Every finding on record at Loft Rehab & Nursing of Normal

Based on interviews and record review, the facility failed to ensure a resident representative was informed and provided opportunity to consent to the administration of a mind-altering medication prior to being administered for one (R5) of three residents reviewed for psychotropic medication management in the total sample list of 14 residents.Findings include:On 8/24/2026 at 1:18 p.m., V6 (R5's) Family Member stated V6 was not notified by the facility about R5's medication for anxiety (Hydroxyzine). V6 Family Member stated V6 never knew about the medication for anxiety (Hydroxyzine) until this time. V6 Family Member stated V6 never gave or signed any consent form for the anxiety medication for R5.On 8/24/2026 at 9:14 a.m., V11 Licensed Practical Nurse (LPN) stated a consent form must be filled out and signed by a cognitively intact resident otherwise a representative must sign before administration of a psychotropic medication.On 8/24/2026 at 9:24 a.m., V12 Registered Nurse (RN) confirmed consent is needed from either a cognitively intact resident or a representative for the cognitively impaired resident before administration of a psychotropic medication.On 8/24/2026 at 12:18 p.m., V2 Director of Nursing (DON) confirmed consent is needed prior to administration of psychotropic medication. V2 DON confirmed R5 has moderate cognitive impairment and V6 Family Member makes the decision for R5. V2 DON confirmed R5 does not have signed consent from V6 Family Member. V2 DON confirmed Hydroxyzine was administered to R5 on 5/25/2026, 5/27/2026 and 5/28/2026 without signed consent. V2 DON confirmed Hydroxyzine is an antianxiety medication and required a consent prior to administration. V2 DON confirmed R5's medical record does not contain any documentation that a verbal consent was obtained for R5's Hydroxyzine.On 8/24/2026 at 2:50 p.m., V1 Administrator stated V1 expects the staff members to follow the facility policy for Use of Psychotropic and Notification of Changes. R5's Order Summary Report dated 8/24/2026 documents R5's diagnoses includes but not limited to Major Depressive Disorder and Anxiety Disorder. This report further documents an admission date of 04/07/2026.R5's Physician Order dated 5/19/2026 documents a physician's order for Hydroxyzine HCI (antianxiety medication) Oral Tablet 25 mg (milligrams), give one tablet by mouth every six hours as needed for anxiety for 14 days.R5's Minimum Data Set (MDS) dated [DATE] documents R5 has moderate cognitive impairment.R5's Medication Administration Record (MAR) dated 5/1/2026 - 5/31/2026 documents Hydroxyzine was administered to R5 on 5/25/2026, 5/27/2026 and 5/28/2026.The Facility's Use of Psychotropic Medication Policy dated 2/10/2026 documents a Policy Explanation and Compliance Guidelines: 11. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g. written consents form, narrative note, etc.).The Facility's Notification of Changes dated 2/2/2026 documents The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guideline: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification #3. Circumstances that require a need to alert treatment. This may include a. New Treatment. Additional considerations: 2. Residents incapable of making decisions: a. The representative would make any decisions that have to be made.

Based on interview and record review, the facility failed to notify a resident's physician of a change in condition for one (R4) of six residents reviewed for change in condition in a sample list of 12. Findings Include:R4's Care Plan dated 6/14/2026 documents diagnoses of Sepsis, Intestinal Obstruction, Acute Kidney Failure, Metabolic Encephalopathy, Repeated Falls, Weakness, Peripheral Vascular Disease, Obstructive Sleep Apnea, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Reduced Mobility, Difficulty in Walking, and Traumatic Ischemia of Muscle. R4's Minimum Data Set, dated [DATE] documents R4 is moderately cognitively impaired. On 7/14/2026 at 10:25 a.m., V37 Hospital Nurse stated R4 entered the emergency room with stroke like symptoms, including left sided facial droop, left arm weakness, and slurred speech (on 7/5/26). V37 stated EMS (Emergency Medical Services) informed hospital staff R4 had been experiencing these symptoms for more than 24 hours, making R4 ineligible for stroke alert interventions. V37 stated R4 was short of breath, and oxygen saturation was low upon arrival. On 7/14/2026 at 10:45 a.m., V11 Register Nurse (RN) stated on 7/5/2026, R4 exhibited facial drooping, shortness of breath, and difficulty swallowing. V11 reported to EMS that R4 was last seen at baseline approximately 24 hours earlier. On 7/14/2026 at 11:45 a.m., V17 Certified Nurse Assistant (CNA) stated on 7/4/2026, R4 did not seem like R4's self. V17 stated when assisting R4 that morning, V17 observed slurred speech, slouching to one side in the wheelchair, and difficulty eating breakfast. V17 stated V17 notified V13 Licensed Practical Nurse (LPN). V17 stated on 7/5/2026, V17 again found R4 with slurred speech and leaning, with symptoms significantly worse than the prior day. V17 stated V17 notified V11, and R4 was transferred to the hospital. V17 told EMS that R4 had been experiencing slurred speech and leaning for 24 hours. On 7/14/2026 at 11:55 a.m., V13 Licensed Practical Nurse stated V13 did not recall being notified by the CNA on 7/4/2026 regarding R4's stroke like symptoms. On 7/14/2026 at 12:45 p.m. V2 Director of Nursing (DON) stated that for nonemergency changes the nurses will fax or call physicians regarding a change in condition. V2 stated for an emergency staff should call 911 if patient needs sent to the emergency room and then notify the doctor. V2 stated V2 expects nurses to call doctors for stroke-like symptoms and not wait 24 hours to update the physician or send a resident out. On 7/14/2026 at 12:50 p.m. V31 Medical Director/Physician stated V31 does not recall receiving any notification regarding R4's change in condition on either 7/4/2026 or 7/5/2026. On 7/14/2026 at 1:09 p.m. V2 DON stated an electronic assessment form was completed on 7/5/2026 when R4 was sent the emergency room, the doctor was notified at 3:00p.m. and the POA (Power of Attorney) was notified at 9:29 a.m. V2 stated there was no documentation regarding R4's symptoms reported by V17 CNA on 7/4/2026. On 7/14/2026 at 3:00 p.m. V2 DON confirmed the electronic assessment form dated 7/5/2026 contains vital signs dated 7/4/2026 at 2:15 a.m. and R4 was sent to the emergency room on 7/5/2026 at 9:29 a.m. The Vital Signs Evaluation section states the most recent vital signs for change in condition are blood pressure 148/64 lying, pulse 73, respirations 16, and temperature 98.1 (degrees Fahrenheit) forehead with Oxygen saturation of 89 percent all dated 7/4/2026 at 2:15 a.m. V2 said the vital signs must have auto populated in the form from an earlier set of vital signs entered in the computer. V2 confirmed there are no vital signs entered for R4 during the time of the change of condition. V2 also confirmed the electronic assessment form documents a start date of symptoms as 6/30/2026. V2 confirmed the date of 6/30/26 is incorrect. On 7/15/2026 at 10:39 a.m. V2 DON also shared that a set of vitals were taken from the EMS staff when they arrived, but no vital signs were measured by the in-house nursing staff. On 7/14/2026 at 12:20 p.m., V33 Family Member reported that the emergency room physician informed him that R4 had experienced a stroke on the left side and was unable to squeeze with the hand or lift the left foot, which was positioned off to the side. The Facility's Notification of Change Policy revised on 2/2/2026 documents the facility promptly informs the resident, consults the resident's physician and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Definitions: life-threatening Conditions for example Heart Attack or Stroke. Under Compliance Guidelines: Circumstances requiring notification include #2 significant change in the resident's physical, mental or psychosocial conditions such as deterioration in health, mental or psychosocial status.

