. She took her medications crushed in applesauce. My observation is she started to decline after her first COVID shot. She started to need more verbal cues. She would eat 75% to 100% then 50% to 25%. then we had to start feeding her again. She was having less speech but remained responsive to tactile, verbal and painful stimuli. I was off the weekend, I came back Monday (6/28/21) and the bath aide said she noted a bruise on (R4's) left shoulder, axillary and breast. I did notify the Nurse Practitioner (V3) of the bruising and she said that she would see her on Tuesday (6/30/21). On that Tuesday she ordered X-RAYS, (laboratory test) and a CT (computed tomography) scan of the head. At this time, her vital signs were stable, we were feeding her and she was needing more assist with care. She was maintaining her weight and did not appear malnourished. I offer fluids every time I go into a room. It never appeared to me that she had a stroke just an over all decline. I had spoke with her daughter (V12) about her decline in appetite and that we were assisting with meals. I notify families of all changes that happen with the residents. On 8/12/21 at 2:25 PM, V5 stated, I was unaware of (R4) having poor intakes. She was taking her pills fine and and swallowing fine for me. I was unaware of the aides having trouble feeding her. On 8/12/21 at 3:45 PM, V5 stated, I did notice a decline in (R4's) intake and I did notify (V3 and V13 Physician). They said just to continue to monitor her. I can't believe I didn't chart that the doctor was notified. I was still getting her to drink fluids and take her medication pass without difficulty. On 8/13/21 at 8:15 AM, V11, LPN, stated, (R4) was declining. She could answer yes or no questions. She was being assisted with feeding. She really never had a good appetite for me. She would take her protein snack for me at bedtime without trouble. (V13 and V3) both knew of her poor intakes and they would say to just continue to monitor her and try. She was still able to eat, the only time she had trouble was when her blood sugar was low. On 8/12/21 at 10:14 AM, V6, Certified Nurses Aide (CNA), stated, When I first started, she (R4) would eat well. I was feeding her at the end. She wasn't eating or drinking by herself. The staff was telling the nurses and speech therapy about her decline in appetite. I offer fluids throughout the day. We will always help someone who needs assistance. On 8/12/21 at 11:30 AM, V7, CNA, stated, I took care of her (R4) often. She did have a decline in her appetite and fluid intake. She wasn't swallowing and liquid would just run out of her mouth for about a week (before she went to hospital). We (the CNA's) had been telling the nurses about her decline. They said speech was working with her. I personally think that the nurses didn't act fast enough. I think she had another stroke, that's what it looked like to me. On 8/12/21 at 2:39 PM, V8, Speech Therapy, stated that he did work with R4 and that she was discharged from Speech Therapy. V8 stated he was not made aware of R4 having difficulty eating or drinking and if he would have been made aware V8 would have gotten an order to evaluate and treat her. On 8/12/21 at 3:00 PM, V9, CNA, stated, (R4) was doing really well with her feedings then for about 2 weeks at the end she wasn't eating or drinking well. The nurses would say they know and we think something is going on with her but they didn't tell me what they were doing. On 8/12/21 at 3:10 PM, V10, CNA, stated, A few weeks before her leaving she was having poor intakes. I was letting the nursing staff know. Some would say OK I will make a note about it. On 810/21 at 2:15 PM, V3, Nurse Practitioner, stated, I was notified of (R4's) decline and bruising to the left axilla, breast area on 6/28/21. I sent her to the emergency room (ER). The ER basically sent her right back. The next day I assessed her and the bruising apparently had gotten worse according to (V14). During this assessment, she was showing pain. I ordered X-rays and labs. The X-ray showed a dislocated shoulder. I ordered her to be sent back to the local ER so that could be put back into place or they could get her to [NAME] if need be for treatment. The ER called me and said the shoulder was not dislocated but they were going to admit her for dehydration and to have orthopedics look at her. In the hospital with some rehydration, she came around a little bit but, she has such a change/decline I ordered a scan of her brain. It showed a possible stroke. Now this scan was done 2 days after the admission so I really don't know when the stroke happened. The family did not want to get real aggressive at this point. During the hospital stay, she wasn't eating. She wasn't alert enough to eat. The family wanted a feeding tube placed. Unfortunately, there was no beds at the Regional Hospital. She was on the list for a bed. I last saw her on 7/2/21 at the local hospital then the hospitalist took over her care. When I came back to the local hospital on 7/5/21, she had been transferred to the Regional Hospital. She was admitted with dehydration. I would classify it as slight dehydration. It was not like she wasn't being taken care of or neglected. I think she had a slight stroke and that is why she was declining, but I can't tell you exactly when it happened. She was not a healthy woman and had a lot of comorbidities. On 8/16/21 at 11:25 AM, V3 stated, When I saw her on 6/29/21, she did not appear as someone who had just had another stroke. I was not aware that (R4) had a decrease in fluid and food intake. Had I known this, I think the only thing different I would have done is be more aggressive about her decrease in insulin and encourage them to push fluids. I do expect to be notified of a decrease in food and fluid intake. On 8/16/21 at 12:23 PM, V13, Physician, stated, I was made aware of an overall general decline but not the specifics of her not having good intakes of fluid and food. On 8/10/21 at 4:05 PM, V2, Director of Nurses (DON), stated, (R4) was having desired weightloss. We had taken out the peg tube because she was eating well. If someone does not eat well, the intake is put into the computer system and then the nurse will talk to to the resident and the staff to see what interventions have been tried. On 8/16/21 at 9:00 AM, V2 stated, The computer system will flag poor intakes for the nurses to review. The aides are very good about bringing problems to me that they feel the nurses are not taking seriously. The aides never brought (R4's) intake concerns up to me. On 8/16/21 at 3:00 PM, V2 stated, The nurses should have been notifying (V3 or V13) about (R4's) poor intakes. R4's July Fluid and Meal Intake Report, print date of 8/10/21, documents, in part, that on 6/12/21 R4 intake was 240 milliliters (mls) and 1 meal of 0% to 25%, on 6/13/21 420 mls of fluid and 1 meal of 0% to 25%, on 6/18/21 280 mls of fluid and 1 meal of 75% to 100%, 1 meal of 26% to 50% and one meal of 0% to 25%, on 6/19/21 70 mls of fluid, 1 meal of 0% to 25% and 1 meal of 26% to 50%, on 6/20/21 360 mls of fluid, 1 meal of 0% to 25% and 1 meal of 51% to 75% and an hour of sleep snack, 6/23/21 180 mls of fluid, 2 meals of 0% to 25% and 1 meal of 26% to 50% and a pudding at hour of sleep, on 6/24/21 240 mls of fluid, 1 meal refused, 1 meal of 0% to 25% and 1 meal of 26% to 50%, on 6/25/21 60 mls of fluid and 3 meals of 0% to 25%, 6/26/21 120 mls of fluid and 3 meals of 0% to 25%, 6/27/21 160 mls of fluid, 1 meal of 0% to 25%, 1 meal of 26% to 50 % and 1 meal refused, on 6/28/21 20 mls of fluid and 3 meals of 0% to 25% and on 6/29/21 0 fluid intake and 2 meals refused and 1 0% to 25%. R4's Speech Therapy Discharge Summary, dated 6/18/21, documents R4 was discharged from Speech Therapy on 6/18/21. This discharge summary also documents, Short term goals: Pt (patient) will complete oral motor exercises with verbal and tactile stimulation. Baseline, 3/15/21, Pt demonstrates moderate to severe oral motor problems. Previous: Pt continues to demonstrate improvements in her oral motor processing skill. Pt was able to complete oral motor exercises with related, delayed, incomplete and complete responses. Pt continues to have some food and liquid loss from the left corner of her mouth, however, it has decreased considerably. Left side neglect remains an issue. Discharge, 6/18/21, Able to take 20 - 25 bites and 120 cc (cubic centimeters) of liquid. Diet texture analysis. Discharge, 6/18/21, pureed diet with honey thick liquids. R4's Nurses Note, dated 6/21/21, documents, Notified provider of low blood sugar results over the last few weeks. NO (new order) received to decrease [MEDICATION(S)] to 15 units at HS (hour of sleep) and update in one week per (V3). R4's Nurses Note, dated 6/24/21, documents, No s/x (signs and symptoms) of adverse reactions including hypo/[CONDITION(S)] observed or reported related to decrease dosage of [MEDICATION(S)] to 15 units @ hs (at night) however there is a decrease in appetite with self feeding and assistance abdomen non-tender or distended bowel sounds present x 4 normal no s/x of GI (gastrointestinal) distress no c/o (complaint of) or non-verbal s/x of pain no acute distress v/s (vital signs) 118/67, 50, 22, 97.4 spo2 (oxygen saturation) 93% RA (room air). R4's Nurses Note, dated 6/25/21 at 4:50 AM, documents, Resident observed to have BGL (blood glucose level) of 46 at this time; cool, no sweats, responded appropriately, A&O (alert and orientated) to self. Order for [MEDICATION(S)] per MD (medical doctor) standing order. MD made aware of use of standing order. R4's Nurses Note, dated 6/25/21 at 3:46 PM, documents, Seen by (V13, Physician) in facility with new order to hold [MEDICATION(S)] for 3 days and notify of blood sugar results. R4's Nurses Note, dated 6/28/21 at 9:56 AM, documents, [MEDICATION(S)] insulin remain on hold with no s/x (signs and symptoms) of hypo/[CONDITION(S)] decrease in appetite and fluid intake <25% with or without assistance alert non-drowsy skin warm and dry abdomen non-tender or distended bowel sounds present normal no s/s of GI distress v/s 108/58, 96.9, 72, 18 spo2 96% RA. R4's Nurses Note, dated 6/29/21 at 1:19 PM, documents, (V3) here in facility to see orders received for x-ray of L (left) shoulder and chest, CT scan of head without contrast dx (diagnosis); [CONDITION(S)] (cardiovascular accident), (labs) in am. R4's Nurses Note, dated 6/29/21 at 9:50 PM, documents, Chest x-ray results and Left shoulder x-ray results called to (V3) New orders received to send to ER for left head humerus to be put back in place. R4's Hospital Record, dated 6/29/21 at 11:21 PM, documents, Impression: Dehydration and Acute Renal Failure. Admit: This patient is admitted to the services of (V3). The patient is an inpatient admission and admitted to Medical/Surgical Services. The patient condition upon disposition was poor. R4's Hospital Registered Nurse (RN) Chart, dated 6/29/21, documents, Skin: The skin is warm. Skin color is pale. Skin tugor is decreased. R4's Laboratory Values, dated 6/29/21 documents, BUN (blood urea [MEDICATION(S)]) (mg/dl) (milligrams per deciliter) 62 (High) Normal values (7 - 20). R4's Laboratory Values, dated 6/29/21 documents, Creatinine (mg/dl) 3.10 (High) Normal values (0.52 - 1.04). R4's Hospital History and Physical, date of service 6/30/21, documents, Patients labs revealed that she was in acute renal failure and dehydration. Today patient will only respond to tactile stimuli. CT(Cat Scan) of the head done last evening was inconclusive for stroke and MRI (magnetic resonance imaging) was recommended so that was ordered to be done today. The results of this show that there is a subacute infarct superimposed along the margins of the more extensive chronic right cerebral infarct without [CONDITION(S)] or mass effect. Plan Dehydration: continue the Intravenous Fluids of normal saline at 125 ml/hr and recheck labs in the am. Date of Service 7/2/21 Plan: Dehydration change her fluids to .45% Normal Saline due to increase in sodium. Due to family wanting a to have (feeding) tube placed, we will need to transfer to a different hospital. R4's Discharge Summary, dated 7/6/21, documents, Patient discharged for higher level of care per ambulance on 7/2/21. Case closed. R4's State of Illinois Death Worksheet, documents, date of death [DATE]. Cause of Death. a. Cardiopulmonary Arrest (pt on hospice) approximate interval between onset and death 7 days. b. acute [CONDITION(S)]. c. severe dehydration [CONDITION(S)]. The Hydration Policy, dated 1/2016, documents, 1. Dietary will provide a minimum of 1440's cc's of fluids with meals for each resident unless contra-indicated by a fluid restriction. Additional fluid will be provided from bedside water pitchers, medication pass, activities and snacks.2. All residents will be assessed by the Dietician for individual fluid needs in Dietician Assessment in (computer). The standard of 25 -30 cc's of fluid per kg of body weight will be used unless contra-indicated by the resident's medical condition and or per professional opinion of the Dietician. (25 cc's will be used with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (R4 is 74 kilograms. 74 kilograms x 25 equals 1850. R4 required 1850 cc of fluid for hydration.)

Based on observation, interview and record review the facility failed to implement safe transfer techniques to prevent accidents and injury during mechanical lift transfers for 2 of 8 residents (R26 and R161) reviewed for supervision to prevent accidents in the sample of 32. This failure resulted in staff unsafely transferring R161 using a sit to stand lift and R161 sustained a large chest bruise and left dislocated shoulder. Findings include: 1. R161's Admission Record, with admitted [DATE], documented R161's diagnosis of [CONDITION(S)] and [CONDITION(S)] affecting left non-dominant side. R161's Care Plan, dated 6/18/21, documented, limited physical mobility, able to transfers with use of sit to stand, and two staff assistance related to, (CVA), [CONDITION(S)], with affected left side. R161's Physical Therapy discharge summary, documents R161 was discharged from therapy on 6/18/21 with sit to stand mechanical lift transfer with the Certified Nurse's Aide (CNAs). R161's Shower sheet dated 6/28/21, documented a bulge and bruise, complained of pain in that arm and on a drawn area to left armpit site. On 7/21/21, at 1:00 PM, V18 and V19, CNAs, were interviewed regarding R161's left arm and chest large bruised area and ability to use the Sit to Stand transfer machine. V18 stated, on 6/28/21, she and V19 identified a lump on R161's chest. V19 stated she was preparing the resident for her shower and found a redden area on her left shoulder area and alerted the nurse. On 7/21/21 at 1:50 PM, V19 stated on Monday 6/28/21 at 1:30 PM, she reported R161's red lump on left armpit area to V7, Licensed Practical Nurse, LPN; and went to the therapy department and reported to therapy the decline with R161 inability to use the sit to stand. V19 stated V12, Physical Therapist told her that R161 was discharged from therapy and continue to use what is ordered, sit to stand. On 7/22/21at 1:47 PM, V7 stated on 6/29/21 she was informed only on this day of 6/29/21 from V19 of R161's declining ability to use the sit to stand. V7 continued to state that she would assess the resident and report to the therapy department if a resident had a decline in their transfer ability, and she did not report this issue with the therapy department because V19 was present in therapy addressing the issue. There was no documentation the facility conducted further assessment of R161's transfer status after an injury was identified to her left arm and chest area. There was no documentation/assessment to ensure that the sit to stand lift was the safest mode of transfer for R161. R161's Progress Note dated 6/29/21 at 4:26 AM, documented an edematous area measuring 13 cm, (centimeters) x 11.5 cm in size to left breast/axilla area with discolored dark purple in color and very warm and firm to touch. R161's Progress note dated 6/29/21 at 4:35 AM, R161 to be sent out to the emergency department for evaluation of resident left breast/axilla area. R161's, Occurrence Report, dated 6/29/21 at 4:26 AM, documented, Upon return from ER, (emergency room ) visit resident, (R161) was assessed for the use of Sit to Stand, (partial mechanical lift) transfers, she did not attempt to stand or hold on to handles of the sit to stand machine. Sit to Stand transfers dc'd, (discontinued) and staff educated on use of full mechanical lift for all transfers, as this is the safest transfer for resident at this time and resident, (R161), noted to have edematous area measuring 13 cm, (centimeters) x 11.5 cm in size left breast/axilla area, discolored, (dark purple in color), and very warm and firm to touch. Resident was sent to ER for evaluation and returned to the facility. Resident does have lt. (left) sided neglect r/t, (related to) history of CVA. Upon return from the hospital ER visit resident was re-assessed for use of sit to stand machine and due to leaning to Lt. side appears injury determined to be related to use of sit to stand belt. On 6/29/21 at 6:17 AM, documented, R161 assessed on the use of the sit to stand, R161 was unable to stand or hold onto to handles of sit to stand machine. The Sit to Stand mechanical transfer was discontinued and changed for the use of a full mechanical lift as the safest transfer for the resident at this time. R161's written internal investigation sheet, undated, documented by V26, CNA, stated, sit to stand transfer-she (R161) didn't hold her own weight, she didn't even try to straighten her leg and she did not hold on with her left hand, I went to therapy and told them about the poor transfer. I was told I could use the full mechanical lift, by (V12, Physical Therapist). R161's Progress note dated 6/29/21 at 5:50 AM, documented, resident returned to facility with new physician orders for icepacks for 20 minutes every 3 hours for 2 days, then moist heat. R161's Progress note dated 6/29/21 at 3:24 PM, documented portable radiology completed at facility for the left shoulder. R161's radiology report, dated 6/29/21 at 7:38 PM, Procedure: Left shoulder, two views, documented, Inferior displacement of the humeral head, (upper long arm bone) in relation to the glenoid, (the socket portion of the shoulder joint that meets the head of Humerus). R161's Progress note dated 6/29/21 at 9:50 PM, documented, new orders received to send to ER for left head Humerus to be put back in place. R161 was admitted to the hospital on 6/30/21. R161's Hospital Radiology Report, dated 6/29/21 at 11:21 PM, documented, Impression: there is a large amount of hematoma formation left anterior chest wall just involving the pectoralis muscle. R161's Hospital Radiology Report, dated 6/30/21 at 10:22 AM, documented, There is inferior subluxation, (partial dislocation) of the left humeral head in respect to the glenoid, On 7/22/21 at 9:50 AM, V1, Administrator stated she would expect nursing staff to assess a resident that has a decline in transfer ability and report to the Therapy Department. The facility's policy and procedure, entitled Safe Resident Handling Program Policy, dated 3/18/18, documented, initial screening will be performed on all residents to assess transfer an ambulating status. Resident transfer status will be reviewed via care-plan time frame and as needed. The facility's policy and procedure, entitled, Safe Resident Handling Program Transfer and Bed Mobility Assessment Tool, dated 2/14/18, documented, Caregivers should always do the safest transfer possible for both the resident, if the level of assistance is increased, immediately notify the floor nurse so that the resident can be evaluated. 2. On 07/21/2021 at 8:10 AM, V22, CNA applied the sling of the sit to stand mechanical lift around R26. Prior to lifting R26, the mechanical lift sling was loose and was not checked by V22 or V23, LPN. R26's knees were not placed against knee pads of the partial mechanical lift. R26 had stockings on her bilateral feet. V23 asked R26 to hold on to the bars, R26 did until the lift started in motion then she let go of the bars. V22 and V23 did not verbally redirect R26 to hold on to the bars and R26 started to slip through the sling where the sling was under R26 armpits (axilla) and her bilateral arms were swinging up in the air. V23 was operating the lift and V22 was moving the wheelchair out of the way and did not have control of R26 and did she support R26 while she was being transferred to her bed from her wheelchair, R26's face sheet, dated 07/22/2021, documents diagnosis of Dementia with behavioral disturbances and [CONDITION(S)]. R26's Minimum Data Set, MDS, dated [DATE], documents R26 requires extensive assistance of 2 staff members for transfers and that R26's cognition was severely impaired. R26's Care Plan, dated 04/08/2019, documents, Fall risk: I (R26) am alert. I require 1-2 staff assist to transfer with (site to stand lift). On 07/21/2021 at 4:15 PM, V1, Administrator, stated she would expect staff to transfer residents safely when using the mechanical lifts. On 07/22/2021 at 10:20 AM, V3, Director of Nurses, stated that she would expect staff to make sure resident's knees were appropriately placed on knee pads and to make sure sling was secured prior to transferring residents. User Instruction Manual for the partial mechanical lift, undated, documents, Position the (partial mechanical lift) so that the patient's feet fit in the foot tray and knees rest against the knee pads. It continues, The patient's hands should be placed on the handgrips.

Based on interview and record review, the facility failed to perform ongoing assessments, recognize a change of condition and failed to notify the Physician/Nurse Practitioner regarding R3's Hallucinations, increased lethargy, confusion/agitation which contributed to R3's critical labs, electrolyte imbalance, hospitalization and death. Findings include: History and Physical dated [DATE] from Hospital, documents R3 sustained a right intra-prosthetic femur fracture following a fall at home. The Minimum Data Set ((MDS) dated [DATE] identifies R3 to be cognitively intact when admitted to the facility on [DATE]. Progress notes reviewed from [DATE] through to [DATE] describe R3 as being pleasant, alert and oriented times three (A&O x 3) and repeats stories often in the same conversation. Progress notes dated [DATE] at 3:34pm, from V8, Nurse Practitioner, document a new order received for Ropinirole 0.25mg (milligram) every pm for two days then increase to 0.5mg as a result of R3 complaining of unrelieved pain and muscle spasms. At 6:30pm on the same day, R3 was documented as being seen by V9, Primary Physician with his note documenting no particular concerns, but ordering a CMP (complete metabolic panel) and a CBC (Complete blood count) to be done on [DATE]. The note also documents that he was made aware of the order for Ropinirole at that time. On [DATE] at 3:47am, V3, Licensed Practical Nurse, (LPN), identifies R3 as being, A&O x 3 (alert and oriented times 3) forgetfulness observed, repeats stories, speech clear, answers questions appropriately. On [DATE] at 2:16am, V3, LPN, documents in the progress notes under the section Psychosocial: attitude, behaviors, support system the following: Daughter (V10) at bedside t/o (throughout) eve (evening); voiced concern with possible adverse effect of new med: delusions, indicates res (resident) voices seeing bugs/ants on the ceiling states res has commented on the ceiling being black, believes to have seen particles like Cheerios on floor (nothing observed on floor by other in the room at the time). Res also observed to be talking by herself in her room; appears to be having conversation with someone while alone in the room. Conversation with daughter noted in Chart/Nurses' Notes. Under the section entitled Neuro: orientation, response, extra movements, pupils' size/reactivity, speech V3 documents Lethargic, difficult to arouse, will react to tactile/verbal cues from staff by turning head in direction of voice, will nod in acknowledgement to whoever is speaking, keeps eyes closed. There is no evidence that V3 notified the physician of this significant change in condition for R3 at the time or further assessed R3 for the root cause of the changes described. On [DATE] at 9:41am, V3 stated she was passing medications around 8:00pm the evening of [DATE] when R3's daughter, V10, told her R3 was saying she was seeing bugs/ants, etc. on the ceiling and floor and that she was more confused. V3 stated V10 was questioning whether it could be the new medication, Ropinirole they had started the night before. V3 stated she did not see R3 hallucinating but, did note that she was lethargic. V3 stated she did see R3 talking to herself which was out of the norm for her but, did not notify the Physician of the changes. V3 stated the observations from 8pm on [DATE] were documented at 2:16am on [DATE]. V3 stated she thought she let the oncoming nurse know on [DATE] but, didn't know for sure or remember who it would have been. On [DATE] at 10am, V12, LPN, stated she took report from V3 the morning of [DATE] and didn't remember anything out of the ordinary such as the hallucinations/increased lethargy being reported to her. V12 stated had she been told, she would have done an assessment herself and informed the Physician because this was different for her. V12 stated she didn't recall anything unusual for R3, but when V11, POA, (Power of Attorney), and V10, daughter, left the afternoon of ,[DATE], they questioned whether R3's new medication Ropinirole was making her more confused. V12 stated she did not document the conversation and/or concerns voiced by R3's POA, V11. Progress notes dated [DATE] entered at 1:16pm by V2, Director of Nurses (DON), documents, Resident continues to c/o (complain of) unrelieved pain to RLE (right lower extremity) resulting in muscle spasms. Speech is slightly hard to understand. POA at bedside states that resident took [MEDICATION NAME] 50mg every 4 hours at home and that was before the fracture to RLE. POA also stated that resident seems more confused and lethargic when taking Ropinirole . At 1:22pm, V2 entered a progress note documenting call out to on call MD for V9, (Primary Physician), to update of residents c/o of unrelieved pain and concern that Ropinirole causing increase in confusion and lethargy. Will wait return phone call. On [DATE] at 10:14am, V2 stated she called the Physician the afternoon of [DATE] because, V12 had told her of the POA and daughters concern with R3 maybe having adverse side effects from the Ropinirole which she attributed her symptoms to as she had looked up the Ropinirole and had most of her symptoms listed. V2 stated she told the Physician that R3 was having hallucinations, increased lethargy etc. Progress notes dated [DATE] at 2:10am by V3, LPN, documents R3 to be very lethargic, difficult to arouse at times. and Will wake up slowly, word salad when awakens and speech mostly clear; difficult to understand at times r/t (related to) vocal tone/quality. The next entry is at 9:26am on [DATE] by V4, LPN, who documents R3 to be lethargic, easily aroused, fed self in room, appetite poor. Progress notes dated [DATE] at 9:31am documents a call from V8, NP, with V9's office requested labs due to increase confusion and mood change, increased anger, A&O to self only. The progress notes dated [DATE] document a CMP and CBC were drawn and a call from the hospital lab was received that R3 had critical labs. At 3:46pm, V9's office called with orders to send to the emergency department. Progress notes dated [DATE] at 8:31pm document R3 transferred to a Springfield Hospital and was admitted for electrolyte imbalance. On [DATE] at 9:51am, V16, V9's Medical Director of Wellness, stated V9 documented he saw R3 on [DATE] and that he documented her chronic conditions were stable and he ordered a CMP and CBC to be done on [DATE]. V16 confirmed a call was received from the facility on [DATE] indicating they wanted to change the [MEDICATION NAME] from every 8 hours to every 4 hours as she had been taking it at home due to unrelieved pain and maybe R3 was having some side effects from the new medication Ropinirole. V16 stated the office record did not have any report in terms of R3 exhibiting new symptoms or onset of anything like hallucinations or talking to herself at that time. V16 stated the next call they received from the facility was on [DATE] reporting critical lab values with increased lethargy and low oxygen saturations, but nothing else. V16 stated they gave an order to transport to the emergency department at that time. The Discharge Summary from the hospital dated [DATE] documents R3 presented to the hospital confused, belligerent, screaming at the top of her lungs and unable to give her own history. The Assessment documents R3 to have acute metabolic [MEDICAL CONDITION], (a disease of the brain caused by a [MEDICAL CONDITION] infection or toxins in the blood) most likely related to [MEDICAL CONDITION] from a Urinary Tract infection of E. Coli. R3's Death Certificate documents R3 expired on [DATE] with cause of death documented as Bacteremia, Urinary Tract Infection. On [DATE] at 11:44am, V8, Nurse Practitioner for V9 stated she reviewed the correspondence from the facility and did not receive any calls from the facility on [DATE]. V8 stated the order for Ropinirole was actually given by V17, on call physician for V9. V8 stated they received a call from the facility on [DATE] requested a prescription for [MEDICATION NAME] but it included nothing on increased confusion, hallucinations or significant change. V8 stated on [DATE] the facility was documented as calling to report critical labs at which time they gave an order for [REDACTED]. On [DATE] at 11:10am, V14 Certified Nurse Aide, (CNA), stated she worked the day shift on [DATE] 6am to 2pm and described R3 that day as agitated and confused. V14 stated R3 had a relative there and didn't seem to be comprehending what the relative was saying. V14 stated this was not normal for R3 who usually was alert and oriented times 3. V14 stated R3 fed herself, drank water when offered. V14 stated she reported the agitation and confusion to the nurse that day. On [DATE] at 2:05pm, V15 CNA stated he worked the last three days R3 was at the facility and did see a change in her but not as much as the daughter did. V15 stated R3 was a little out of it on [DATE] but her oxygen level was low. The facility's policy entitled Guidelines for Physician Notification of Change in Resident Condition dated ,[DATE] documents the purpose as To define resident care situations that require physician notification with the Standards being Staff observe, document, and communicate to the physician changes in resident condition promptly. The policy documents change in condition may include change in mental status or level of consciousness, change in gait, speech patterns or balance, symptomatic urinary tract infections.

Based on observation, interview, and record review, the facility failed to supervise a steam table to prevent potential thermal hazard/burns. This has the potential to affect 4 of 4 residents (R4, R6, R7, R11) in the sample of 17 and 6 residents (R18, R19, R20, R22, R23 and R24) in the supplemental sample. This failure resulted in an Immediate Jeopardy which was identified to have begun on 5/15/17 when the facility failed to supervise a steam table having a surface temperature exceeding 160 degrees Fahrenheit (F) to protect residents from potential injury from steam table's surface temperature and the hot water in the steam table. While the Immediate Jeopardy was removed on 5/17/2017 the facility remains at Severity Level 2 as the facility continues to in-service staff and update policies and procedures as needed. Findings include: On 05/15/17 at 9:40 AM, the 400 Hall dining room double doors were open and no staff were present. The steam table was noted to be on and had a large amount of visible steam rising out from underneath the lids. A Thermolabel was placed on the steam table lids. The Thermolabel temperature sensitive tape turned black when applied to the outside of the right and left steam table pan lids which indicates a temperature of at least 160 degrees Fahrenheit (F). The water temperature in the middle steam well was 207.1 degrees F when taken with a digital thermometer. The water temperature in the right side steam well was 196.5 degrees F when taken with the thermometer. The steam table has a sign on it that documents, Remember Turn off the steam table then . unplug it. Thank you for being safe. 05/15/17 at 10:20 AM, the 400 Hall dining room double doors were open and no staff were present in the dining room. The steam table was noted to be on and had a large amount of visible steam rising out from underneath the lids. At 10:38 AM, the 400 Hall dining room double doors were open and no staff were present. The steam table was noted to be on and had large amount of visible steam rising out from underneath the lids. 05/15/17 at 10:40 AM, E3, Dietary Aide, entered the dining room, placed food in the steam table and covered the food with the lids. E3 exited the dining room and the double doors remained open. 05/15/17 at 11:05 AM, the 400 Hall dining room double doors were open and no staff were present. The steam table was noted to be on and visible steam continued to rise out from underneath the lids. On 5/15/17 at 11:17 AM, R23 entered the 400 dining room and sat at a table. No staff were present to supervise the steam table. R23's Minimum Data Set (MDS), dated [DATE], documents she has a Brief Interview of Mental Status (BIMS) Score of 9 which indicates moderately impaired cognition. The MDS also documents R23 ambulates independently on the unit using a walker. 05/15/17 at 11:20 AM, E3, Dietary Aide, was in the dining room preparing lunch service. E3 left the dining room with R23 still in dining room unsupervised. There was visible steam coming from the steam table. At that time, the Thermolabel temperature sensitive tape turned black when applied to the steam table pan lid which indicates a temperature of 160 F or greater. On 5/15/17 at 11:22 AM, R24 was self propelling himself in his wheelchair down the 400 hallway. R24 stopped in the entrance of doorway to the 400 dining room. The dining room doors were opened. No staff were present in the dining room at this time. R24's MDS, dated [DATE] documents R24's inability to complete the BIMS. The MDS documents he has severe cognitive impairment. The MDS documented he requires extensive assistance of 1 staff member for mobility with a walker or wheelchair although R24 was observed self propelling himself down the 400 hallway to the 400 dining room. 05/15/17 at 3:25 PM, E4, Dietary Manager, stated The steam table on 400 Hall gets unplugged at night and the doors are closed during the day. On 5/16/17 at 8:05 AM, E3, Dietary Aide, stated I make sure the lids are on and the pans are covered. I make sure water levels are OK so they don't dry up. I make sure temperatures stay up. I keep the dial at level 5 on the dial. After breakfast the dining room is cleaned and then the doors are closed and the lights are turned off. The doors don't lock. I open the doors back up about 11:30 AM to start getting ready for lunch. I stay in the dining room after I open the doors, but I didn't yesterday because I didn't give them hot drinks. After I serve hot drinks I don't leave the dining room. The steam table is unplugged, turned off and the water emptied after lunch. It is not used for the evening meal. The facility provided an untitled document, dated 5/15/17 at 10:30 AM. This document identified the following residents as currently confused, able to ambulate independently without staff assistance and all reside on the 400 hall: R7, R18 and R19. The facility provided an untitled document dated 5/15/17 at 10:30 AM. On this document the facility identified the following residents as currently confused, able to self propel in their wheelchairs without staff assistance and reside on the 400 hall: R4, R6, R20, R11 and R22. On 5/15/17 at 3:20 PM, E2, Director of Nurse's confirmed the resident information identified on the documents were accurate. R4's MDS, dated [DATE], documents R4's BIMS score was 10, indicating moderately impaired cognition. The facility identified R4 as being able to self propel a wheelchair independently without staff assistance. R6's MDS, dated [DATE], documents R6's BIMS score was 5, indicating severely impaired cognition. The facility identified R6 as being able to self propel a wheelchair independently without staff assistance. R7's MDS, dated [DATE], documents, in part, R7 has a Brief Interview of Mental Status (BIMS) Score of 12, which indicates moderately impaired cognition. This MDS also documents R7 is independent with mobility on the unit using a walker. R18's MDS, dated [DATE], documents, in part, R18 has a BIMS score of 11 which indicates moderate cognitive impairment. This MDS also documents R18 is independent with mobility on the unit using a walker or a wheelchair. R19's MDS, dated [DATE], documents R19 has a BIMS score of 11 indicating moderately impaired cognition. The facility identified R19 as being able to ambulate independently without staff assistance. R20's MDS, dated [DATE], documents R20 has a BIMS score of 8 indicating moderately impaired cognition. The facility identified R20 as being able to propel a wheelchair independently without staff assistance. R11's MDS, dated [DATE], documents R11 has a BIMS score of 5 which indicates severely impaired cognition. The facility identified R11 as being able to propel a wheelchair independently without staff assistance. R22's MDS, dated [DATE], documents, in part, R22 has a BIMS score of 12 which indicates moderately impaired cognition. This MDS also documents R22 is independent with mobility on the unit with set up help from staff using a walker or wheelchair. On 5/16/17 at 11:15 AM, E1, Administrator, stated We do not have a policy on the temperature of the water in the steam table. We just have the steam table policy. You got me. It should be off. The facility's Steam Table policy and procedure, dated 10/13, documents, in part, Turn off after serving of food is completed. Katcher, L.K. (1981). Scald Burns from Hot Tap Water. Journal of Am Med Assoc., 246 (11), 1219-1222), documents Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. Studies of Thermal Injury: II. The Relative Importance of Time and Surface Temperatures in the Causation of Cutaneous Burns, written by Moritz and A.R. Henriques F.C. Jr., dated 1947, documents the damage to skin causing a 3rd degree burn in relation to the temperature of the water and the length of time of exposure as follows: 155 degrees F for 1 second (sec) ; 148 degrees F for 2 sec; 140 degrees F for 5 sec; 133 degrees for 15 sec; 127 degrees for 1 minute (min); 124 degrees for 3 minutes; and 120 degrees F for 5 minutes. The Immediate Jeopardy began on 5/15/17, when the facility failed to supervise a steam table having a surface temperature exceeding 160 degrees Fahrenheit (F) to protect residents from potential injury from steam table's surface temperature and the hot water in the steam table. On 5/17/17 at 1:50 PM, E1, Administrator, E2, Director of Nurses, E23, Regional Director and E24, Regional Nurse were notified of the Immediate Jeopardy. On 5/22/17, surveyors determined through observation, interview and record review, the facility took the following actions to remove the Immediacy: 1. On 5/16/17, mid-morning, the 400 hall dining room steam table was shut down. 2. On 5/16/17, at 11:45 AM, the 400 hall dining room steam table was turned on for meal service use. This was 30 minutes prior to the noon meal. 3. On 5/16/17, at 12:30 PM, the steam table in 400 hall dining room was shut completely down and unplugged. 4. On 5/16/17, at 1:00 PM, the 400 hall dining room steam table was removed from the facility. The facility does not intend to have the steam table returned to the 400 hall dining room. 5. On 5/16/17 at 5:00 PM, a hot cart food service was initiated for all meal service for the 400 hall dining service area. 6. On 5/16/17, prior to the noon meal, the day and evening meal service staff of the dietary department were in-serviced regarding the steam table policy by the dietary manager. 7. On 5/17/17, from 1:40 PM to 4:30 PM, All department staff were in-serviced regarding the steam table policy that the steam table be turned off after meal service. Additionally, staff were educated that no resident remains in the dining room unattended while a steam table is in use; and that dining room doors remain closed until a dining room steam table is cooled. 8. The dietary manager initiated meal observations to ensure adherence to the steam table policy. This observation process will be continued randomly to ensure staff compliance.