Based on interview and record review, the facility failed protect the resident's right to be free from physical abuse by another resident for two (R2, R3) of three residents reviewed for abuse in a sample list of 12.Findings include:R2's Electronic Health Record (EHR) documents R2 admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Primary Insomnia, Diabetes Mellitus With Diabetic Neuropathy, Lymphedema, Type 2 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Bilateral, Venous Insufficiency, and Dementia, Mild, With Agitation.R2's Minimum Data Set, dated [DATE] documents R2 has mild cognitive impairment.R3's EHR documents R3 admitted to the facility on [DATE] with diagnoses including Convulsions, Cerebral Infarction, Intellectual Disabilities, Major Depressive Disorder, Cognitive Communication Deficit, and Alzheimer's Disease.R3's EHR documents on June 30, 2026 R3 has moderate cognitive impairment.The facility's Final Incident Report Form, undated, labeled 5 day follow up, documents After investigation which included interviews, (R2) stated (R2) did not think (R2) was moving fast enough in his wheelchair while leaving the dining room which caused (R3) to become aggravated. According to a CNA's (V3) statement, R3 then lightly hit R2. R2 then grabbed R3's shirt and told R3 to not put R3's hands on R2 again.On 7/13/26 at 10:45AM, R2 stated R3 was in a rush to get out of the dining room and R2 was moving slowly and R3 hit him. R2 stated R3 hit me but it was no big deal, I wasn't injured, and then (R3) went on by me like it was no big deal.On 7/13/26 at 10:48AM, R3 stated R3 did not recall any incident's with other residents.On 7/13/26 at 12:55PM, V6, R2's spouse, stated V6 was notified that R2 and R3 had a disagreement and R2 was hit by R3 when the residents were coming out of the dining room. V6 stated V6 was told there was no injury to R2.On 7/13/26 at 2:39PM, V3 Certified Nursing Assistant confirmed V3's written statement. V3 stated V3 was assisting residents in the dining room, and witnessed R3 make contact with R2 while R2 was leaving the dining room. V3 stated V3 separated the residents.On 7/13/26 at 2:45PM, V4 Licensed Practical Nurse stated V4 was informed of the incident between R2 and R3 in which R3 was observed hitting R2.On 7/14/26 at 1:45PM V2, Director of Nursing, confirmed the abuse policy documents residents have a right to be free from abuse. V2 stated the policy was not followed if the incident took place. The facility's abuse policy dated 2/11/2025 documents It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies' and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Section VI Protection of Resident documents The facility will make efforts to ensure all residents are protected from physical and psychosocial harm.

Based on observation, interview and record review the facility failed to obtain admission orders from the hospital upon admission, failed to complete a timely admission assessment and wound assessment, failed to timely administer medications for the treatment of a leg infection, diabetes, hypertension and other comorbidities and failed to provide mobility devices. The facility also failed to implement physical and occupational therapy evaluations upon admission which resulted in R1 having to stay in bed and use a bedpan for toileting needs. These failures affected one (R1) of three residents reviewed for admissions in the sample list of nine. These failures resulted in R1 sustaining ongoing, significant emotional distress, tearfulness and fear of a delayed recovery. Findings include: R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15, indicating no cognitive impaired. R1's same MDS documents R1 has a0 lower extremity impairment in range of motion on one side. On 5/16/26 at 11:00 am, R1 was seated bedside, in a wheelchair with the right leg rest elevated. The leg rest had a pillow under R1's right leg for additional support. R1's right leg was wrapped in a compression bandage from R1's right knee down to R1's toes. R1's stated (R1) was admitted a week ago Friday (5/08/26). R1 stated (R1) had an agency nurse when (R1) was admitted (later identified as V10, Agency Licensed Practical Nurse). R1 stated (R1) did not remember (V10's) name. R1 stated (V10) did not do any kind of assessment of (R1). (V10) told (R1) that (V10) did not have the discharge orders from the (local) hospital, so (V10) could not do anything for (R1) and (R1) had to stay in bed. R1 stated (V10) told R1 nothing could be done until (V10) gets the paperwork from them (the local hospital). R1 stated that (R1's) biggest concern (R1 became tearful) was going without my antibiotic. R1 stated (R1) has cellulitis in (R1's) leg. R1 stated that it was a serious infection. R1 stated that (R1) is diabetic, and infections can get much worse if (R1) misses the antibiotic. R1 stated that (R1) has neuropathy in both legs and cannot feel pain so (R1) would not be able to tell the nurses if the infection was getting worse. R1 stated (R1) knows that pain is a clear sign of an infection worsening. R1 stated (R1) did not receive (R1's) insulin either. R1 stated (R1) did not know if there was any impact from not receiving the insulin. R1 stated (V10) did not check (R1's) blood sugar that night. R1 stated (R1) was so scared (R1) could barely sleep. R1 stated (V10) said (V10) could not check (R1's) blood glucose because (V10) had no orders from the hospital. R1 stated I worried terribly (R1 paused and became more tearful) about my cellulitis infection, my blood pressure and my blood sugar. R1 stated the hospital had already told me they could not do surgery on my broken (later in hospital records identified as torn) Achilles until the infection was gone. R1 stated (R1) worried all night long. R1 stated this was a terrible experience. R1 stated (R1's) blood pressure medications were not given and (R1's) blood pressure had been elevated since (R1) was admitted . R1 stated (R1) is getting the medications now, but my blood pressure is still elevated. R1 stated (R1) saw someone yesterday that came in to talk about my diet choices. R1 stated I don't like the food here and I don't choose my own meal. R1 stated what is served is what I get. R1 stated (R1) would not eat noodles and potatoes all the time because (R1) is diabetic and manages (R1's) diet at home. R1 stated (R1) has never asked for an alternative menu. R1 stated (R1's) friend could provide more information and R1 provided R1's friend's name (V8, R1's friend) and phone number. R1 stated the CNA (V9, Certified Nursing Assistant) came in to see how I was doing several times but (V10) did nothing except tell me I could not get out of bed, and I could not get my medication. R1 stated (V9) apologized repeatedly and said that (V10) told (V9) that (V10) couldn't do anything for (R1).R1 also stated I had already missed my meds (medications) several times when (V2, Director of Nursing/DON) came in. R1 stated V2's name and that V2 completed R1's registration. R1 stated that a floor nurse (unidentified) took over and helped. R1 stated (V2) was the one that got the paperwork from the hospital so I could get all my medications. R1 stated (R1) was supposedly going to get therapy that day. R1 stated (R1) was very active before falling a couple weeks ago. R1 stated (R1) did a ten-mile hike not long before the fall. R1 stated (R1) received therapy in the hospital and walked with a walker there. R1 stated (R1) was supposed to be getting up with a walker and could use a wheelchair. (R1) began to cry. R1 stated they did not have a wheelchair or walker for me to use here. R1 stated (R1) just had to lay in bed and use a bed pan and a brief (incontinent brief), until (R1) could be assessed by therapy. R1 stated (R1) received some medication that Saturday afternoon and received the antibiotic later that evening. R1 stated (R1) was worried sick and is still scared. R1 stated (R1) is waiting for the other shoe to drop. R1 stated the facility caused me so much anguish and it is hard to focus on getting healthy enough to go home.R1 also stated they had a care plan meeting on Monday (5/11/26). R1 stated (R1) went over everything and it was overwhelming to relive those first few days I was here. (V2, DON) got me a bed control for my bed because I did not have one when I came in. R1 stated (R1) was so worried about (R1's) situation and then (R1's) bed was a problem too. R1 stated (R1) had to stay in bed with no way to adjust the bed. (V10) said (V10) had to put in a work order in to get a bed control and (R1) would have to wait until Monday when the maintenance person came into work. R1 stated (R1) was restless, until a CNA (unidentified) was able to adjust something at the foot of (R1's) bed overnight. R1 stated no one should have to go through this, the feelings of despair I am still fighting off. (R1 became more tearful). R1's hospital admission to discharge paperwork dated 5/1/2026 - 5/8/2026 (7 days), documents the principal problem was Cellulitis and abscess of right legR1's Discharge Summary documents R1 has a history of Type 2 Diabetes Mellitus, Diabetic Neuropathy, Hypertension, Hyperlipidemia, and Hypothyroidism and was admitted for evaluation and management of acute kidney injury and persistent right lower extremity cellulitis and swelling refractory to outpatient oral antibiotics. Cellulitis and Abscess of Right Leg. R1 presented with ongoing swelling, erythema and pain of the right lower extremity following a fall in early April. R1 had some improvement from multiple courses of oral antibiotics (Bactrim and Cephalexin). On admission R1 had extensive cellulitis with edema and imaging revealed diffuse subcutaneous edema and a partial or full-thickness tear of the distal Achilles tendon. Doppler was negative for DVT (Deep Vein Thrombosis).R1's MRI (Magnetic Resonance Imaging) confirmed a high-grade (severe-partial) Achilles tendon tear.Initially managed with broad-spectrum antibiotics with IV (Intravenous) cefepime (Broad spectrum antibiotic) ID (infectious disease department) consulted. Cefepime transition to IV Rocephin (broad-spectrum antibiotic) followed by p.o. (by mouth) Zyvox (Linezolid, antibiotic) for cellulitis and with concern of underlying myositis (chronic inflammation of the muscle) to complete (medication) by 5/15/2026. CRP (C-reactive Protein that gets into the blood stream, as a response to inflammation) improved. ABI (ankle-brachial index - comparative blood pressure ankle and arm) normal. Complete rupture of right Achilles tendon-podiatry consulted, plan to treat nonoperatively. Splinted in maximal plantarflexion non weight bearing right foot. Evaluated by PT OT (Physical and Occupational Therapy) and patient will be discharged to rehab (the long-term care facility) and follow-up with podiatry. Acute Kidney Injury -possible prerenal and with antibiotics. Managed with IV fluids and resolved. Resume home meds on discharge for chronic comorbid conditions and follow-up with PCP (Primary Care Physician) for long-term management. Consults: Orthopedic surgery infectious disease.This same hospital Discharge Summary note documents: (R1) pleasant alert walking with therapy with a walker. Breathing comfortably on room air.Medication List: Start taking these medications:Linezolid 600 MG Tabs Commonly known as: ZYVOX, take 1 Tablet by mouth every 12 hours for 15 doses. Indications: Infection of the Skin and/or Soft Tissue.Change how you take these medications:Lantus Solostar (insulin) 100 UNIT/ML (units per milliliter) Generic drug: insulin glargine Inject 26 units under the skin every evening. Hold if blood glucose is lower than 140 at night. What changed: additional instructions.Continue taking these medications:Alendronate 10 MG (Milligram)Tabs Commonly known as: FOSAMAX Take 1 Tablet by mouth every morning (before breakfast).Aspirin 81 MG Tabs, Take 1 Tab by mouth daily.Calcium carbonate-vitamin D, 600-400 MG-UNIT Tabs Commonly known as: Calcium 600 + D Take 1 Tablet by mouth 2 times daily.Freestyle Lite Strip Generic drug: glucose blood. Test blood Glucose Four time daily (before meals and at bedtime) Insulin dependent (Diabetic Type II).Levothyroxine 100 MCG (Micrograms) Tabs Commonly known as: SYNTHROID Take 1 Tablet by mouth daily.Lisinopril (Ace inhibitor to treat high blood pressure) 20 MG Tabs, Commonly known as: PRINIVIL, ZESTRIL Take 2 Tablets by mouth daily.Magnesium Oxide 400 MG Caps Take 1 Capsule by mouth daily.Metformin (oral medication to lower blood glucose) 1000 MG Tabs Commonly known as: GLUCOPHAGE TAKE 1 TABLET BY MOUTH TWICE DAILYSimvastatin 20 MG Tabs, commonly known as: ZOCOR, Take 1 Tablet by mouth nightly.R1's same Hospital discharge notes documents: Care Timeline: admitted to ED 05/01/26 at 5:39 pm. discharged [DATE] at 4:35 pm. discharged /Transferred to SNF (Skilled Nursing Facility).R1's local hospital After Visit Summary dated 5/8/26 documents when the medications were scheduled to be given and some, but not all of the medication orders document the last time the medication was administered at the hospital.R1's Alendronate 10 MG (Milligram) Tabs does not document when R1 was administered the last dose at the hospital. This only documents when the medication is scheduled to be given, in the morning. Aspirin 81 MG Tabs, take 1 Tab does not document when R1 was administered the last dose at the hospital. Ask your nurse or doctor and is scheduled to be given in the morning. Calcium carbonate-vitamin D, 600-400 MG-UNIT Tabs does not document when R1 was administered the last dose at the hospital. This only document when the medication is scheduled to be given in the morning and at bedtime. Test Blood Glucose Four Times Daily (BEFORE MEALS AND AT BEDTIME). This does not document when R1 received R1's last Glucose test at the hospital. Lantus Solostar 100 UNIT/ML 26 units does not document the last time R1 was given this medication at the hospital. Ask your nurse or doctor. Levothyroxine 100 MCG Tabs last time given in the hospital 5/8/26 at 6:17 am, in the hospital. Linezolid 600 MG Tabs, given last time 5/8/26 at 12:05 pm in the hospital. Lisinopril 20 MG Tabs, last time given 