Based on interview, observation and record review, the facility failed to assess/monitor and develop a plan to address gradual weight loss and failed to provide needed assistance in eating for 2 of 6 residents (R3, R13) reviewed for nutritional status and weight loss in the sample of 17. This failure resulted in an unplanned significant weight loss and a decreased [MEDICATION NAME] level for R3. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], identifies R3 as having severe cognitive impairment. The MDS documents R3 requires extensive assist of one staff for eating. R3's Weight loss records document a gradual weight loss of 18 pounds from 9/15/15 at 158.8 pounds to 140.2 pounds on 3/5/16 which is an 11% weigh loss within 6 months. R3's Care Plan, dated 2/10/16, identifies a nutritional focus dated 7/15/15 documents (R3) is within her desired body weight range of 111.0-157.00 pounds. She resides on the secured unit and eats in the Oakwood dining room. She is independent with eating but does require assistance at times. The Goal is: Maintain current weight through next review - target dated 3/22/16 with two interventions. The first is to ensure that R3 has her glasses on at mealtime, dated 2/4/16, and provide LCS (Low Concentrated Sweet) diet with regular texture and consistencies with no changes or revisions as of 4/7/16. On 4/5/16 at 12:01 PM, R3 received her lunch tray from E8, Certified Nurse Aide (CNA). R3 was sitting at the circular assist table. R3 did not have her eye glasses on. R3 had ground meat with gravy, mashed potatoes with gravy, and corn in a divided plate. R3 also received a glass of tea and water, but no milk even though it was listed on the menu. R3 sat and poked at her meal with no assistance and/or cueing or encouragement provided. No interventions were offered such as verbal cueing, encouragement or substitutions offered as she sat in front of her meal. At 12:50 PM, R3 backed her wheelchair up and when asked if she was done by E8, rolled herself out of the dining room to the activity room. She ate 50% of her meat, no potatoes or dessert bar, and less than 25% of the corn. On 4/6/16 at 12:15 PM, R3 received ground fish, cream noodles, tomato/zucchini salad in a divided plate and a small bowl of fruit cocktail and a 1/2 piece of bread pudding from E13, CNA. R3 was again sitting at the assist table. R3 picked up her spoon and attempted to eat the fruit, dropping it into her salad and fish and onto the tray. R3 attempted to spoon up the bread pudding, then picked it up with her fingers and ate it. R3 struggled as she attempted to put food onto her spoon, and then set the spoon down and stated she was done. E13 asked R3 if she wanted any more, but failed to offer assistance, cueing, encouragement or substitutions for food uneaten. R3 left the table. The food on R3's divided plate was all mixed up. R3 ate none of her fish that had fruit on it, no noodles, 50% of the tomato/zucchini salad, 100% of the bread pudding and only about 50% of her fruit which was mostly on her tray. A Quarterly Note, dated 12/28/15 by E4, Dietary Manager (DM), documents that R3's weight was 158.3 pounds on 12/5/15, [MEDICATION NAME] level was 3.4 Low, and a gradual weight loss had been noted. On 2/18/16, E4's significant change note documented R3's [MEDICATION NAME] level to be 3.2 Low and that R3 seemed to be having difficulty processing some meats. Her present diet will likely be downgraded to mechanical textures. R3's weight recorded then was 143.3, 30 day from 159.4 and six month 156.7. There is no documentation regarding any changes to R3's plan of care in an effort to increase her intake and maintain her weight. On 4/7/16 at 12:45 PM, a Registered Dietician's (RD) Assessment was requested from E2, Director of Nurses. A one page Dietary Recommendations for physician approval, dated 2/14/16 written by E10, RD, was provided which documents R3's weight to be down, appetite poor/fair with recommendations to add MedPass 60 cc (cubic centimeters) TID (three times daily.) There is no documentation that E10 evaluated or assessed R3 and her weight loss including a decline in functional ability or possible increased need for assistance/verbal cueing/encouragement in eating. An additional RD Note, dated 3/14/16 by E10, documents Sig wt (Significant weight) change note for resident c (with) wt (weight) 3/5/16 140 # (pounds), weight fairly stable since RD last note, Reg (Regular) diet ordered and oral supplements initiated 2/29. Appetite/intake fair. No new labs and no skin concerns or [MEDICAL CONDITION] noted. Will continue to monitor for wt stability w (with)/adequate intake of food/supplements. No changes at this time. There is no indication in this note that the dietician assessed R3's functional ability for decline or the need for increase assistance including verbal cueing/encouragement or substitutions for food uneaten. On 4/7/16 at 2:11 PM, E12, Registered Nurse (RN), stated R3 takes her Medpass Supplement about 50% of the time and refused it at lunch earlier. E12 stated that nurses document whether R3 takes it or not on the Medication Administration Record [REDACTED] On 4/7/16 at 2:20 PM, E1, Administrator, stated R3's weight problem started with a [MEDICAL CONDITION] in January 2016. However, monthly weight sheets document R3's weight on 1/26/16 with readmission to the facility following the fracture was 156 pounds and subsequent weights document gradual decrease in weight. R3's weight on 2/5/16 was 145.4, 2/9/16 143.3, 2/23/16 121.3 and on 3/5/16, 140.2 pounds. In addition, there is no change/addition and/or revisions to the Care Plan since 2/4/16 when they added the eye glass interventions. Dietary failed to develop a nutritional plan to reflect R3's weight loss risk, subsequent loss and need for increased assistance and/or verbal cues/encouragement. 2. R13' MDS, dated [DATE], identifies R13 to have severe cognitive impairment and requires minimal assist of one staff for eating. R13's Care Plan, dated 1/27/16, documents under the Focus area that R13 is within his desired body weight range of 129-183 pounds, resides in the secured area of the facility, has upper and lower dentures, but refuses to wear them. The goal is to maintain weight +/- 3 pounds through next review. Interventions include providing regular diet with regular textures and consistencies, and offer a soft protein alternative when having difficulty chewing meat. On 4/5/16 at 12:03 PM, R13 received his lunch meal and received meat loaf, potato/gravy and corn. R13 was served on a regular plate with the corn in a bowl. R13 also received a dessert bar. At 12:10 PM and 12:15 PM, R13 was sitting unengaged and not eating. At 12:25 PM, he was taking small bites and having difficulty getting the fork/spoon to his mouth. R13 would also try to load his fork with the food falling off the fork and put an empty fork into his mouth. No staff assisted/cued/encouraged or offered substitutions during this time. At 12:40 PM, R13 told E5, Restorative Nurse/License Practical Nurse (LPN), that he had to go to the toilet and he would come back to finish his meal. E5 assisted R13 out of the toilet and R13 did not return to finish his meal. R13 ate 50% of his dessert bar and corn, no potato/gravy and 75% of his meatloaf. No soft protein alternative was offered as indicated in the Care Plan. On 4/6/16 at 10:30 AM, R13 was given an bag of crackers, cup of coffee with cream and a glass of punch for a snack in the dining room. R13 sat for along time before eating one of the crackers and had difficulty getting the glass and coffee cup to his mouth. He would lift the cup and come within an inch or two of his mouth, hold it for a few seconds, then set it back down on the table. No staff intervened to assist. R13 remained in the same chair until lunch was served. R13's full cup of cold coffee from snack time was set on his lunch tray along with the glass of punch. R13 was served fish, cream noodles, fruit cocktail, and tomato/zucchini salad along with bread pudding for dessert. E11, Unit Aide was in the dining room, but failed to note R13 having difficulty eating. R13 would sit for long periods of time without eating with no staff interventions to cue/encourage and/or assistance offered. At 12:38 PM, E1, Administrator, was asked about assistance for R13. E1 went over to R13 and asked if he was having difficulties eating and he said yes. E1 then offered to assist and R13 allowed E1 to feed him bites of food. E1 assisted for a short while then left to get the therapist. A short time later, E16, Certified Occupational Therapy Assistant, came into the dining area and asked R13 if he was having difficulty feeding himself to which he responded yeah. E16 then cued him to eat and he picked up a bite. E16 then turned around, left the dining room stating He just needed to get going, I think he's okay. No soft protein alternative was offered as indicated in the Care Plan. The weight records show a gradual decline of 13.4 pounds or 9% since 10/22/15 for R13. The records document R13's weight as 141.1 pounds on 10/22/15 and 127.7 pounds on 3/5/16. R13's Dietary assessement, dated 1/21/16 by E4, DM, documents that R13's [MEDICATION NAME] is low at 3.0, he's independent in eating and has no issues at this time although he'd already lost 9 pounds in three months (141.1 to 132.3) according to R13's weight record. No additions or revisions have been done to the Care Plan in an effort to maintain R13's weight and prevent further loss. There has been no assessments towards his weight loss in regards to functional decline and/or increased needed assistance except on 2/24/16 when a supplement was initiated which is also not on the Care Plan.

Based on interviews, observations and record review, the facility failed to provide adequate supervision and assistance to prevent falls for 2 of 6 residents (R10 and R11) in the sample of 15. This failure resulted in R10 falling within 24 hours of readmission following a fractured right hip repair and sustaining a fracture on the left hip 4/27/14. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] identifies R10 to have severe cognitive impairment and independent in all activities of daily living including ambulation. According to an Occurrence Report dated 4/22/14 at 17:55 (5:55pm), R10 was found laying on her left side holding her right leg. The Occurrence Report documented that R10 was transferred to the emergency room at 6:10pm and according to a Hospital Operative Report dated 4/24/14, R10 had a right femoral neck fracture which required surgical intervention. Nurses Notes written by E15, Licensed Practical Nurse (LPN) dated 4/26/14 at 1815 (6:15pm) documents that R10 returned to the facility accompanied by Z2, R10's daughter. The Nurses Notes, with no date or time, written by E15, documented "continuation: low bed + pressure pad in place", provided no explanation as to why an alarm or low bed was placed the evening on R10's readmission. There are no other nurses notes written on 4/26/14. Nurses Notes written by E16 Registered Nurse (RN) dated 4/27/14 at 2am documents "resident up to bathroom c (with) walker and 2 person extensive assist . Slow gait." The note further documented R10 "education provided on safety and call light usage." No further notes until 4:55am when the notes documents R10 "observed lying supine on floor c head near closet doors and feet near foot of bed, yelling out in pain." The physician (Z1) was notified and R10 was transferred again to the emergency room where, according to discharge records dated 4/30/14, she was diagnosed with [REDACTED]. E15, LPN, on 6/12/14 at 12:10pm, stated in interview that she was the nurse who readmitted R10 from the hospital on [DATE] and that R10 didn't understand why she couldn't get up and walk or why she needed to use the call light to call for help. E15 stated they placed the pressure alarm and low bed due to R10 repeatedly trying to get up unassisted and that the Certified Nurses Aides (CNA) were constantly going back into her room. E15 stated they showed her how to use the call light but she "just didn't seem to understand" the purpose of the button or call light. E15 stated the daughter was here that evening and also knew R10 was trying to get up on her own. Asked how often R10 attempted to get up, E15 replied multiple times per hour. E10 stated she left work at 10pm and passed the information to the oncoming nurse. There is no evidence the facility further assessed R10 for additional safety measures given that R10 continued to attempt to get out of bed except the alarm. On 6/12/14 at 2pm, it was noted that R10's room was not by the Nurse Station and was 2/3rds of the way down the hall. There is no evidence the facility moved R10 closer to the nurses station for closer observation. There is also no indication the facility got her up and set her in a higher traffic area for better monitoring. On 6/12/14 at 1pm, Z1 Physician agreed that R10 would be unable to use the call light or call for help to get up due to her cognitive impairment. Z1 stated the hospital had 1:1 on her due to her constantly trying to get up and thought the hospital actually discharged her early due to that fact. Z1 also agreed that the alarm would not be a reminder for R10 to call for help also due to her cognitive impairment and that her history when she was at home was to be up a lot at night. Z1 agreed that the facility could have put a sitter with her and/or move her closer to the desk to increase monitoring. On 6/12/14 at 3:15pm, Z2, R10's daughter stated she was at the facility the night R10 returned from the first hospitalization for the right hip fracture. Z2 stated R10 was confused and didn't understand why she couldn't get up and was unable to use her call light due to cognitive impairment. Z2 stated the hospital had trouble keeping her in bed and had actually used restraints. Z2 stated R10 repeatedly attempted to get up out of bed setting off the alarm and that when she left that evening, before 10pm, she told the nurse that her mother continued to constantly try to get up on her own. On 6/13/14 at 9:10am, E16 RN stated in interview that she was the only nurse in the building along with at least 4 aides the evening R10 returned from the hospital the first time. E16 stated she was told that R10 by E15 during report that R10 repeatedly tried to get up and that a low bed and bed alarm had been placed. E16 stated R10 would be unable to use the call light due to her cognitive impairment. According to the facility's policy entitled "Fall Assessment, Risk Identification and Management Policy", it is the policy of the facility to "assess each residents fall risk on admission." The Fall Assessment may address assessment of factors listed but not limited to the following: general state of health, age, sensory deficits related to hearing and vision, mobility, medications, mental status, wandering tendencies, previous falls." Interventions are based on the resident assessment and the circumstances surrounding the risk for injury or actual injury or fall and include falls related to confusion, gait/balance deficits and poor judgement or knowledge deficit among others. 2. R12's Care Plan of 5/26/14 documents R12 is a Fall Risk related to Dementia and Left hip fracture with repair. Care Plan documents R12 is a recent re-admit status [REDACTED]. Facility Fall Details Report of 5/19/14 documents R12 lost her balance and fell on [DATE] and was sent to the hospital. Hospital History and Physical of 5/20/14 documents R12 was ambulatory without assistance prior to the fall and fell at the Nursing Home and sustained a fractured left hip. Facility Fall Details Report of 5/30/14 documents R12 was observed sitting on the floor between bed and wall. Report documents R12's alarm was not sounding. On 6/12/14 at 4PM, E2, Director of Nursing (DON), stated that the alarm was not working due to a dead battery.

Based on interview and record review, the facility failed to operationalize its' Abuse Prevention Policy to ensure proper and timely reporting of all allegations of abuse to the Administrator, thorough investigation of an allegation of abuse and timely reporting to the Department. This has the potential to affect all of the 71 residents living in the facility. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 7/17/12 the facility remains out of compliance at severity level two, while the facility continues to educate staff on recognizing and reporting abuse. The findings include: 1. The facility's "Policy and Procedure regarding Abuse and Neglect..." documents under "Reporting" that "A facility employee or agent who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility administrator. (77 Ill. Administrator Code Section 300.3240 (b)". The policy also documents "A facility administrator, employee, or agent who becomes aware of alleged abuse or neglect of a resident shall also report the matter to the Department. (77 Ill. Administrator Code Section 300.3240 (d)". Under the section "Investigating" the policy states "After an initial report of suspected abuse or neglect is sent to (Department), the Administrator or designee shall investigate all alleged incidents of abuse or neglect." Under the section "Protection" the policy states "If the incident involves alleged abuse by an employee as the perpetrator of abuse, then the Administrator shall immediately suspend the employee suspected to be involved in the alleged abuse without pay pending investigation of the incident". The policy also states "If the incident involves alleged abuse or neglect, the Administrator shall provide the (Department) with initial notice of the alleged abuse or neglect by telefaxing to the Department a copy of a report of the incident completed within 24 hours after the incident becomes known". The Policy and Procedure does not state immediately. 2. On 7/3/12 at 1:55 PM, E1, Administrator, was made aware of an allegation of abuse with R32. E1 was told by the Department that R32 told E12 , Social Service Director, that staff was "rough" with her when they put her to bed. R32 confirmed on 7/3/12 at 12:30 PM that staff were "rough" when putting her to bed as reported to E12, Social Service Director, "a few weeks ago". E1 denied knowledge of the abuse allegation that R32 was "thrown" into bed and was "scared" but did not investigate the abuse allegation until 7/9/12. E12, Social Service Director, stated in an interview on 7/3/12 at 10:30 AM that about 2 weeks ago she had been asked to speak to R32 and R33. E12 stated when she spoke to R32 and R33 they stated afternoon staff , E14, Certified Nurse Aide (CNA), had been rough with them. E12 stated she went to E1, Administrator, and he took over from there. E12 confirmed on 7/3/12 at 1:25 PM, that she reported to E1 that staff was "rough" putting R32 to bed. E12 stated she did not document the incident and was not sure what happened after reporting the incident. E12 stated in an interview on 7/9/12 at 10:00 AM that she had not talked to R33 regarding the incident which occurred June 5 or 6 th. E12 stated in an interview on 7/12/12 at 10:10 AM that she talked to R32 on June 5th or 6th. E12 stated R32 did not state the date when staff was rough with her but she told E1 right after she talked to R32. R32, stated in an interview on 7/3/12 at 12:30 PM, that "a few weeks ago" an aide "threw" her in bed. R32 stated that was "all she could call it" was that the aide "threw" her. R32 stated she was in her wheelchair and the aide put her hand on her shoulder and back and "threw" her. R32 stated she was not sure of the aides name. R32 stated R32 was in her wheelchair and the aide picked her up and threw her in bed. R32 stated she had not had anyone do that before and it "scared" her. R32 stated E12 and E1 came in to talk to her about it and R32 thought the aide got in trouble. R32 stated she thought the aide got reprimanded because she hasn't done it since. R32 stated the aide doesn't talk to her, but she can tell the aide got in trouble. R32 was identified as "interviewable" by the facility on the facility roster. The most current Minimum (MDS) data set [DATE] identified R32 as a "15" out of 15 score for "Cognitive Patterns" score. R32 stated in an interview on 7/9/12 at 11:45 AM that she told E1 that the aide was rough with her. R32 stated E1 came in to talk to her and she told E1. R33 was present during the interview and was asked if she saw R32 thrown into bed. R33 did not answer but R32 answered for her and stated R33 did not observe the incident. E1 stated, in an interview on 7/3/12 at 1:55 PM, that E12 did not tell him R32 had said staff was rough with her. E1 stated E12 told him R32 did not want to go to bed early. E1 stated when he talked to R32 she told him she didn't want to go to bed at 6:00 PM, but did not mention staff being rough with her. E1 stated he wrote a note to tell staff not to put R32 to bed too early. E1 provided a signed, written note dated 6/5/12 that stated "Do not put her in bed until she wants to go to bed! If she wants to eat in her room, let her!" E1 stated he had not done an investigation or reported the allegation of abuse with R32 to the Department. E1 stated there was only one abuse investigation report from June 1 through July 3 and that was for R6. E1 stated, in an interview on 7/9/12 at 10:40 AM, that he had not, as of 7/9/12 at 10:40 AM, done an abuse investigation regarding the abuse allegations with R32. E1 stated he had not done an abuse investigation because R32 did not mention staff being rough with her to him when he spoke to her on 6/5/12. E1 confirmed he did not ask R32 about the allegation on 6/5/12. E1 confirmed that he was told on 7/3/12 that an allegation of abuse had occurred with R32 by the Department. E1 confirmed he was aware R32 had alleged staff were rough with R32 and threw her into bed which scared her. E1 provided an employee schedule which confirmed E14 had worked 21 shifts since June 5 th. E1 stated, in an interview on 7/12/12 at 11:30 AM that he had waited until 7/9/12 to do the abuse investigation for R32. E1 confirmed he had been notified on 7/3/12 about the allegations of staff being rough and throwing R32. E1 stated he waited until 7/9/12 because R32 had not said to him that staff were rough or had thrown her on 6/5/12 when he had talked to her. E1 stated R32 told him on 7/9/12 that the incident happened on 6/4/12. The "Abuse Allegation Summary/Worksheet" dated 7/9/12 documented the allegation as "Staff threw me into bed". The "Evidence that doesn't support accusations" documented "CNA not working 6/4/12 when resident said she was thrown into bed". and "No staff has direct knowledge of (R32) being thrown into bed". The conclusion of the investigation was: "There is nothing to substantiate this residents allegations being thrown into bed by (E14)". E1 did identify two staff in the "Summary of Incident" and the written statements, E12 and E17, CNA. E1 identified in the summary that R32 had told staff she had been thrown her into bed or staff had been rough with her. E1 documented that both staff identified 6/4/12 as the date the incident occurred. E1 documented there was nothing to substantiate the allegations. E17 stated in an interview on 7/12/12 at 4:10 PM that she could not recall the date when R32 told her she wanted E17 to put her to bed because she was "sick and tired of being thrown into bed" by E14. E17 stated it was about a month ago. E17 stated she had not reported the allegations when R32 made that statement. The written statement dated 7/9/12 by E12 documented "(R32) told me that (E14) is rough with her when she puts her in bed. She never told me that she was thrown in bed". The written statement by E17 dated 7/9/12 documented "Has (R32) told you that any staff member has thrown her into bed? Yes. (E14) I am not sure when it was. She said she was sick and tired of being thrown into bed, I'll have you put me into bed". Review of the nurses notes and social service notes from June 1 through July 3 for R32 and R33 did not identify any allegations of abuse. Review of the abuse allegation report from June 1 through July 3, 2012 only documented 1 abuse investigation and that was for R6. 3. On 6/23/12, according to the "Abuse Allegation Summary/Worksheet" dated 6/24/12, the facility staff failed to immediately report an allegation of abuse to the Administrator. E16, Certified Nurse Aide (CNA), witnessed E15, CNA, roughly transfer R8 and hit her knee on the bed on 6/23/12 at 5:15 AM. E1, Administrator, confirmed by interview on 7/5/12 at 12:35 that the allegation of abuse was not reported timely to him. E1 confirmed the abuse allegation was not reported until 11:04 PM on 6/23/12. E15 was not immediately suspended and did finish her shift. 4. On 7/2/12, E1 did not report an allegation of abuse to the Department in a timely manner. On 7/2/12 at 10:00 AM, E1 stated in an interview that there was only one allegation of abuse investigated since 6/1/12 which was with E8 on 6/23/12. In an interview with E6, Licensed Practical Nurse, on 7/2/12 at 3:16 PM she stated an allegation of abuse was made on 7/2/12 at 4:30 AM by R31. R31 told E6 that her roommate, R28, was slapped by a CNA. E1 stated he did not mention the abuse allegation regarding R28 that morning because he was still investigating the report. The "Report to (Department)"which states "An allegation of physical abuse towards a resident by a CNA" as the initial report was not faxed to the Department until 7/2/12 at 5:24 PM. 5. The "Facility Data Sheet" dated 7/2/12 documents that the facility has 71 residents living in the facility. The Immediate Jeopardy situation was identified on 7/3/12 and determined to have begun on 7/3/12 when E1, Administrator, was notified of the Immediate Jeopardy on 7/12/12 at 12:25 PM. On 7/17/12, with interviews with E1, Administrator; E9, Licensed Practical Nurse; E12, Social Service Director; E21, dietary; E22, activities; E 11, E23, E26 and E27, CNAs; E24, Maintenance; E25, housekeeping; E28 and E29, Corporate Staff and review of the facility policy and inservice records, it was determined the facility took the following actions to remove the Immediate Jeopardy: 1. All facility staff including management were provided inservice to the policy and procedure regarding abuse and neglect, involuntary seclusion, misappropriation of resident property and injuries of unknown origin on 7/3, 7/5, 7/6, 7/11 and 7/12/12. 2. The Administrator was re-educated to the policy and procedure regarding abuse and neglect, involuntary seclusion, misappropriation of resident property and injuries of unknown origin on 7/12/12 by the Vice President of Operations. 3. On 7/17/12 the facility amended language to Item #64 of the abuse prohibition policy to include the reporting of incidents of abuse, neglect and incident of unknown origin to be reported immediately to the Administrator and the the Administrator shall provide the Department with the initial notice immediately after the incident becomes known. The facility Administrator was inserviced to this policy change on 7/17/12. 4. The facility has posted contact information in the employee break area as a means for them to communicate any concern which they feel remains unresolved, suspected violations of laws, or violations of company policy. All staff was re-educated on this posting on 7/17/12. 5. Effective 7/13/12, the Vice President of Operations will monitor the performance of the facility Administrator and address any noted failure to adhere to the facility policy and/or regulatory compliance and address performance accordingly.

Based on record review and interview, the facility failed to immediately report an allegation of abuse to the administrator, thoroughly investigate the allegation, and notify the Department of an allegation of abuse in a timely manner for 1 of 9 residents ( R8) reviewed for abuse in a sample of 9, and for 3 residents (R28, R32, R33) in the supplemental sample. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 7/17/12, the facility remains out of compliance at severity level two, while the facility continues to educate staff on recognizing and reporting abuse. The findings include: 1. On 7/3/12 at 1:55 PM, E1, Administrator, was made aware of an allegation of abuse with R32. E1 was told by the Department that R32 told E12 , Social Service Director, that staff was "rough" with her when they put her to bed. R32 confirmed on 7/3/12 at 12:30 PM that staff were "rough" when putting her to bed as reported to E12, Social Service Director, "a few weeks ago". E1 denied knowledge of the abuse allegation that R32 was "thrown" into bed and was "scared" but did not investigate the abuse allegation until 7/9/12. E12, Social Service Director, stated in an interview on 7/3/12 at 10:30 AM that about 2 weeks ago she had been asked to speak to R32 and R33. E12 stated when she spoke to R32 and R33 they stated afternoon staff , E14, Certified Nurse Aide (CNA), had been rough with them. E12 stated she went to E1, Administrator, and told him about the allegation and he took over from there. E12 confirmed on 7/3/12 at 1:25 PM, that she reported to E1 that staff was "rough" putting R32 to bed. E12 stated she did not document the incident and was not sure what happened after reporting the incident. E12 stated in an interview on 7/9/12 at 10:00 AM that she had not talked to R33 regarding the incident which occurred June 5 or 6 th. E12 stated in an interview on 7/12/12 at 10:10 AM that she talked to R32 on June 5th or 6th. E12 stated R32 did not state the date when staff was rough with her but R12 told E1 right after she talked to R32. R32, stated in an interview on 7/3/12 at 12:30 PM, that "a few weeks ago" an aide "threw" her in bed. R32 stated that was "all she could call it" was that the aide "threw" her. R32 stated she was in her wheelchair and the aide put her hand on R32's shoulder and back and "threw" her. R32 stated she was not sure of the aides name. R32 stated R32 was in her wheelchair and the aide picked her up and threw her in bed. R32 stated she had not had anyone do that before and it "scared" her. R32 stated E12 and E1 came in to talk to her about it and R32 thought the aide got in trouble. R32 stated she thought the aide got reprimanded because she hasn't done it since. R32 stated the aide doesn't talk to her, but she can tell the aide got in trouble. R32 was identified as "interviewable" by the facility on the facility roster. The most current Minimum (MDS) data set [DATE] identified R32 as a "15" out of 15 score for "Cognitive Patterns" score. R32 stated in an interview on 7/9/12 at 11:45 AM that she told E1 that the aide was rough with her. R32 stated E1 came in to talk to her and she told E1. R33 was present during the interview and was asked if she saw R32 thrown into bed. R33 did not answer but R32 answered for her and stated R33 did not observe the incident. E1 stated, in an interview on 7/3/12 at 1:55 PM, that E12 did not tell him R32 had said staff was rough with her. E1 stated E12 told him R32 did not want to go to bed early. E1 stated when he talked to R32 she told him she didn't want to go to bed at 6:00 PM, but did not mention staff being rough with her. E1 stated he wrote a note to tell staff not to put R32 to bed too early. E1 provided a signed, written note dated 6/5/12 that stated "Do not put her in bed until she wants to go to bed! If she wants to eat in her room, let her!" E1 stated he had not done an investigation or reported the allegation of abuse involving R32 to the Department. E1 stated there was only one abuse investigation report from June 1 through July 3 and that was for R6. E1 stated, in an interview on 7/9/12 at 10:40 AM, that he had not, as of 7/9/12 at 10:40 AM, done an abuse investigation regarding the abuse allegations with R32. E1 stated he had not done an abuse investigation because R32 did not mention staff being rough with her to him when he spoke to her on 6/5/12. E1 confirmed he did not ask R32 about the allegation on 6/5/12. E1 