5/8/26 at 9:31 am in the hospital. Magnesium Oxide 400 MG Caps Take 1 Capsule by mouth daily and does not document the last time R1 was administered at the hospital. Metformin 1000 MG Tabs TAKE 1 TABLET BY MOUTH TWICE DAILY and does not document the last time R1 was administered at the hospital. Simvastatin 20 MG Tabs Take 1 Tablet by mouth nightly and does not document the last time R1 was administered at the hospital.R1's medical record does not document R1 was admitted to the facility 5/8/26. The same medical record does not document that a physician was notified and there were no admission orders from the hospital to provide care for R1.There is no documentation in R1's facility medical record to indicate any of the above medications were discussed with the hospital to determine when the last doses were given. There is no documentation in R1 medical record that documents any of the medications were administered on 5/08/26.R1's Medication Administration Record (MAR) dated 5/01/26 - 5/31/26 does not document that any of R1's medications were administered on 5/8/26, or on 5/09/26 until 4:36 pm. The same MAR dated 5/01/26 - 5/31/26 does not document blood glucose measurements were completed until 5/10/26 at 7:00 am.R1's Medication Administration audit report documents R1 medication administration was delayed until 5/9/26 at 4:36 pm. R1's same MAR documents a new physician order that was supposed to be administered beginning 5/10/26. R1's new physician order documents: Alendronate Sodium 70 MG Tablet, give 1 tablet by mouth in the morning every Sunday related to Type II Diabetes Mellitus Without Complications, sit up for 30 minutes after taking medication -Start Date- 05/10/2026 at 0500 am. R1's Alendronate Sodium 70 MG Tablet was not administered until the following Sunday 5/17/26.On 5/17/26 at 1:00 pm R1's Census record was reviewed with V30, Business Office Manager (BOM). R1's Census record documents R1's admission as Saturday 5/09/26. V30 confirmed R1's Census record was not accurate. R1's admission date was 5/08/26. V30 stated (V29, admission Coordinator) called me Saturday morning and ask me if (R1) was admitted (to the facility). That was about 9:00 am. (R1) was expected Friday (5/8/26). I had to tell (V29) I did not know. I went to the facility and laid eyes on (R1). (R1) had been admitted . (R1) told me about the whole situation. I could see (R1) was really upset. (R1) was very nice about it but very concerned about (R1's) leg infection and medications. I found out the DON (V2,) was coming in. I apologized for all the issues that occurred. I documented the wrong date on (R1's) Census. It should have been recorded as 5/08/26. The first documentation is recorded below. R1's Health Status Note below is not documented as a late entry.R1's Health Status Note dated 5/9/2026 at 1:06 pm documents Note Text: Resident (R1) admitted to facility from (Local) hospital via ambulance to room (R1's room number). Resident medications had a delay in arrival due to pharmacy miscommunication (5/8/26, V10, Agency Nurse had no hospital paperwork according to interviews documented). Residents were given all AM medications this morning (not documented as administered until 4:36 pm). Residents have family at bedside. Explained all medications ordered and antibiotics are being stat delivered today. Resident alert and oriented x3 (person, place and situation, no cognitive impairment). Oriented to call light and room (R1 had been in the facility since hospital note above documents transfer 5/8/26 at 4:35 pm). Pleasant and cooperative. Here for treatment for RLE (Right Lower Extremity) Cellulitis. (R1) is non weight bearing. The right lower leg and will be evaluated by PT (Physical Therapy) today (5/9/26).R1's Health Status Note dated 5/9/2026 at 1:16 pm documents: Note Text: Spoke with (V16), Physician and notified (V16, Physician) of admission and delay in medication arrival.R1's Physical Therapy assessment dated [DATE] at 4:37 pm documents R1 is totally dependent on staff for transfer from bed to chair. (Health Status Note dated 5/9/2026 at 1:06 pm, documented above, R1 was to have been evaluated by Physical Therapy on 5/9/26).On 5/17/26 at 11:20 am V23, Director of Rehab (DOR) stated V23 was present in R1's care plan meeting. V23 said, (V23) was aware (V24, Physical Therapist (PT)) was not in the building on Saturday May 9, 2026, when (R1) was supposed to be evaluated for occupational and physical therapy. (V24) had a sick child that day. My (V23) understanding is that (R1) was evaluated on Sunday May 10, 2026. V23 also stated the transfer status R1 came from the hospital as, should have been followed, if safe. V23 stated, Therapy wants all residents out of bed as soon as possible, if safe to do so, following hospital directives. V23, also stated (R1) should have had a wheelchair and walker provided. Staff have access to the ancillary room which has the equipment available. The manager on duty, also has a key to access additional equipment in an outside building. V23 also stated (R1) should have been out of bed. Staff could have used a full mechanical lift if they were unsure of the transfer status. R1's Progress Notes *NEW* Adv- Skin Check dated 5/11/26 at 12:19 pm (three days after admission 5/8/26), signed by V11, Wound Registered Nurse/Assistant Director of Nursing, documents the following: Skin: Skin is pale in color. Skin warm / dry to touch. Normal skin turgor. Foot evaluation completed. Skin Issue: Skin issue has not been evaluated. Location: Front right lateral lower leg ([NAME]) (sic). Issue type: Other skin issue. Other skin issue description: Cellulitis Wound was present on admission. It is unknown how long the wound has been present. Undermining: No. Tunneling: No. Skin Issues Note: Generalized bruising to either arm, from hospital blood thinners and insulin shots on the abdomen; small areas of redness on the shin where the splint was present (all blanchable erythema) Skin issue education: Moisture barrier. Skin issue education: Signs and symptoms of infection. Skin issue education: Care of skin issue(s).On 5/16/26 at 1:35 pm (V11) stated I came in and assessed (R1's) Cellulitic leg on day two, Monday (5/11/26) (three days after R1's actual admission 5/8/26). (R1) had a few small areas of redness from (R1's) brace (splint) on (R1's) right lower leg. (R1) had a splint on, and had padding on those areas. (R1) had scant amount of swelling compared to (R1's) other leg. Those small spots blanched and therefore were not pressure areas. There was no heat, no open areas and (R1) stated (R1) did not feel pain because (R1) had a diagnosis of Diabetic Neuropathies. (R1's) Achillies showed no indication of infection either. I did not measure the slight swelling (R1) had in (R1's) lower leg. There were no markings on (R1's) lower leg to determine the diameter of (R1's) calf or the extent of cellulitis while (R1) was in the hospital. I did not see much swelling when I assessed it. I should have measured the area so we could monitor (R1's) progress while (R1) is in the facility. I did not do that.R1's same MDS dated [DATE] documents R1's Mood assessment as follows: Total Severity Score of 11 out of a possible 27, indicated R1 had moderate depression.R1's Admitting Diagnoses list dated 5/8/26 does not document R1 as having a diagnosis of Depression or any psychiatric diagnoses/disorder.On 5/17/26 at 8:48 am V8, R1's Friend stated I was with (R1) the afternoon (R1) was admitted . We left the hospital at 4:30 pm. The hospital handed (R1's) discharge paperwork to the ambulance staff. I know they (Emergency Medical Technician) provided those too that nurse. The whole admission process was a horrible experience for (R1). I have never seen (R1) so distraught. My heart was broken to see (R1) crying over this. I told them how (R1) was overwhelmed and afraid (R1) was not going to get (R1's) antibiotic, or insulin medications. Then (R1) had to stay in bed for two days and had no therapy. (R1) has always been very active. Just lying around in bed played a big part on (R1's) psyche. Using a bed pan and (incontinent brief) was awful for (R1). (R1) couldn't get up and they had no walker for (R1). (R1) just wanted to heal and come home. The nurse (V10, Agency LPN) told (R1) that (R1) had to stay in bed. We are not rule breakers. (R1) followed the rules. The hospital had (R1) using a walker and had (R1) pivot transfer. V8 stated (R1) told them in the care plan meeting (R1) felt like (R1) was going down a black tunnel and had been fearful since (R1) got to the facility. V8 stated, I stayed with (R1) until well after 10:00 pm. The head nurse (V2, Director of Nursing) came in the next day around 11:30 am. I was told (V2) would be here at 9:00 am. By 11:30 am (R1), had missed more of (R1's) medications. (V2) was very apologetic about the whole ordeal. V8 stated the facility had stock medication they could give R1, but not (R1's) antibiotics. It was not given because it had to come from the pharmacy. That did not happen until later that evening. This added to (R1's) despair. It seemed to go on and on. (R1's) blood pressure has been elevated since (R1) got to the facility. V8 also stated (V8) had concerns with the timing of R1's leg treatment not being done until 5/11/26 when it was supposed to be changed every two days. V8 also stated (R1's) therapy evaluation was not completed in a timely manner.On 5/16/26 at 11:45 am during review of R1's medical record, V2, Director of Nursing (DON) stated I am very aware of all the failures that occurred on (R1's) admission. This was an agency nurse (V10). (V10) did not meet my expectations for Quality of Care in our facility. I DNR-ed (Do Not Return to work) (V10), immediately. V2 then said I came in Saturday late morning (5/9/26). This was the day after (R1) was admitted (5/08/26). I came in as soon as I heard what had happened. (R1) had not even had an initial assessment. (R1's) orders were here from the hospital when I came in. I'm not sure how the orders were missed that night. All the hospital information was here. This should have been reviewed prior to (R1's) admission, or at least once (R1) arrived. (R1) came in after 6:00 pm, I believe. There is no excuse for failing to complete (R1's) full admission assessment. Without review of (R1's) hospital medical records and no assessment, we can't provide continuity of care. Thankfully, there was no major impact on the residents (R1). The failures could have resulted in major problems. (R1) was extremely upset, not agitated, but very emotional. (R1) was holding back tears, as anyone would be. I apologized repeatedly for everything. We have meds in the stat (immediately available) safe (medication storage) and most meds were on hand. (V10) should have called the hospital, if (V10) didn't think the orders were here. I reviewed the orders immediately and started a full assessment. The floor nurse (unidentified) finished the assessment, while I started picking up the pieces from all the failures. Numerous errors were made. I got (R1's) medications ordered. The meds were ordered Stat (to be delivered as soon as possible), from (private company) Pharmacy. The ones (medications) we had here in the facility were given immediately. Morning meds were given early afternoon. (R1) did miss (R1's) antibiotic on admission. (R1) may have missed one or two doses all together. (R1) also missed one dose of (R1's) insulin the night of (R1's) admission. We actually had insulin on hand. (R1) is alert and oriented. (R1) asked for, and should have gotten (blood glucose checks) that should have been done at the resident's request, (R1's) a Diabetic. The antibiotic was not a common antibiotic that we have in our stat safe. It had to be ordered from the pharmacy. The pharmacy knew this was needed right away. It came later in the afternoon and was given. (V16, Physician,) was on call. (V16) confirmed (R1's) meds and said all the hospital orders should have been followed. (V16) was aware that (R1's) admission assessment was not completed until I came in that next day. I notified (V17) Regional Nurse Manager, of everything that happened. V2 also stated Of course, I did get (R1) a bed remote that morning. There was no reason for (R1) not to have had that the night before. (R1) remained pretty upset. I just kept repeating how sorry I was. We had a full, care plan meeting Monday. We discussed every need (R1) had. There was no reason for (V10) to drop the ball. (R1) now has a walker and wheelchair. (R1) could have had them both when (R1) was admitted . There was no reason for (R1) to lie in bed all that time. Hospital paperwork was clear. (R1) was to be up with a walker and staff assistance. V2 also stated (V10) should have completed an assessment of R1's leg. (V10) did not assess that either. (V11, Wound Licensed Practical Nurse/ADON) our Wound nurse assessed (R1's) leg on Monday. (V11) determined there was no open areas and no sign of infection. (R1) had been taking antibiotics in the hospital. Therefore, there was no negative outcome to the wound itself. A delay in wound assessment was just one more of the issues. I did everything I could to fix all this stuff, once I was aware.The facility policy Physician/Practitioner Orders dated reviewed /revised 2/10/2026, documents the following: Policy: The attending physician shall authenticate orders for the care and treatment of assigned residents. Policy Explanation and Compliance Guidelines:1. A physician/practitioner may include, but is not limited to, a resident's: a. Attending physician.The facility policy Pharmacy Services dated reviewed /revised 2/10/2026, documents the following: Policy: It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice.The facility policy Safe Resident Handling/Transfers dated reviewed /revised 2/10/2026, documents the following: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the residents while keeping the employees safe in accordance with current standards and guidelines. Compliance Guidelines: 1. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. 2. The resident's mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations.