confirmed that he was told on 7/3/12 that an allegation of abuse had occurred with R32 by the Department. E1 confirmed he was aware R32 had alleged staff were rough with R32 and threw her into bed which scared her. E1 provided an employee schedule which confirmed E14 had worked 21 shifts since June 5 th. E1 stated, in an interview on 7/12/12 at 11:30 AM that he had waited until 7/9/12 to do the abuse investigation for R32. E1 confirmed he had been notified on 7/3/12 about the allegations of staff being rough and throwing R32. E1 stated he waited until 7/9/12 because R32 had not said to him that staff were rough or had thrown her on 6/5/12 when he had talked to her. E1 stated R32 told him on 7/9/12 that the incident happened on 6/4/12. The "Abuse Allegation Summary/Worksheet" dated 7/9/12 documented the allegation as "Staff threw me into bed". The "Evidence that doesn't support accusations" documented "CNA not working 6/4/12 when resident said she was thrown into bed". and "No staff has direct knowledge of (R32) being thrown into bed". The conclusion of the investigation was: "There is nothing to substantiate this residents allegations being thrown into bed by (E14)". E1 did identify two staff in the "Summary of Incident" and the written statements, E12 and E17, CNA. E1 identified in the summary that R32 had told staff she had been thrown her into bed or staff had been rough with her. E1 documented that both staff identified 6/4/12 as the date the incident occurred. E1 documented there was nothing to substantiate the allegations. E17 stated in an interview on 7/12/12 at 4:10 PM that she could not recall the date when R32 told her she wanted E17 to put her to bed because she was "sick and tired of being thrown into bed" by E14. E17 stated it was about a month ago. E17 stated she had not reported the allegations when R32 made that statement. The written statement dated 7/9/12 by E12 documented "(R32) told me that (E14) is rough with her when she puts her in bed. She never told me that she was thrown in bed". The written statement by E17 dated 7/9/12 documented "Has (R32) told you that any staff member has thrown her into bed? Yes. (E14) I am not sure when it was. She said she was sick and tired of being thrown into bed, I'll have you put me into bed". Review of the nurses notes and social service notes from June 1 through July 3 for R32 and R33 did not identify any allegations of abuse. Review of the abuse allegation report from June 1 through July 3, 2012 only documented 1 abuse investigation and that was for R6. 2. E1, stated in an interview on 7/2/12 at 10:00 AM that there had been one abuse investigation since 6/1/12, and that was on 6/23/12 for R8. E1 provided the file for review. On 7/2/12 at 2:50 PM, E1 stated in an interview that there had been two allegations of abuse since February, 2012. E1 stated abuse investigations were done for R6 and R8. E1 did not mention any abuse investigations regarding R28 and R32. E1 was then specifically asked if he was aware of an abuse allegation involving R28 and R31. E1 stated that morning at 4:54 AM he had received a call from E6, Licensed Practical Nurse (LPN), that R31 had a "concern" about a midnight CNA and it was investigated this morning. E1 stated it was not abuse. E1 stated E6 told him on the phone that R31 had said to her "CNA had slapped (R28)". E1 stated E6 had the CNA, E8, there and put her on the phone to talk to him. E1 stated he sent E8 home. E1 stated the reason he had not reported it to the Department was because he was "still working on it". E1 confirmed in an interview at 4:25 PM on 7/2/12 that he had not reported the abuse allegation to the Department with an initial report. E1 stated he thought he had up to 24 hours to report it. E6, LPN, stated in an interview on 7/2/12 at 3:16 PM, that on 7/2/12 at about 4:30 AM, E8, CNA, came to her and said R31 was probably going to say E8 was hitting R28. E8 told her R31 woke up and asked E8 if she was hitting R28 while E8 was giving care to R28. E6 stated she went down to talk to R31. R31 told her R28 woke her up screaming and she thought E8 was slapping R28. E6 stated R31 told her R31 had never heard R28 scream like that and E8 had told R31 that she was just changing R28. E6 stated she did not ask R28 any questions but did check her and there were no marks on her. E6 stated she called E1 and he said to send E8 home. E3, Registered Nurse, stated in an interview on 7/3/12 at 10:10 AM that he went in to check R28 at approximately 9:05 AM after E1 told him there was an allegation of abuse on R28 made by her roommate, R31. E3 stated he did a skin check and found 2 bruises on R28's stomach due to [MEDICATION NAME] shots and a fading bruise on R28's right forearm. E3 stated he did not ask R28 what had happened. R31 stated in an interview on 7/2/12 at 2:40 PM, that she was asleep and heard her roommate, R28, say "You're hurting me, you're hurting me". R31 stated R28 never says that and when she asked the aide what she was doing, the aide said she was just changing her. R31 stated she told the nurse and then E2, Director of Nursing, E3, and E1 came in to talk to her. R28 was unable to answer questions during an interview on 7/3/12 at 11:50 AM. According to the "Report to (Department) faxed to the Department on 7/2/12 at 5:24 PM the "Summary" documented "An allegation of physical abuse towards the resident by a CNA". The report for R28 documented the incident occurred on 7/2/12 at 5:00 AM. 3. The "Report to (Department) dated 6/24/12 documented an "allegation of physical abuse toward resident". According to the report, the date and time of the occurrence was 6/23/12 at 5:15 AM. Review of the "Abuse Allegation Summary/Worksheet" documented that E16 did not report the alleged abuse until 6/23/12 at 11:04 PM. E16, CNA, reported E15, CNA, was rough with R8 during a transfer. The abuse allegation initial report to the Department was not reported until 6/24/12. In a written statement dated 6/24/12 at "0150" by E16 she documented "Last night (E15) was rough with (R8). We were transferring her from bed to wheelchair. She was very rough and didn't give me a chance to help. When we went to transfer her I almost fell because she didn't take her time. When she was transferred it was too quick and (E8) knee hit the end of the bed. This happened at 0515 Saturday morning. (R8) was saying "ow" like her knee was hurt. She has a bruise on her knee, the one that got hit on the end of the bed." The "Report to (Department) dated 6/27/12 documented in the "Summary" that "(E16) CNA stated (E15) CNA was rough during a transfer with (R8) and did not take her time with the transfer. A thorough investigation was completed and (E15) CNA was found to have transferred (R8) roughly. (The facility) does not tolerate rough handling of residents. (E15) CNA was terminated from employment with (Facility) as a result of this". E1, Administrator, stated in an interview on 7/5/12 at 12:35 PM that R16 did not report the abuse allegation in a timely manner. E1 confirmed the incident occurred on 6/23/12 at 5:15 AM and was not reported until 6/23/12 at 11:04 PM. The Immediate Jeopardy situation was identified on 7/3/12 and determined to have begun on 7/3/12, when E1, Administrator, was notified of the Immediate Jeopardy on 7/12/12 at 12:25 PM. On 7/17/12, through interviews with E1, Administrator; E9, Licensed Practical Nurse; E12, Social Service Director; E21, dietary; E22, activities; E 11, E23, E26 and E27, CNAs; E24, Maintenance; E25, housekeeping; E28 and E29, Corporate Staff and review of the facility policy and inservice records, it was determined the facility took the following actions to remove the Immediate Jeopardy: 1. All facility staff including management were provided inservice to the policy and procedure regarding abuse and neglect, involuntary seclusion, misappropriation of resident property and injuries of unknown origin on 7/3, 7/5, 7/6, 7/11 and 7/12/12. 2. The Administrator was re-educated to the policy and procedure regarding abuse and neglect, involuntary seclusion, misappropriation of resident property and injuries of unknown origin on 7/12/12 by the Vice President of Operations. 3. On 7/17/12 the facility amended language to Item #64 of the abuse prohibition policy to include the reporting of incidents of abuse, neglect and incident of unknown origin to be reported immediately to the Administrator and the the Administrator shall provide the Department with the initial notice immediately after the incident becomes known. The facility Administrator was inserviced to this policy change on 7/17/12. 4. On 7/17/12, facility has implemented a system of communication follow up by the Administrator or his/her designee wherein any reporter of abuse will be notified of the initiation of investigation as verified by the reporters person interview statement. 5. Effective 7/17/12, the Administrator will make verbal follow up with any employee who made report of abuse at the conclusion of investigation. 6. The facility has posted contact information in the employee break area as a means for them to communicate any concern which they feel remains unresolved, suspected violations of laws, or violations of company policy. All staff was re-educated on this posting on 7/17/12. 7. Effective 7/13/12 the administrator will report every abuse allegation/investigation immediately to the Vice President of Operations via phone and/or e-mail and will ensure timely reporting and investigation with appropriate resolution by utilizing various worksheets and checklists. 8. Effective 7/13/12, the Vice President of Operations and/or Nursing Field Supervisor will conduct a review of the investigation and outcome to ensure al requirements are met prior to final reporting to the Department 9. Effective 7/13/12, the Vice President of Operations will monitor the performance of the facility Administrator and address any noted failure to adhere to the facility policy and/or regulatory compliance and address performance accordingly.

A) Based on interview and record review, the facility failed to develop and operationalize it's Abuse Prevention Policy to ensure proper reporting of all allegations of abuse to the Administrator and failed to recognize abuse according to the definition in their policy. This has the potential to affect all of the 74 residents living in the facility. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 5/30/12, the facility remains out of compliance at severity level two, while the facility continues to educate staff on recognizing and reporting abuse. Findings include: 1. The facility's POLICY AND PROCEDURE regarding Abuse and Neglect, Involuntary seclusion, documents under TRAINING(T) - EMPOWERMENT #23 documents that the "The Administrator (Coordinator of the Abuse Prohibition Program) will in-service all staff on the need to immediately report any signs of abuse or suspected abuse to their supervisor" and not the Administrator. 2. The facility's POLICY AND PROCEDURE regarding Abuse and neglect, Involuntary seclusion, documents that all residents have the right to be free of from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy's definition of VERBAL ABUSE is "means the use by an employee or agent of oral, written or gestured language that includes disparaging and derogatory terms to a resident or within his or her hearing or seeing distance, regardless of the resident's age, ability to comprehend or disability. The definition of Involuntary seclusion means "Separation of a resident form other residents or from his or her room or confinement to his or her room (with or without room mates) against the resident's will, or the will of the resident's legal representative. 3. On 1/26/12 E16 and E17, Certified Nurse Aids, (CNA) reported that on 1/25/12 E15, CNA, told R25 to keep his a-s in his room and that she had seen putting her fingers in R25's face and say, " you are annoying the s--t out of me. " She also allegedly placed the sit to stand mechanical device in front of his door to keep him in his room. The facility did an investigation and did not substantiate abuse, even though they had 4 witnesses that stated they had witnessed these events. E15 was allowed to continue to work on the hall where R25 resided. 4. Interviews with E16, Certified Nurses Aide (CNA) on 5/17/12 at 1:15pm indicates she reported an incident to E2, Director of Nursing, DON on 1/26/12 at 10am that happened on 1/25/12 at approximately 6am. On 5/17/12 at 2pm, E22 CNA stated in interview that she would report an incident of abuse to her supervisor and/or nurse if E1 (Administrator) was not here. Interview with E19 CNA on 5/17/12 at 2:20pm stated she would report incidents of abuse to her nursing supervisor or DON or Administrator. E23, Licensed Practical Nurse in interview of 5/18/12 at 7:45am stated she would report incidents of abuse to the DON or Administrator. E24, CNA said in interview on 5/18/12 that she would report abuse incidents to the nurse then the Administrator. 5. The Resident Census and Conditions of Residents, CMS 672, dated 5/16/12 documents that the facility has 74 residents living in the facility. The Immediate Jeopardy situation was identified on 5/30/12 and determined to have begun on 1/25/12, when E15 verbally abused and placed a mechanical device in front of R25's door. E1, Administrator, was notified of the Immediate Jeopardy on 5/30/12 at 8:40AM. Based on observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. The staff member involved was re-suspended on May 30, 2012. 2. The Abuse and Neglect policy was reviewed by the facility and Central Office Staff on May 30, 2012. 3. All staff, including the administrative staff was re-educated on abuse and neglect, including reporting, on May 30, 2012. 4. The administrator was re-educated on abuse and neglect on May 30, 2012. B) Based on interview and record review, the facility failed to develop and operationalize it's Abuse Prevention Policies to ensure proper reporting of all allegations of abuse, misappropriation of resident funds, and injuries of unknown origin to the Administrator. This has the potential to affect all of the 74 residents living in the facility. Findings include: 1. The facility POLICY AND PROCEDURE REGARDING ABUSE AND NEGLECT, INVOLUNTARY SECLUSION, MISAPPROPRIATION OF RESIDENT PROPERTY AND INJURIES OF UNKNOWN ORIGIN dated 7-1-11 documents under Identification and Injuries of Unknown Origin, "Serious injuries of unknown source, including, but not limited to, significant bruises, fractures, dislocations, lacerations, abrasions, contusions, lumps and /or severe swelling shall be reported immediately to the charge nurse, the Director of Nurses and the Administrator. The charge nurse shall document the nature of the injury in the resident's medical record and assure that the Administrator and Director of Nurses are informed of the injury. The charge nurse shall complete an Incident Report describing the injury and the circumstances surrounding the discovery of the injury..." 2. Facsimile sent to R3's Physician dated 3-2-12 documents R3 was found to have a 0.5 cm x 0.5 cm skin tear to her right elbow. There is nothing in R3's Nurses Notes addressing how the skin occurred. Nurses Note of 3-17-12 documents R3 was noted to have a 2.5 cm x 1.5 cm skin tear to R3's posterior right calf. Facsimile sent to R3's Physician dated 3-17-12 documents R3 was noted to have a 2.5 cm x 1.5 cm skin tear to the posterior right calf. There is nothing in the Nurses Notes that address how R3 obtained the skin tear. Nurses Note of 4-4-12 documents CNA informed the Nurse that R3 had abnormal area on right and left feet/ankles and was complaining of a lot of pain in the right ankle. During interview with E2, Director of Nursing (DON) on 5-16-12 at 11:10AM, E2 stated there were no investigations done concerning the for R3's skin tears and bruising of unknown origin. E2 stated there are no Incident Reports addressing the skin tears and bruising. 3. The Resident Census and Conditions of Residents, CMS 672, dated 5/16/12 documents that the facility has 74 residents living in the facility.