Based on interviews and record review the facility repeatedly failed to maintain complete and accurate medical records for one of three residents (R1) reviewed for admission/medical records on the sample list of nine.Findings include:R1's Census record documents R1 was admitted to the facility on [DATE] (per hospital note below, R1 was admitted to this long-term care facility on 5/8/26).R1's ED (Emergency Department) to Hosp-admission (Hospital-Admission) dated 5/1/2026 - 5/8/2026 (7 days), Status: discharged (Local Hospital) Medical Center.R1's same Discharge note documents Treatment team, Principal problem: Cellulitis and abscess of right leg post fall in April.The same Discharge note documents R1 was admitted to the local hospital 05/01/26 at 5:39 pm. discharged to this long-term care facility for Physical and Occupational Therapy on 5/08/26 at 4:35 pm.R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15, indicating no cognitive impaired. R1's same MDS documents R1's was admitted to the facility on [DATE]. R1's same MDS documents R1 has had no falls prior to admission. R1 was admitted from the hospital, as noted above for a leg injury from a fall at home.R1's Adv - Psychotropic Evaluation dated 5/16/26 at 12:34 pm documents R1's Brief Interview of Mental Status score as 11 out of 15, indicating moderate cognitive impairment. On 5/17/26 at 12:35 pm V5, Registered Nurse/Minimum Data Set/ Care Plan Coordinator (RN/MDS/CPC) reviewed R1's electronic medical record. V5 confirmed R1's Minimum Data Set was documented inaccurately when V5 entered the wrong admission date of 5/9/26, off the census that was also incorrect. R1 was admitted [DATE]. V5 continued the review of R1's electronic medical records. V5 said V5 found a note that documents R1 had a fall at home prior to (R1's) admission to the hospital therefore V5 had coded the MDS wrong. V5 confirmed R1's Brief Interview of Mental Status score (BIMS) is correctly recorded as 15 out of 15, indicating no cognitive impairment on V15, Social Service Director assessment. V5 recognized V5 had documented R1's BIMS as 11 out of 15, indicating R1 was moderately impaired in the Psychotropic Evaluation dated 5/16/26 at 12:35 pm. V5 confirmed V5 documented this in error.On 5/17/26 at 1:15 pm V15, Social Service Director stated R1's BIMS score is 15 not 11. R1 is alert and oriented. That had to be inaccurately documented.There is no documentation in R1's medical record that R1 was admitted to the facility on [DATE]. R1's Hospital Discharge summary above was found by V2, Director of Nursing, on 5/09/26 according to V2's interview, below.There is no documentation that hospital paperwork was not provided to the facility 5/8/26.There is no documentation that a physician was notified 5/8/26, that there was no admission orders received from the hospital, to provide R1's care, medications and treatments.There is no documentation in R1 medical record that any of the medication and treatments ordered on the hospital discharge paperwork were entered into the electronic medical record and transmitted to the pharmacy on 5/8/26.There is no documentation R1 was assessed on admission on [DATE].R1's Medication Administration Record dated 5/1/26-5/31/26 documents a new physician order that was supposed to be administered beginning 5/10/26. R1's new physician order documents: Alendronate Sodium 70 MG Tablet, give 1 tablet by mouth in the morning every Sunday related to Type II Diabetes Mellitus Without Complications, sit up for 30 minutes after taking medication -Start Date- 05/10/2026 at 0500 am. R1's Alendronate Sodium 70 MG Tablet was not documented as being administered on 5/10/26.On 5/17/26 at 1:00 pm V30, Business Office Manager (BOM) confirmed R1's Census record documents R1's admission as Saturday 5/09/26. V30 confirmed R1's Census record was not accurate. V30 stated V30 had documented the wrong date on R1's Census record. V30 confirmed R1's admission date should have been recorded as 5/08/26.There is no documentation in R1 medical record that any of the medication and treatments ordered on the hospital discharge paperwork were entered into the electronic medical record and transmitted to the pharmacy on 5/8/26.There is no documentation that a physician was notified there were no admission orders to provide care for R1.R1's Health Status Note below is not documented as a late entry. R1 was admitted [DATE] not 5/9/26 as documented below.R1's Health Status Note dated 5/9/2026 at 1:06 pm documents Note Text: Resident (R1) admitted to facility from (Local) hospital via ambulance to room (R1's room number). Resident medications had a delay in arrival due to pharmacy miscommunication (5/8/26, V10, Agency Nurse had no hospital paperwork according to interviews documented). Residents were given all AM medications this morning (not documented as administered until 4:36 pm). Residents have family at bedside. Explained all medications ordered and antibiotics are being stat delivered today. Resident alert and oriented x3 (person, place and situation, no cognitive impairment). Oriented to call light and room (R1 had been in the facility since hospital note above documents transfer 5/8/26 at 4:35 pm). Pleasant and corporative. Here for treatment for RLE (Right Lower Extremity) Cellulitis. (R1) is non weight bearing. The right lower leg and will be evaluated by PT (Physical Therapy) today (5/9/26).On 5/16/26 at 11:00 am R1 said R1 was admitted a week ago Friday (5/08/26) by V10. (V10) said nothing could be done until (V10) gets the paperwork from them (local hospital). R1 said V10 did not complete an admission assessment. R1 said R1's admission assessment was not completed until 5/9/25 by V2, Director of Nursing who obtained the hospital paperwork.On 5/16/26 at 11:45 am V2, Director of Nursing (DON) confirmed R1's hospital paperwork was not obtained until 5/9/26, and V10, LPN had not completed an admission assessment or documented a note on R1's admission 5/8/26.The facility policy Documentation in Medical Record dated as revised 02/02/26 documents the following: Policy:Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.Policy Explanation and Compliance Guidelines:1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.3. Principles of documentation include, but are not limited to:a. Documentation shall be factual, objective, and resident centered.i. False information shall not be documented.ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided.iii. Subjective information shall be recorded only as relevant, such as the resident's verbalizations, in quotation marks.b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the residents' care and/or responses to care.c. Documentation shall be timely and in chronological order.