Based on record review and interview, the facility failed to immediately report an allegation of abuse to the administrator, thoroughly investigate the allegation, and notify the Department of an allegation of abuse in a timely manner for 1 of 9 residents ( R8) reviewed for abuse in a sample of 9, and for 3 residents (R28, R32, R33) in the supplemental sample. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 7/17/12, the facility remains out of compliance at severity level two, while the facility continues to educate staff on recognizing and reporting abuse. The findings include: 1. On 7/3/12 at 1:55 PM, E1, Administrator, was made aware of an allegation of abuse with R32. E1 was told by the Department that R32 told E12 , Social Service Director, that staff was "rough" with her when they put her to bed. R32 confirmed on 7/3/12 at 12:30 PM that staff were "rough" when putting her to bed as reported to E12, Social Service Director, "a few weeks ago". E1 denied knowledge of the abuse allegation that R32 was "thrown" into bed and was "scared" but did not investigate the abuse allegation until 7/9/12. E12, Social Service Director, stated in an interview on 7/3/12 at 10:30 AM that about 2 weeks ago she had been asked to speak to R32 and R33. E12 stated when she spoke to R32 and R33 they stated afternoon staff , E14, Certified Nurse Aide (CNA), had been rough with them. E12 stated she went to E1, Administrator, and told him about the allegation and he took over from there. E12 confirmed on 7/3/12 at 1:25 PM, that she reported to E1 that staff was "rough" putting R32 to bed. E12 stated she did not document the incident and was not sure what happened after reporting the incident. E12 stated in an interview on 7/9/12 at 10:00 AM that she had not talked to R33 regarding the incident which occurred June 5 or 6 th. E12 stated in an interview on 7/12/12 at 10:10 AM that she talked to R32 on June 5th or 6th. E12 stated R32 did not state the date when staff was rough with her but R12 told E1 right after she talked to R32. R32, stated in an interview on 7/3/12 at 12:30 PM, that "a few weeks ago" an aide "threw" her in bed. R32 stated that was "all she could call it" was that the aide "threw" her. R32 stated she was in her wheelchair and the aide put her hand on R32's shoulder and back and "threw" her. R32 stated she was not sure of the aides name. R32 stated R32 was in her wheelchair and the aide picked her up and threw her in bed. R32 stated she had not had anyone do that before and it "scared" her. R32 stated E12 and E1 came in to talk to her about it and R32 thought the aide got in trouble. R32 stated she thought the aide got reprimanded because she hasn't done it since. R32 stated the aide doesn't talk to her, but she can tell the aide got in trouble. R32 was identified as "interviewable" by the facility on the facility roster. The most current Minimum (MDS) data set [DATE] identified R32 as a "15" out of 15 score for "Cognitive Patterns" score. R32 stated in an interview on 7/9/12 at 11:45 AM that she told E1 that the aide was rough with her. R32 stated E1 came in to talk to her and she told E1. R33 was present during the interview and was asked if she saw R32 thrown into bed. R33 did not answer but R32 answered for her and stated R33 did not observe the incident. E1 stated, in an interview on 7/3/12 at 1:55 PM, that E12 did not tell him R32 had said staff was rough with her. E1 stated E12 told him R32 did not want to go to bed early. E1 stated when he talked to R32 she told him she didn't want to go to bed at 6:00 PM, but did not mention staff being rough with her. E1 stated he wrote a note to tell staff not to put R32 to bed too early. E1 provided a signed, written note dated 6/5/12 that stated "Do not put her in bed until she wants to go to bed! If she wants to eat in her room, let her!" E1 stated he had not done an investigation or reported the allegation of abuse involving R32 to the Department. E1 stated there was only one abuse investigation report from June 1 through July 3 and that was for R6. E1 stated, in an interview on 7/9/12 at 10:40 AM, that he had not, as of 7/9/12 at 10:40 AM, done an abuse investigation regarding the abuse allegations with R32. E1 stated he had not done an abuse investigation because R32 did not mention staff being rough with her to him when he spoke to her on 6/5/12. E1 confirmed he did not ask R32 about the allegation on 6/5/12. E1 confirmed that he was told on 7/3/12 that an allegation of abuse had occurred with R32 by the Department. E1 confirmed he was aware R32 had alleged staff were rough with R32 and threw her into bed which scared her. E1 provided an employee schedule which confirmed E14 had worked 21 shifts since June 5 th. E1 stated, in an interview on 7/12/12 at 11:30 AM that he had waited until 7/9/12 to do the abuse investigation for R32. E1 confirmed he had been notified on 7/3/12 about the allegations of staff being rough and throwing R32. E1 stated he waited until 7/9/12 because R32 had not said to him that staff were rough or had thrown her on 6/5/12 when he had talked to her. E1 stated R32 told him on 7/9/12 that the incident happened on 6/4/12. The "Abuse Allegation Summary/Worksheet" dated 7/9/12 documented the allegation as "Staff threw me into bed". The "Evidence that doesn't support accusations" documented "CNA not working 6/4/12 when resident said she was thrown into bed". and "No staff has direct knowledge of (R32) being thrown into bed". The conclusion of the investigation was: "There is nothing to substantiate this residents allegations being thrown into bed by (E14)". E1 did identify two staff in the "Summary of Incident" and the written statements, E12 and E17, CNA. E1 identified in the summary that R32 had told staff she had been thrown her into bed or staff had been rough with her. E1 documented that both staff identified 6/4/12 as the date the incident occurred. E1 documented there was nothing to substantiate the allegations. E17 stated in an interview on 7/12/12 at 4:10 PM that she could not recall the date when R32 told her she wanted E17 to put her to bed because she was "sick and tired of being thrown into bed" by E14. E17 stated it was about a month ago. E17 stated she had not reported the allegations when R32 made that statement. The written statement dated 7/9/12 by E12 documented "(R32) told me that (E14) is rough with her when she puts her in bed. She never told me that she was thrown in bed". The written statement by E17 dated 7/9/12 documented "Has (R32) told you that any staff member has thrown her into bed? Yes. (E14) I am not sure when it was. She said she was sick and tired of being thrown into bed, I'll have you put me into bed". Review of the nurses notes and social service notes from June 1 through July 3 for R32 and R33 did not identify any allegations of abuse. Review of the abuse allegation report from June 1 through July 3, 2012 only documented 1 abuse investigation and that was for R6. 2. E1, stated in an interview on 7/2/12 at 10:00 AM that there had been one abuse investigation since 6/1/12, and that was on 6/23/12 for R8. E1 provided the file for review. On 7/2/12 at 2:50 PM, E1 stated in an interview that there had been two allegations of abuse since February, 2012. E1 stated abuse investigations were done for R6 and R8. E1 did not mention any abuse investigations regarding R28 and R32. E1 was then specifically asked if he was aware of an abuse allegation involving R28 and R31. E1 stated that morning at 4:54 AM he had received a call from E6, Licensed Practical Nurse (LPN), that R31 had a "concern" about a midnight CNA and it was investigated this morning. E1 stated it was not abuse. E1 stated E6 told him on the phone that R31 had said to her "CNA had slapped (R28)". E1 stated E6 had the CNA, E8, there and put her on the phone to talk to him. E1 stated he sent E8 home. E1 stated the reason he had not reported it to the Department was because he was "still working on it". E1 confirmed in an interview at 4:25 PM on 7/2/12 that he had not reported the abuse allegation to the Department with an initial report. E1 stated he thought he had up to 24 hours to report it. E6, LPN, stated in an interview on 7/2/12 at 3:16 PM, that on 7/2/12 at about 4:30 AM, E8, CNA, came to her and said R31 was probably going to say E8 was hitting R28. E8 told her R31 woke up and asked E8 if she was hitting R28 while E8 was giving care to R28. E6 stated she went down to talk to R31. R31 told her R28 woke her up screaming and she thought E8 was slapping R28. E6 stated R31 told her R31 had never heard R28 scream like that and E8 had told R31 that she was just changing R28. E6 stated she did not ask R28 any questions but did check her and there were no marks on her. E6 stated she called E1 and he said to send E8 home. E3, Registered Nurse, stated in an interview on 7/3/12 at 10:10 AM that he went in to check R28 at approximately 9:05 AM after E1 told him there was an allegation of abuse on R28 made by her roommate, R31. E3 stated he did a skin check and found 2 bruises on R28's stomach due to [MEDICATION NAME] shots and a fading bruise on R28's right forearm. E3 stated he did not ask R28 what had happened. R31 stated in an interview on 7/2/12 at 2:40 PM, that she was asleep and heard her roommate, R28, say "You're hurting me, you're hurting me". R31 stated R28 never says that and when she asked the aide what she was doing, the aide said she was just changing her. R31 stated she told the nurse and then E2, Director of Nursing, E3, and E1 came in to talk to her. R28 was unable to answer questions during an interview on 7/3/12 at 11:50 AM. According to the "Report to (Department) faxed to the Department on 7/2/12 at 5:24 PM the "Summary" documented "An allegation of physical abuse towards the resident by a CNA". The report for R28 documented the incident occurred on 7/2/12 at 5:00 AM. 3. The "Report to (Department) dated 6/24/12 documented an "allegation of physical abuse toward resident". According to the report, the date and time of the occurrence was 6/23/12 at 5:15 AM. Review of the "Abuse Allegation Summary/Worksheet" documented that E16 did not report the alleged abuse until 6/23/12 at 11:04 PM. E16, CNA, reported E15, CNA, was rough with R8 during a transfer. The abuse allegation initial report to the Department was not reported until 6/24/12. In a written statement dated 6/24/12 at "0150" by E16 she documented "Last night (E15) was rough with (R8). We were transferring her from bed to wheelchair. She was very rough and didn't give me a chance to help. When we went to transfer her I almost fell because she didn't take her time. When she was transferred it was too quick and (E8) knee hit the end of the bed. This happened at 0515 Saturday morning. (R8) was saying "ow" like her knee was hurt. She has a bruise on her knee, the one that got hit on the end of the bed." The "Report to (Department) dated 6/27/12 documented in the "Summary" that "(E16) CNA stated (E15) CNA was rough during a transfer with (R8) and did not take her time with the transfer. A thorough investigation was completed and (E15) CNA was found to have transferred (R8) roughly. (The facility) does not tolerate rough handling of residents. (E15) CNA was terminated from employment with (Facility) as a result of this". E1, Administrator, stated in an interview on 7/5/12 at 12:35 PM that R16 did not report the abuse allegation in a timely manner. E1 confirmed the incident occurred on 6/23/12 at 5:15 AM and was not reported until 6/23/12 at 11:04 PM. The Immediate Jeopardy situation was identified on 7/3/12 and determined to have begun on 7/3/12, when E1, Administrator, was notified of the Immediate Jeopardy on 7/12/12 at 12:25 PM. On 7/17/12, through interviews with E1, Administrator; E9, Licensed Practical Nurse; E12, Social Service Director; E21, dietary; E22, activities; E 11, E23, E26 and E27, CNAs; E24, Maintenance; E25, housekeeping; E28 and E29, Corporate Staff and review of the facility policy and inservice records, it was determined the facility took the following actions to remove the Immediate Jeopardy: 1. All facility staff including management were provided inservice to the policy and procedure regarding abuse and neglect, involuntary seclusion, misappropriation of resident property and injuries of unknown origin on 7/3, 7/5, 7/6, 7/11 and 7/12/12. 2. The Administrator was re-educated to the policy and procedure regarding abuse and neglect, involuntary seclusion, misappropriation of resident property and injuries of unknown origin on 7/12/12 by the Vice President of Operations. 3. On 7/17/12 the facility amended language to Item #64 of the abuse prohibition policy to include the reporting of incidents of abuse, neglect and incident of unknown origin to be reported immediately to the Administrator and the the Administrator shall provide the Department with the initial notice immediately after the incident becomes known. The facility Administrator was inserviced to this policy change on 7/17/12. 4. On 7/17/12, facility has implemented a system of communication follow up by the Administrator or his/her designee wherein any reporter of abuse will be notified of the initiation of investigation as verified by the reporters person interview statement. 5. Effective 7/17/12, the Administrator will make verbal follow up with any employee who made report of abuse at the conclusion of investigation. 6. The facility has posted contact information in the employee break area as a means for them to communicate any concern which they feel remains unresolved, suspected violations of laws, or violations of company policy. All staff was re-educated on this posting on 7/17/12. 7. Effective 7/13/12 the administrator will report every abuse allegation/investigation immediately to the Vice President of Operations via phone and/or e-mail and will ensure timely reporting and investigation with appropriate resolution by utilizing various worksheets and checklists. 8. Effective 7/13/12, the Vice President of Operations and/or Nursing Field Supervisor will conduct a review of the investigation and outcome to ensure al requirements are met prior to final reporting to the Department 9. Effective 7/13/12, the Vice President of Operations will monitor the performance of the facility Administrator and address any noted failure to adhere to the facility policy and/or regulatory compliance and address performance accordingly.

A) Based on interviews and record review, the facility failed to report an alleged abuse to the Administrator in a timely manner for 1 of 4 residents (R25) reviewed for abuse investigations reviewed in the supplemental sample. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 5/30/12, the facility remains out of compliance at severity level two, while the facility continues to educate staff on recognizing and reporting abuse. Findings include: An Abuse Allegation Summary/Worksheet dated 1/26/12 documents 2 (E16 and E17) Certified Nurses Aides (CNA) overheard E15, CNA tell R25 to "get his a-- back to his room because" she was "tired of dealing with him." The allegation also alleged that a sit to standing device was moved in front of his bedroom door so he couldn't "leave his room." The worksheet does not identify when the incident occurred but indicates it was reported at 10:25am on 1/26/12. In interview on 5/17/12 at 1:15pm, E16 stated she observed the incident between E15 and R25 the day before she reported it (1/25/12) and that after her and E17 talked about it the morning of 1/26/12, decided it was abuse and needed to be reported. On 5/17/12 at 1pm in interview, E1 Administrator confirmed that the incident occurred at shift changed on 1/25/12 and wasn't reported until 10am the next day on 1/26/12. B) Based on record review and interview, the facility failed to investigate injuries of unknown origin for 1 of 4 (R3) residents reviewed for abrasions and bruising in the sample of 15. Findings include: R3's most current Minimum Data Set (MDS) of 5-7-12 identifies R2 as having cognitive impairment and being totally dependent on 2 or more staff for transfer. Facsimile sent to R3's Physician dated 3-2-12 documents R3 was found to have a 0.5 cm x 0.5 cm skin tear to her right elbow. There is nothing in R3's Nurses Notes addressing the skin tear. Nurses Note of 3-17-12 documents R3 was noted to have a 2.5 cm x 1.5 cm skin tear to R3's posterior right calf. Facsimile sent to R3's Physician dated 3-17-12 documents R3 was noted to have a 2.5 cm x 1.5 cm skin tear to the posterior right calf. Nurses Note of 4-4-12 documents CNA informed the Nurse that R3 had abnormal area on right and left feet/ankles and was complaining of a lot of pain in the right ankle. The left foot was noted to dried blood between 4th and and 5th digit and under 5th digit. Bruising also between 4 and 5 digits and on top of left foot. A 1.2 cm cut was noted between the 4th and 5th digit. On the right foot the lateral right heel had a 1 cm x 2 cm purple bruise and the ankle was swollen. R3 was unable to move ankle/foot due to expressing pain. Nurses Notes document the Hospice Nurse was in the facility and was notified of findings and unknown origin. R3's Power of Attorney was in the facility and asked to see the areas. "Upset about unknown origin." During interview with E2, Director of Nursing (DON) on 5-16-12 at 11:10AM, E2 stated there were no investigation of incidents of unknown origin for R3 during the past year. E2 stated she was informed of R3's feet injuries on on 4-4-12 and determined it must have occurred from the mechanical standing lift. E2 stated there was no incident report filled out. During interview with E2 on 5-17-12 at 9:45AM E2 stated E8 and E9, CNA's, were the ones who found R3's injuries on 4-4-12. E2 doesn't know who would have transferred R3 on the standing mechanical lift causing the injuries. The Immediate Jeopardy situation was identified on 5/30/12 and determined to have begun on 1/25/12, when E15 verbally abused and placed a mechanical device in front of R25's door. E1, Administrator, was notified of the Immediate Jeopardy on 5/30/12 at 8:40AM. Based on observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. The staff member involved was re-suspended on May 30, 2012. 2. The Abuse and Neglect policy was reviewed by the facility and Central Office Staff on May 30, 2012. 3. All staff, including the administrative staff was re-educated on abuse and neglect, including reporting, on May 30, 2012. 4. The administrator was re-educated on abuse and neglect on May 30, 2012. 5. The investigation was reviewed on May 30, 2012.

Based on interview, observations and record review, the facility failed to prevent verbal abuse and involuntary seclusion for 1 of 4 residents (R25) reviewed for abuse investigations in the supplemental sample. This failure resulted in R25 being verbally abused and place in involuntary seclusion. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 5/30/12, the facility remains out of compliance at severity level two, while the facility continues to educate staff on recognizing and reporting abuse. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE], R25 is an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Mood/Behaviors also indicates he has feelings of being down, depressed or hopeless on half or more of the days. R25 resides on the closed Dementia unit. An Abuse Allegation Summary/Worksheet dated 1/26/12 documents 2 (E16 and E17) Certified Nurses Aides (CNA) overheard E15, CNA tell R25 to "get his a-- back to his room because" she was "tired of dealing with him." The allegation also alleged that a sit to standing device was moved in front of his bedroom door so he "couldn't leave his room." The worksheet does not identify when the incident occurred but indicates it was reported at 10:25am on 1/26/12. The list of evidence documents that the accusations also included seeing a "sit to stand parked in front of room while resident was in room. Staff heard (E15) raise her voice to R25 to go back to room." Interviews conducted during the investigation by E1, Administrator on 1/26/12 with E16 and E17 indicated that E16 stated E15 told R25 to back to his room and take his "a-- back to his room because she is tired of dealing with him. She (E15) also parks the sit to stand in front of his room door to block him in his room." E17 documented at 1330 (1:30pm) "E15 told R25 to keep his a-- in his room. I have seen her put her fingers in his face and say "you are annoying the s--t out of me." Both were signed by the CNAs and Administrator, E1. Additional statement from E19, CNA on 1/26/12 documents "E15 stated to CNA that she was tired of his bulls--t and following her around getting on her nerves" and when asked about the sit to stand blocking his doorway, wrote "yes, same day as CNA stated was tired of him." On 1/27/12 at 10:45am, E20, CNA wrote she heard comments by E15 for R25 to get back to his room as she is tired of dealing with him also documenting that "her tone was raised." When asked about the sit to stand, E20 stated "Yes, I don't know if the wheels were locked on the sit to stand. I was relieving E15 on break. R25 was in his room walking around. I moved the sit to stand away from his doorway." A statement by E15 on 1/30/12 at 11am documents that when asked about raising her voice at R25 wrote "I have because there was water or something on the floor. He wasn't listening so I did raise by voice to keep him from slipping when he opens other resident's door I tell he him can't come in and he says "Huh." so I raise my voice so he can hear me. When asked about blocking his door, E15 reported that she had, there was a puddle of urine on the floor and he would stay out of the area so I could clean it up so he wouldn't fall or slip in it." Written statements gathered by the facility from both E16 and E17 fail to include observations of puddles under the sit to stand in the doorway. In interview on 5/17/12 at 1:15pm, E16 CNA stated she observed the incident between E15 and R25 the day before she reported it and you could really tell that E15 was aggravated by R25 that morning. The incident occurred at change of shift as they were coming down the hall and E15 was leaving. E16 stated she observed E15 put her finger in his face and state "get your a-- back in your room." At 1:37pm, E16 also observed the sit to stand parked in front of R25's door that prevented him from coming out of his room which she considered a "restraint." E16 identified the behavior observed as "abusive" and stated that was why she reported it. On 5/17/12 at 2:10pm, E17 stated she heard and saw E15 point her finger in R25's face and say "get your a-- back in your room, I'm sick of looking at you." E17 also confirmed that the sit to stand placed by E15 earlier was blocking R25's doorway preventing him from coming out of his room. E17 did not note a puddle being present underneath it. E17 identified the behavior she observed from E15 toward R25 was abusive and that it included preventing him from coming out of his room. On 5/15/12 at 10am, R25 was observed to be ambulating independently in the hallway of the unit and continued to do so throughout the survey. R25 was also observed to follow staff up and down the hallway during the day. On 5/17/12 at 2:20pm, E20 CNA stated E15 told her on midnight shift that she got tired of R25 following her up and down the hall and had noted the sit to stand parked in front of his doorway. She stated she told R15 that she couldn't do that and removed the sit to stand from the doorway. E25 stated she has overheard E15 talking to others roughly too but was unable to provide names, times as she only works midnights occasionally. E20 stated she would agree that it was abusive behavior and didn't understand why E15 was left on the dementia hall after the incident occurred with R25. When asked if she had reported any of the incidents she observed, stated no but others had. The facility's POLICY AND PROCEDURE regarding Abuse and neglect, Involuntary seclusion, documents that all residents have the right to be free of from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy's definition of VERBAL ABUSE is "means the use by an employee or agent of oral, written or gestured language that includes disparaging and derogatory terms to a resident or within his or her hearing or seeing distance, regardless of the resident's age, ability to comprehend or disability. The definition of Involuntary seclusion means "Separation of a resident form other residents or from his or her room or confinement to his or her room (with or without room mates) against the resident's will, or the will of the resident's legal representative. On 5/17/12 at 1pm in interview, E1 Administrator was asked why he would determine that the incident wasn't abusive when it fit the facility's definition? He stated there was animosity between E15 and E20 but agreed that the allegations and observations were actually made by E16 and E17. E 1 agreed that the alleged incident occurred on the morning of 1/25/12 and not on 1/26/12 and confirmed that E15 was overheard by E16 and E17 but E15 denied it. E1 stated E15 had left the morning of the incident following her shift and was suspended pending the investigation on 1/26/12. E1 stated she returned to work and worked on the same dementia unit until just a few weeks ago. E1 stated E15 was not inserviced and/or disciplined in regards to the incident on 1/25/12. On 5/31/12, at 1:20pm, E1 stated that E15 requested to be transferred to the evening shift. He could not give an exact date. E15 put on the schedule to work the evening shift and was scheduled for all halls in the facility starting 3/25/12. The staffing sheet documents E15 worked on the dementia unit 5/20, 5/23,5/27, 5/29 and 5/30/12. Review of R25's care plan on 5/30/12 fails to reflect any information reflecting that R25 is at risk for abuse due to his wandering and following behaviors. The Immediate Jeopardy situation was identified on 5/30/12 and determined to have begun on 1/25/12, when E15 verbally abused and placed a mechanical device in front of R25's door. E1, Administrator, was notified of the Immediate Jeopardy on 5/30/12 at 8:40AM. Based on observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. The staff member involved was re-suspended on May 30, 2012. 2. The Abuse and Neglect policy was reviewed by the facility and Central Office Staff on May 30, 2012. 3. All staff, including the administrative staff was re-educated on abuse and neglect on May 30, 2012. 4. The administrator was re-educated on abuse and neglect on May 30, 2012. 5. The investigation was reviewed on May 30, 2012. 6. The resident's care plan was reviewed and updated on May 30, 2012.

Based on observation, record review, and interview, the facility failed to comprehensively assess, determine causes of weight loss, develop interventions, re-evaluate the effectiveness of interventions, and attempt alternative interventions to prevent further weight loss from occurring for 2 (R3, and R11) of 9 residents reviewed for weight/nutrition concerns in the sample of 15. This failure resulted in R1 and R11 experiencing unplanned significant weight loss. Findings include: 1. R3's Minimum Data Set (MDS) of 4-20-11 documents he requires tray set up supervision at meals. R3's Physician order [REDACTED]. R3 has an order for [REDACTED]. R3's Nutritional assessment of 3-31-11 identifies R3 as being admitted to the facility on [DATE] with a weight of 157 lbs, and readmitted on [DATE] with a weight of 151.2 lbs. The Nutritional Assessment documents R3 is 5'9" tall with a desirable weight range (DWR) of 129 - 183 lbs. The Nutrional Assessment documents estimated total calories needs at 1718 cal, 69 gram of protein and 2062 cc's fluid a day. The Dietitian note of 4-11-11 documents readmitted on [DATE] after hospitalization for urosepsis. Weight is down 3.7% to 151.2 lbs secondary to recent illness. Weight remains within his DWR. Oral food intake is fluctuating 60 - 75% and adequate to maintain weight. The recommendation was made to continue general diet and add daily multivitamin with iron. and monitor weight and intake. The next note is written 4-9-11 stating weighted silverware was added to general diet. The Facility weight records document R3 weighed 157 lbs in March 2011, 151.9 lbs in April 2011 and 149.3 lbs. in May 2011. R3's June 2011 was recorded as 144.8 lbs. R3's Hospital History and Physical of 5-31-11 documents he was admitted to the hospital on 5-31-11 with Urosepsis and Urinary Tract Infection. The Nurses Notes document he was readmitted back to the facility on [DATE] and had pressure sores. There is no further Nutritional Assessment as of 6-10-11 addressing R3's Nutritional Needs required to aide in healing pressure sore, weight loss, or recent hospitalization for Urinary Tract Infection and Urosepsis. R3's current Care Plan does not address weight loss or pressure sores. There are no interventions to prevent further weight loss. R3 was observed on 6-7-11 at the noon meal to be eating food in his room that his wife brought in. He did not have any other fluids, and the only water to drink was from the pitcher in his room. R3 was observed at noon meal on 6-8-11 to only eat his pudding. E8, Certified Nurse Aide, CNA, stated he usually only eats his dessert. E27, Nurse Aide, stated he ate 100% at breakfast. On 6-9-11, R3 was observed to eat his noon meal. R3 received his tray at 12:25PM and his 2% milk and yogurt were not opened. R3 was observed to eat his cake. At 12:45PM, E28, CNA, was observed to to come to the table and feed R3. R3 consumed 100% of his meat and 60% of his carrots and cake. On 6-9-11, at 10:30AM, E2, Corporate Nurse, was informed of concern of R3 having a significant unplanned weight loss and pressure sores and a lack of Nutritional Assessment and Care Plan addressing his weight loss and needs to aide in healing pressure sores. On 6-13-11, the Registered Dietitian (RD) assessed R3's Nutritional needs. The Nutritional Assessment documents R3's weight as 144.8 lbs, and R3 as being on a limited concentrated diet. Assessment shows a low [MEDICATION NAME] at 2.4 mg/dl. Total protein is 6.2 (within normal limits). The Nutritional Assessment documents a significant weight loss, and two stage 2 pressure sores on his coccyx, one on right ischium and an unstageable pressure sore on his heel. Estimated daily nutritional needs are 1974 calories, 92.1 gram of protein and 1975 cc's of fluid a day. A Note is written documenting, "Weight in June 144.8 (-3% x 1 mo, -7.8% x 3 mos.) ...Wife brings in supper meal at times & he sometimes eats what she brings in rather than the menued meal which may not be the same nutritionally. RD did interview resident, he said he doesn't like the ground meat it all tastes the same. He doesn't like the weighted silverware & OT (Occupational Therapy) is looking into this. He would like an AM & PM snack, & d/t (due to) skin integrity recommend 30 ml Liquid protein supplement BID (twice a day). Monitor wt, intake & hydration refer to RD prn (as needed). Will leave note for nursing to ask for Speech Therapy review & possible upgrade in texture." 2. R11 was observed at noon meal on 6-7-11 to receive mashed potatoes/gravy, pudding dessert, cantaloupe and a large glass of water. R11 was observed to sleep with his head down and eat only a couple bites of his pudding dessert. At 1:35PM, R11 was observed to propel his wheel chair from the dining room. E29, Nurse Aide, asked him if he was done. R11 was not offered any substitutions or encouragement to eat. On 6-8-11, R11 was observed through out the morning to be sitting in his recliner slumped over with his feet on the floor and sleeping. R11 was observed sleeping in his bed during the noon meal. E24 and E25, CNA's, stated he didn't want to eat. He stated he was tired and wanted to go to bed. They stated R11 eats a big breakfast and often refuses lunch. The Facility weight records docuemnt R11 weighed 159.7 lbs in January 2011 and was down to 142.4 lbs in May 2011. R11's June 2011 POS documents a diagnoses, in part, Diabetes Mellitus. The POS documents a regular diet, and order of 4-20-11 for 60 cc of Med Pass Supplement BID (twice a day). The MDS of 4-11-11 identifies R11 as being independent with eating and being 5'5" tall and weighing 149 lbs. The Physician Note of 4-18-11 documents per CNA - eats everything. R11's current Nutritional Assessment of 7-21-10 documents R11 was admitted on [DATE], and weight is 147.6 lbs with a DWR of 115 - 162 lbs. R11 has a stage 2 pressure sore. There is no documentation of R11's calorie, protein or fluid needs. A Note is written that a general diet is adequate to meet estimated nutrition needs. A Recommendation for a multiple vitamin to help heal area. The Note of 8-18-10 documents R11 weighed 157.6 lbs, and had a possible wrong admission weight. The RD note of 3-10-11 documents weight in March 2011 as 149 lbs a 5.5%/8.7 lb. loss in 1 month. The weight loss is due to initiation of [MEDICATION NAME]. A Note of 5-18-11 documents May 2011 weight is 142.4 lbs a 9.7 % x 3 months loss and 9.1 % x 6 months loss. The Note documents "Due to h/o (history of) pressure ulcers, & cont'd gradual decline in meal intake suggest daily MVI (multiple vitamin with iron) & increase med pass supplement to 60cc TID (three times a day). Monitor for further wt loss & need for changes in intervention." There is nothing in R11's current Care Plan addressing weight loss or nutritional needs. There are no interventions to prevent further weight loss. Record review of R11's June 2011 POS on 6-9-11 documents the facility failed to get an order for [REDACTED]. This was confirmed with E2 on 6-9-11 when E2 was informed of concern of poor food intake and RD's recommendations not being followed. E2 was also informed of [MEDICATION NAME] ordered in April with side effects documented on his [MEDICAL CONDITION] Medication Consent form as sedation, confusion, loss of appetite, weight loss and drowsiness. The RD Note of 6-13-11 documents R11 was referred d/t cont'd wt loss, June wt 135.9 lbs (-4.6% x 1 month, - 8.8% x 3 mos and - 15.4 % x 6 months. "Oral food intake is inadequate, avg (average) 36%...RD did interview resident & he says he just is not hungry & doesn't need anything. Meds reviewed & [MEDICATION NAME] is being decreased to 25 mg. Staff report resident has been sleeping a lot & decrease in [MEDICATION NAME] may help him not be so sleepy. Recommend continue diet as ordered, MD may wish to consider [MEDICATION NAME] to stimulate appetite. R11 does take the med pass & does not eat hot cereal @ B (so no increased pro (protein) cereal) as a supplement. He does like cookies & milk & I will leave a note for dietary to send an am snack. Diet includes 60 cc med pass tid (three times a day) (360 cal, 15 g protein). Monitor wt, intake & refer prn. addendum: He continues on 2 diuretics which may have contributed to his wt loss; & now has a healing st (stage) II ulcer on his L knee. He does have dementia & does not understand that his weight loss is a problem."

Based on observation, record review and interview, the facility failed to provide monitor, assess, provide appropriate catheter care, appropriate incontinent care, and toileting for 6 (R2, R3, R4, R6, R7 and R11) of 7 residents reviewed for urinary tract infection and incontinent/catheter care in the sample of 9 and 4 supplemental residents (R12, R13, R14, R15). Findings include: 1. It is documented on R3's Hospital History &Physical (H&P) of 7-8-11, "Chief Complaint: [MEDICAL CONDITION] secondary to urinary tract infection; altered mental status; [MEDICAL CONDITION] causing the urinary tract infection..." The H&P documents, "In the nursing home, he had developed [MEDICAL CONDITION] and had a Foley catheter placed. He had been doing quite well with this, but wanted the catheter out. Last week he was treated for [REDACTED]. From that date on, he had had no urinary output and became quite confused, delirious. He was crying out in pain at the nursing home and was pulling at his penis. He came to the hospital. In the hospital emergency room , a Foley catheter was placed. Dark, thick, pus - laden urine was evacuated, over 1000 cc of fluid returned in the Foley catheter bag. The patient was admitted for a urinary tract infection,[MEDICAL CONDITION], and altered mental status." R3's Nurses Notes of 7-5-11 documents at 1930, R3's urinary catheter was not draining but patent. "Attempted irrigation without success. Called MD (Medical Doctor), gave order st DC (discontinue) Foley now. This was done and Resident has urinated in stool x 3 this evening, but unable to determine how much." R3's MEDICARE FLOWSHEET of 7-6-11 documents yellow urine and incontinent with a line drawn next to abdominal distention. Nurses Note of 7-6-11 at 0145 states R3 is resting, quiet at this time and no complaints of pain or discomfort. Incontinent care given. Temperature is recorded at 97.6 Fahrenheit. Note at 1400 states R3 was given pain pill due to lower abdominal pain. Depends wet x 3 this shift. Note at 2130 states R3 is having lower abdominal pain. Tylenol was given and worked well. Temperature 98.6. R3's MEDICARE FLOWSHEET of 7-7-11 documents yellow urine and a line drawn by abdominal distention and a line drawn through pain control. Nurse Note of 7-7-11 at 0130 document that R3 was resting quietly in bed with no complaint of pain or discomfort voiced. Temperature is recorded at 98. The next Nurses Note is written at 2115 stating CNA's (Certified Nurse Aides) unable to change resident clothing due to agitation. skin warm and clammy, pale. Unable to understand resident. R3 is thrashing around in bed. When asked if he was in pain he did say yes and grabbed his groin ares. Call placed to Z1 (R3's Physician) and orders to send to ER. Temperature was documented as 100.2. R3's INTAKE & OUTPUT FLOW SHEET for July 6 documents R3 urinated 7 times. July 7 th documents 6 times. There is nothing in R3's medical record that documents amount of urine R3 voided. During interview with E13, CNA, on 7-26-11, E13 stated she took care of R3 when his catheter was removed. She stated at first he would tell staff when he needed to go to the bathroom. She stated she could not tell if he urinated, how much or color because he would flush the toilet before staff could see. She states he has always flushed the toilet right even after a bowel movement, ever since he was admitted to the facility. E13 stated he later was urinating in his incontinent brief. She stated the incontinent brief would be a little wet in front with reddish colored urine. Record review of R3's Care Plan of 4-29-11 documents R3 has an indwelling catheter related to physician [DIAGNOSES REDACTED]. There is nothing on R3's Care Plan addressing a plan of care for when his catheter was removed and interventions for monitoring urine output, consistency, color and odor and [MEDICAL CONDITION]. Record review of NURSE AIDE'S INFORMATION SHEET that is used by the CNA's for information on caring for R3 shows there was no documentation addressing his catheter removal. On 7-27-11 at 12:35PM, E11, Care Plan Coordinator stated she did not care plan for the removal of R3's urinary catheter. "It was out only a few days before he went to the hospital. He then came back with orders to not remove the Foley so at that time it was a moot point." On 7-27-11 at 1:30PM, E2, Director of Nursing, stated the facility does not have a Policy and Procedure for assessing and monitoring a resident for [MEDICAL CONDITION] after the removal of a urinary catheter. E2 stated they possibly could have used a hat in the toilet or a urinal to monitor R3's urine. Hospital Emergency Department Physical Exam of 7-7-11 states history of UTI and is on Cipro. "Tender suprapubic/swelling...Dry mucous membrane" ER Physician Diagnoses; included, in part, UTI [MEDICAL CONDITION]. R3's Laboratory tests of 7-7-11 at 2230 show elevated Blood Urea Nitrogen at 41 mg/dl (normal 7 -18), elevated BUN at 1.4 mg/dl (normal 0.6 - 1.3), elevated White Blood Count at 11.8 UL (normal 4.8 - 10.8). Urinalysis of 7-7-11 at 2308 shows turbid urine with protein, and 4 + bacteria, amber color. Culture and Sensitivity shows >100,000 col/ml of Proteus mirabilis. During interview with Z1, R3's Physician, on 7-26-11 at 11AM, Z1 stated she would expect the facility to monitor urine output very closely for R3 when his catheter was removed due to his history of UTI, [MEDICAL CONDITION] and Urosepsis. The facility did not call until no urine output for 1 day. With his history it was a little to late. Z1 stated she was reluctant to remove the catheter but R3 was so insistent. Z1 stated it would be good if the facility would respond more quickly. 2. R11's July 2011 Physician order [REDACTED]. R11's Care Plan of 7-11-11 identifies R11 as being incontinent of urine with intervention to assist with perineal care after every incontinent episode. R11 was observed on 7-22-11 at 11:15AM to be transferred to the toilet by E14 and E15, CNA's. R11's incontinent brief was saturated with urine and had feces smears. R11 had a bowel movement and urinated when toileted. E15 washed R11's buttocks and anal area, but failed to wash his penis, scrotum and front abdominal area that had been soiled with urine. 3. R4's July 2011 POS shows she has a urinary catheter and a history of UTI. On 7-22-11 at 12:15AM, E14, CNA, was observed to empty R4's urinary catheter bag while R4 was lying in bed. E14 put the urinal on R4's bed and then lifted the urinary catheter above R4's bladder to drain the bag. There was urine in the urinary tubing that flowed back towards the bladder. E14 and E15 then transferred R4 from her bed to her wheel chair using a mechanical sling lift. E15 hooked R4's catheter bag on the mechanical sling lift hook, placing the bag about two feet above R4's bladder. The urine in the tubing was observed to back flow towards the bladder. R4 was observed to unhook the catheter bag from the lift hook and hold the bag down below her bladder at her side. 4. According to the MDS (6/9/11), R7 has short/long term memory deficits with moderate cognitive impairment. The MDS indicates R7 requires limited assist of one staff for mobility, hygiene and is always incontinent of urine and bowel. The care plan dated 6/15/11 identifies R7 's bladder incontinence due to the disease process, inability to communicate needs and decrease in functioning functioning. The stated goal is "will have fewer episodes of incontinence through next review" with interventions as On 7/22/11 at 10am, R7 was sitting in her wheelchair in the dining room of the Alzheimer's Unit. R7 was observed at 10:20am, 10:30am, 10:45am, 11:03am, 11:10am, 11:20am, 11:28am, 11:40am and at 12 noon. At 12:05pm, R7 was taken to the shower room to be toileted by E7 and E9, Certified Nurses Aides who stated they last toileted and repositioned her between 8:30am and 8:45am. R7 was then taken to her room and laid down by E8 and E9, CNA's. E10, Licensed Practical Nurse (LPN) was in attendance both in the bathroom and the bedroom. R7's incontinent brief was soaked with urine and had feces smeared crossed it. Her outer pants were soaked with urine. E8 gave poor incontinent care as she wiped numerous times front to back with the same wash cloth as R7 continued to ooze bowel movement. E8 only cleansed the inner buttocks and rectal area and provided no cleansing to the perineal/labial area, hips, or groin. A clean incontinent brief was then applied. All staff attending to R7 appeared to be unaware that she was on a plan to decrease her bladder incontinence. 5. According to the MDS dated [DATE], R2 requires limited assist of one staff for transfers and mobility, hygiene/bathing and is occasionally incontinent of bowel movement and frequently incontinent of urine. The Admission sheet indicates R2 has a history of urinary tract infections. The care plan dated 6/15/11 identifies her incontinence due to inability to communicate needs and disease process. The goal is for R2 to be incontinent less than 50% of the time with interventions being: Restorative program, establish voiding patterns, provide perineal care after every incontinent episode, and monitor for UTI's (urinary tract infections.) On 7/22/11 at 10am, R2 was observed in her wheelchair in the dining area of the unit. She was observed at 10:20am, 10:30am, 10:45am, 11:03am, 11:10am, 11:20am, 11:28am, 11:40am and at 11:50 am, E7 and E9 transferred R2 to the toilet. E9 confirmed that her incontinent brief was wet with urine. Both CAN's stated they last toileted R2 between 8:30am and 8:45am. E7 wet the wash cloth and handed it over to E9 who wiped R2's rectal/inner buttocks area. No soap was observed to be applied and/or used during the incontinent care. E9 wiped R2 several times from the back with two different cloths, neither had soap on them, then placed a dry incontinent brief. No cleansing was done to R2's perineal area, groin, buttocks or inner thighs. 6. R6's Minimum Data Set (MDS), dated [DATE], documented R6 was totally dependent on two plus persons on physical assistance with transfer and toileting and limited assistance of one person physical assistance with mobility. It was also noted R6 was at risk for pressure sore development. R6's Ulcer Care Plan - Treatment Plan, dated 7-9-11, document a 2.0cm x 2.0cm open area on her right ischial. It was also noted R6 was to be positioned at least every two hours. R6's Care Plan, target date 8-7-11, documented R6 was at risk for skin breakdown related to decreased mobility. It was also noted R6 was to be offered toileting more often and encouraged fluids. During observation of R6's turning and repositioning, on 7-16-11, R6 was observed from 9:27a.m. to 10:00a.m. sitting up in her wheel chair without being turned and repositioned or offered toileting. E4 and E5 were observed, on 7-16-11 at 10:00a.m., placing a sling under R6 and lifting her up from her wheel chair with a mechanical lifting device. R6 remained in the sling for less than two minutes before E4 and E5 lowered her back in her wheel chair. R6 continued to be observed without turning and repositioning or toileting until 12:00p.m and until she left the facility to go to an physician's appointment. During an interview with E2, on 7-27-11 at 11:40a.m., E2 stated R6 would be turned and repositioned and toileted "upon rounding...around every two hours." 7. Additional examples of residents sitting from 10am through lunch when the observation ended at 12:24pm include R12, R13, R14, R15 - all residents were in a wheelchair. All residents except R15 were identified at risk of developing pressure ulcers and have a pressure ulcer prevention plan in their care plan which includes toileting before and after meals as an intervention under pressure ulcer prevention. All residents reside on the Dementia unit of the facility.