Based on observation, interview, and record review the facility failed to promote dignity for three (R6, R15, R20) of three residents reviewed for dignity in a sample of 23 residents. This failure resulted in R15 experiencing increased anxiety and becoming upset as V53 was overheard yelling/cussing (using foul language in a loud and derogatory manner) towards staff outside of R15's doorway. R6's Minimum Data Set (MDS) dated [DATE] documents R6 has severe cognitive impairment. R6's Care Plan dated 10/18/2022 documents R6 is at potential risk for abuse due to Dementia. Despite R6's inability to comprehend interview questions, R6 was repeatedly observed independently propelling to and remaining near the nurse's station located by the facility's front door where V53 (Former Administrator), V32 Receptionist, and V41 Business Office Manager offices were located. This observation made R6 have the potential to place R6 at risk to hear when V53 Administrator was allegedly being verbally inappropriate and unprofessional towards staff in the hallway. On 3/23/2026 at 9:45am, R6 was in R6's wheelchair in the room and appeared to be clean and well-groomed. R6 was able to propel self in and out of the room independently. R6 could not fully participate in the interview due to decreased cognitive status. On 3/23/2026 at 11:00AM, R6 was observed sitting in a wheelchair in the hallway at the nurse station by the front door. On 3/24/2026 at 9:30AM, R6 was propelling self in the hallway towards the nurse's station by the front door. On 3/24/2026 at 3:52PM, R6 was observed sitting in a wheelchair in the hallway at the nurse's station by the front door. On 3/25/2026 at 10:42AM, R6 was observed sitting in a wheelchair at the nurse's station by the front door. On 3/30/2026 at 09:07AM, R6 was propelling self in the hallway towards the nurse's station by the front door. On 3/30/2026 at 09:26AM, R6 was observed sitting in a wheelchair at the nurse's station by the front door. On 3/30/2026 at 1:24PM, R6 observed sitting in a wheelchair at the nurse's station by the front door. On 3/30/2026 at 3:56PM, R6 observed sitting in a wheelchair at the nurse's station by the front door. On 3/24/2026 at 1:00PM, V41 Business Office Manager stated V53 Former Administrator had been verbally inappropriate and unprofessional in the hallways towards staff members with residents present in the hallway. V41 stated V41 had heard V53 say cuss words like S*** (expletive) or A** (expletive) loudly towards staff members by the nurse station where R6 usually sits. V41 stated V41 would think R6 heard what V53 said although R6 has impaired cognition. V41 stated V41 did not report it to anyone because the incident was discussed during the morning meeting where V53 was present and aware of the concern. On 3/30/2026 at 9:34AM, V56 Receptionist stated V56 has heard V53 Former Administrator cuss loudly in V53's office. V56 stated V56 was not sure if there was another person in the office with V53. V56 stated that V53 then came out of office appeared angry as V53 loudly yelled and cussed while having a conversation over the phone. V56 stated R6 was in the hallway (closer to the reception area and V53's office) where R6 always sits and could hear V53 cussing and yelling. On 3/30/2026 at 10:12AM, V59 (R6's) family member stated V59 and R6 never discussed anyone being verbally inappropriate toward staff or residents. V59 stated R6 would be very upset if anyone was cussing or yelling around R6. On 3/24/26 at 9:20AM, R15 was lying in bed and stated R15 gets to move back to R15's regular room after being in isolation for Respiratory Syncytial Virus (RSV). R15 was clean and well-groomed. R15 stated R15 had heard V53 Former Administrator on one occasion when staff were bringing the crash cart down the hallway, and equipment was positioned on both sides of the hall. R15 stated that V53 began yelling loudly at staff, saying, This is why all these items should be on one side of the hallway! R15 felt anxious and became upset due to V53's yelling. R15 stated that R15 had already been anxious because of the emergency situation occurring at that time, and V53's yelling increased R15's anxiety. R15 also stated that V53 had cursed at staff members on previous occasions in the hallway, and R15 did not like that. On 3/24/2026 at 8:32AM, V32 Receptionist stated V32 has heard V53 cussing loudly in the hallway. V32 stated V32 does not remember the exact dates, but V32 knows that whenever V53 does not like what V53 sees in the hallway V53 will get mad and cuss at staff members. V32 stated V32 has heard V53 say to staff you all are F***** (expletive) S****** (expletive), why don't you take your head out of your A***** (expletive)! R15's Minimum Data Set (MDS) completed on 3/20/2026 documents R15 is cognitively intact. R15's Care Plan with revision date of 8/15/2025 documents R15 is at risk for altered well-being and/or psychological distress related to history of abuse. On 3/24/2026 at 10:06 AM, R20 stated R20 never heard V53 Administrator cuss or use vulgar words, but R20 knows V53 was not a nice person. R20 stated sometime in February R20 went to V53's office to tell V53 about a missing part on R20's wheelchair. R20 stated V53 got mad and walked out of the office. R20 stated V53 did not even look at R20's wheelchair. R20 stated R20 served in the military for 20 years, and R20 was respected but R20 never felt respected by V53 at that time. R20 stated that R20 felt upset because R20 knew what leadership was supposed to look like, and V53's reaction at that time did not reflect that. R20 stated that R20 felt as though V53 was looking down V53's nose at R20. On 3/24/2026 at 2: 28 PM, V32 Receptionist stated V32 has seen R20 going to V53 Former Administrator's office in the past but V32 never knew what was discussed. R20's Minimum Data Set (MDS) dated [DATE] documents R15 has moderate cognitive impairment. The Facility's Conduct and Behavior Policy with a revised date of 2/11/2025 documents all team members must adhere to accepted professional standards. This includes displaying business conduct and behaviors and always exhibiting high integrity. Examples of conduct and behavior that are considered inappropriate and are prohibited by this company include, but not limited to the following: Using profanity, abusive or suggestive languages or gestures, or any other unprofessional behavior. Conflicts between employees should not be discussed in front of visitors or residents and should always be settled in a calm manner.