Based on observation, record review and interview, the facility failed to have a plan of care to prevent and assess for Urinary Tract Infection [MEDICAL CONDITION]/Urosepsis for 1 (R3) of 5 residents with catheters, and failed to provide appropriate catheter care, appropriate incontinent care, and toileting for 6 (R1, R2, R3, R4, R7, and R9) of 7 residents observed for incontinent/catherer care on the sample of 15. This failure resulted in R3 being admitted to the hospital twice with a UTI and Urosepsis. Findings include: 1. R3's Nurse Notes document that R3 was admitted to the facility on [DATE]. MEDICARE DAILY FLOWSHEET's from 3-6-11 thru 3-13-11 under Mood/Behavior documents "Pleasant". On 3-13-11 "flat" is documented. The Flowsheet for 3-14-11 is left blank (no documentation). On 3-15-11 "Quiet" is documented. The Flow sheets from 3-7-11 thru 3-10-11 show documentation for Orientation, R3 was oriented x 2. Documentation on 3-11-11 shows, "alert". Documentation on 3-12-11 oriented x 2. 3-13-11 shows x oriented x 1. There is no documentation for 3-14-11 and 3-15-11 documents "alert to self." Document for elimination shows urine is yellow and no abdominal distention from 3-6-11 thru 3-15-11, with no documentation on 3-14-11. R3's Nutritional Intake Flowsheet from 3-5-11 to 3-15-11 show R3 started to have a decline in food intake on 3-12-11 with no food or fluid intake at breakfast - Lunch - 3 bites 240 cc's fluid - Supper 10% with only 60 cc's of fluid intake. 3-13-11 shows Breakfast - 25% food intake with 420 cc's fluid - lunch 10% with 480 cc's fluid and 0% food intake at supper with 480 cc's of fluid. 3-14-11 shows few bites at breakfast with 360 cc's fluid - lunch 0% food and fluids - supper 0% with 240 cc's of fluids. 5-15-11 breakfast shows no food or fluid intake. (There is nothing in R3's Nurses Notes identifing decreased intake.) The Nurses Note of 3-13-11 at 1720 documents R3 is agitated in bed. Restless behavior, tugging at clothes, reaching into the air. Physician called at 1700 to report change in condition. Blood sugar at 385. New order given. (POS shows an order for [REDACTED]. The Nurses Note on 3-15-11 at 0920 document R3 has low grade temperature of 98.9. Lungs diminished. Tremors from [MEDICAL CONDITION]. Appetite poor. Fluids encouraged but intake is poor. Notified Doctors office. The Note at 0945 documents to send to emergency room (ER). R3's Hospital History and Physical (H&P) of 3-15-11 documents Chief Complaint: Altered mental status. R3 was presented to the emergency room (ER) with a distended abdomen. A urinary catheter was introduced with greater than a liter of turbid urine returned. "The patient had strong signs of dehydration. Laboratory data confirmed this...referred for admission with dehydration and urosepsis." R3's MEDICARE FLOW SHEET of 3-23-11 documents R3 was readmitted to the facility: Oriented x 3 with good mood and behavior, and with a urinary catheter. R3's Nutritional Assessment of 4-4-11 documents R3's estimated fluids needs are 2062 cc's of fluids per day. R3's currrent Care Plan documents he was readmitted to the facility on [DATE]. There is nothing in the Care Plan addressing R3's urinary catheter, Urosepsis or Dehydration. The Nurses Notes of 5-30-11 document at 0224, Urinary catheter urine cloudy. Note at 0250 states R3 found on floor next to the head of the bed. R3 yelled out when left arm was raised. R3 was transferred to the hospital for X ray and evaluation. The Note at 0515 states R3 returned to the facility with arm in a sling for shoulder sprain and to follow head injury precaution. The Nurses Notes of 5-30-11 document temperature of 99.7, ate 5% at supper, acting agitated, very restless. The Nurses Note of 5-31-11 at 1245 documents R3 is lethargic and difficult to arouse. Doctor notified and orders given to send to ER. R3's Nutritional Intake Flowsheet from 5-28-11 thru 5-31-11 documents a decline in food and fluid intake. It is documented on 5-28-11 he was asleep at breakfast, and had no food or fluid intake. Lunch had 50% food intake and 240 cc's of fluids. Supper had no documentation of food or fluid intake. On 5-29-11 the flow sheet documents Breakfast had 25% food intake with 240 cc's of fluids. Lunch had 50% food intake with 240 cc's of fluids. Supper had 100% food intake with 360 cc's water. On 5-30-11 the flow sheet documents Breakfast 0% food intake with 120 cc's fluids. Lunch had 50% food intake with 60 cc's of fluid. Supper had few bites with 40 cc's fluid intake. On 5-31-11 the flow sheet documents Breakfast no food or fluid intake with documentation R3 sleeping. The Hospital H&P of 5-31-11 documents R3 has a Chief Complaint: Urosepsis secondary to UTI and Altered mental status. "Over the last day the wife had noted a change in his engagement with her and he was not eating or drinking a lot. She also noted that his urine had been getting darker. The patient has a Foley catheter permanently because of [MEDICAL CONDITION] and obstruction. So she was able to monitor the urine in this way. Today, because of lack of responsiveness he was brought to the ER for further evaluation and treatment. In the ER urinalysis showed significant bacteria and signs of infection...He is being admitted for [MEDICAL CONDITION] secondary to urinary tract infection with altered mental state, low [MEDICATION NAME] of 2.6, and [MEDICAL CONDITION]." Report documents he has a urinary catheter in place draining dark urine. The facility Medicare Flowsheet's document urine of 5-29-11 and 5-30-11 of yellow urine WNL (within normal limits). On 6-7-11, R3's wife stated R3 had a UTI last week and was in the hospital. She stated R3 was not eating, his urine was dark, and he was confused, "out of it." She stated she kept telling staff for 2 days of her concerns, and the third day they sent him to the hospital. R3's Physician order [REDACTED]." On 6-7-11 R3 was observed in his room eating the noon meal that was brought in by his wife. There were no fluids with the meal other than his bedside water. On 6-8-11 at noon meal, R3 was observed to not drink his water. On 6-9-11 at the noon meal, R3 was served a large glass of water and a carton of 2% milk on his tray. He was observed to drink a few sips out of the water, and his milk was not opened for him to drink. He left the dining room, did not consume the milk, and drank less than 60 cc's of water. On 6-9-11 R3's water pitcher in his room was observed to be full of warm water from 9:30AM to last observation made at 3:35PM. The water pitcher remained in the same place on table next to his bed and not within R3's reach. R3's current Care Plan does not address his need to take in 2000ml (cc's) of fluid a day. It does not address his urinary catheter, history of Urosepsis, and Dehydration. On 6-8-11 at 12:10PM, R3 was in bed and had a small bowel movement. E24, Certified Nurse Aide, CNA, was observed to wipe feces from R3's anal area and wearing the same soiled gloves did catheter care. 2. R4's POS for June 2011 documents a history of Urinary Tract Infection, and R4 has a Urinary Catheter. R4 was observed on 6-7-11 at 12:25PM to be transferred from bed to her wheel chair by E8, CNA, and E26, Licensed Practical Nurse (LPN). R4 had a saturated foul smelling bandage on her knee that was coming off. E8 handled the bandage, and then proceeded to transfer R4 and handle R4's Catheter tubing with the same soiled gloves. E8 and E26 placed R4's catheter bag on her lap above her bladder, and urine in the tubing was observed to backflow towards R4's bladder. R4 was observed again on 6-8-11 at 11:45AM, to be transferred from bed by E24 and E25, CNA's, to her wheel chair by a sling lift. The CNA's attached R4's catheter bag to the sling about fourteen inches above her lap/bladder. Urine was observed in the tubing to flow back towards her bladder. 3. R9's June POS documents he has a history of UTI. Laboratory tests of 5-11-15 document a UTI. The Culture and Sensitivity provided to the facility on [DATE] documents Pseudomonas Aeruginosa and Escherichia Coli. The POS documents the facility failed to get a treatment order [MEDICATION NAME] 5-18-11. Interview with E2, Corporate Nurse, on 6-8-11 confirmed [MEDICATION NAME] not ordered until 5-18-11. 4. R2's Minimum Data Set, MDS, of 3/21/11 indicates that she has short/long term memory deficits with cognitive impairment and requires limited assist of one staff for transfers, toileting/hygiene and is continent of bowel and bladder. The care plan does not reflect R2's continence. A urinalysis dated 5/30/11 identified R2 to have a UTI of E. Coli >100,000. On 6/8/11 at 9:50pm, R2 returned to the unit from therapy. At 10:05am, R2 was taken to the shower room to be toileted. R2 had a paper incontinent brief on which was wet with urine, and had bowel movement smeared in her brief. She had deep creases across both upper back thighs/buttocks, and had no pressure relieving cushion in her wheelchair. E10 and E11, CNA's, provided poor incontinent care as they didn't cleanse between the labias or the perineal area except to wipe several times from the back as she stood up at the toilet to ensure that stool was not present. She was transferred back to her wheelchair and taken to the dining room. She remained in the dining room until her family came and propelled her across the hall to the activity area. At 12:30pm, she was taken to the dining room and served her lunch meal. No toileting was done prior to the meal. R2 was still sitting in her wheelchair in the dining room at 1:08pm when the observation ended. The facility failed to identify R2's incontinence, failed to assess it and failed to develop a plan to minimize her incontinent episodes and restore her back to being continent in addition to toileting her timely in an effort to prevent her from having a decline in her continency. On 6/10/11 at 12:50pm, E12, Registered Nurse, RN, working on R2's hallway stated R2 is almost always incontinent and has been. E12 stated she was sure the MDS done in 3/11 was in error adding that most of the people "down here" (referring to the Dementia Unit) are usually incontinent. 5. R7's MDS dated [DATE] identifies her to be incontinent of urine and occasionally incontinent of bowel. The MDS indicates R7 requires limited assist of one staff for mobility and toileting. The care plan dated 3/20/11 identifies R7's incontinence and includes 2 separate goals - 1) will be reminded to ask for and receive necessary assistance through next review and 2) have fewer incidents of incontinence through next review. Interventions include cue with verbal reminders, provide perineal care after every episode, report changes in bowel/bladder output and report, and two person assistance for entire process, take to BR (bathroom), transfer on/off toilet, ensure safety, provide pericare, adjust clothing and wash hands. On 6/8/11, from 9:20am until 12:02pm, R7 was observed in her wheelchair in the activity room sleeping off and on. R7 slept through most of the morning and at 10:10am, was propelled to the dining room for snacks and drinks. At 11:16am, staff pushed her out of the dining room and down the hall back to the dining room without repositioning or toileting her. At 12:02, E10 and E11, CNA's, transferred her to bed using the sit to stand lift. No toileting was provided. R7 was incontinent of urine which had a strong odor, and R7 had deep creases across both upper thighs and buttocks. E11 washed R7's buttocks and groin area, but failed to cleanse between the legs, labia area and perineal area well. A dry attends was placed on R7, and R7 was transferred back to her wheelchair following incontinent care. The facility failed to follow R7's plan for increasing continence, and failed to provide timely complete incontinent care. 6. R1's MDS dated [DATE] documented cognitive impairment, total dependence of two plus persons physical assistance with toileting and an indwelling catheter. During observation of R1's transfer and perineal care on 6-8-11at 8:20a.m., E15, and E8, (CNA's) transferred R1 from chair to bed with a mechanical lifting device. R1's rectum was observed with dried and newly forming fecal matter. E15 and E8 did not check R1's indwelling catheter for soiling from the fecal matter, or provide indwelling catheter care. During observation of R1's perineal care on 6-8-11 at 9:20a.m., R1's rectal area was observed with medium amount of newly formed fecal matter. E16, and E17 (CNA's) did not check R1's indwelling catheter for soiling from the fecal matter, or provide indwelling catheter care.