Based on observation, interview, and record review, the facility failed to recognize and respond to a change in condition that required immediate intervention for two (R1, R8) of three residents reviewed for quality of care and failed to implement the physician's order for continuous oxygen therapy for one (R8) of three residents reviewed for oxygen in a sample of 23 residents. These failures resulted in R8 experiencing acute respiratory distress and being sent to the emergency department for hypoxia. R8 was diagnosed with Acute Respiratory Failure and Acute Congestive Heart Failure exacerbation.Findings Include:1.On [DATE] at 9:36 AM, R8 was observed lying in bed with oxygen at two (2) liters per minute via nasal cannula. R8 appears frail and opens and closes R8's eyes in response to verbal stimuli but does not answer questions or follow commands. R8's lips were noted to be dry and cracked. R8 did not verbally respond during this interaction. R8's Minimum Data Set (MDS) dated [DATE] documents that R8 has the following active diagnoses: Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease, and Chronic Respiratory Failure with Hypoxia, and Congestive Heart Failure. This MDS documents that R8 has severe cognitive impairment and requires continuous oxygen therapy as well as non-invasive mechanical ventilation. R8's Care Plan dated [DATE] documents that R8 has altered respiratory status and difficulty breathing related to Pulmonary Edema, Sleep Apnea, chronic respiratory failure and COPD with an intervention for staff to monitor R8 for signs and symptoms of respiratory distress and report to medical doctor as needed if R8 has any of the following: increased respirations; decreased pulse oximetry; increased heart rate; restlessness; diaphoresis; headaches; lethargy; confusion; hemoptysis; cough; pleuritic pain; or if observed using accessory muscle; and any skin color changes to blue/grey. An additional intervention for this problem area dated [DATE] documents that R8 is to have oxygen via nasal prongs at 2 liters continuously and that R8 will have no complications related to shortness of breath (SOB) though the review date. R8's Electronic Health Record (EHR) contains a hospital discharge summary documenting that R8 was hospitalized from [DATE]–[DATE] and intubated for acute respiratory failure with hypoxia and acute on chronic diastolic heart failure; discharged back to the facility [DATE]. R8 returned to the facility on [DATE] with a physician's order for continuous Oxygen at 2 liters via nasal cannula. On [DATE] at 11:42 AM, V20 Licensed Practical Nurse (LPN) stated V20 recalls the night of [DATE] when R8 was drowsy and complained of shortness of breath (SOB) with a respiratory rate (RR) of 44. V20 stated V20 administered a nebulizer treatment and rechecked R8's vital signs and notified the oncoming nurse of the resident's condition. R8's Electronic Health Record (EHR) documents the post nebulizer treatment respiratory rate on [DATE] at 7:18 AM was 36 breaths per minute. No provider notification is documented at that time. R8's EHR contains a progress note dated [DATE] by V42 LPN and documents that V42 entered R8's room and observed R8 experiencing SOB. This note documents that V42 performed an assessment and R8 was noted to have wheezing with evaluated respirations at 28 breaths per minute. This progress note documents that R8 has a known history of Chronic Obstructive Pulmonary Disease (COPD). V42 documented that she obtained R8's vital signs with the following abnormal findings: heart rate (HR) 109 bpm (beats per minute), RR 28 breaths per minute and oxygen saturation 93% on five (5) liters of oxygen via nasal cannula. V42 documents that a nebulizer treatment was administered to R8. V2 documented that R8's vital signs were reassessed post treatment with the following findings: HR 102 bpm, and RR 24 breaths per minute. No provider notification is documented at that time. On [DATE] at 12:36 PM, V42 LPN stated the day prior to R8 being sent to the hospital V42 was the nurse taking care of R8 on the night shift. R8 stated it was around 5:00 AM when V42 went into R8's room to give R8's morning medication when V42 found R8 struggling to breathe. V42 stated V42 asked R8 if R8 was having a hard time breathing and R8 shook R8's head yes. V2 stated V2 works through an agency and was unsure of the facility protocol regarding how to handle a resident experiencing SOB, so V2 asked the registered nurse (RN) working the floor and the RN told her to give the resident breathing treatment and pass along to the day shift. On [DATE] at 11:07 AM, V47 RN stated R8 had been in and out of the hospital recently, so V47 had been monitoring R8's vital signs closely during the night shift. V47 stated that on the night prior to R8's admission to the hospital on [DATE], V47 observed that R8's respirations were fast and shallow, but R8's other vital signs appeared stable, so V47 was not concerned. V47 stated that when V47 assessed R8's respirations and obtained a respiratory rate of 31, V47 was not concerned because he did not notice any dramatic change from R8's usual presentation. On [DATE] at 4:14 PM, V51 RN for V64 Nephrologist stated R8 had an appointment with V64 on [DATE] and that according to V64's progress notes from this visit it documents that R8 presented to the office in acute respiratory failure 911 was called and R8 was sent to the emergency department for further evaluation. On [DATE] at 10:07 AM, V52 Transport Driver stated that on [DATE], when V52 transported R8 to V64's office, R8 did not appear to be doing well. V52 stated that R8 was breathing fast, and R8's breathing became worse during the drive to the clinic. V52 reported that V52 was concerned about R8's condition, and upon arrival at the appointment, V52 informed the receptionist that R8 was not doing well. V52 was unsure if R8 was wearing oxygen. On [DATE] at 12:04 PM, V38 Assistant Director of Nursing (ADON) stated that a floor nurse (unsure of name) informed V38 that R8 had been at a routinely scheduled appointment, and that the doctor sent R8 to the emergency room because R8 was lethargic. V38 stated that R8 had been in and out of the hospital recently for Congestive Heart Failure exacerbations. V38 stated that the nurse should have called the physician or sent R8 out with a respiratory rate of 44 breaths per minute and complaints of shortness of breath. V38 stated a respiratory rate of 44 breaths per minute is a significant clinical finding. On [DATE] at 3:34 PM, V51 the RN for V64 (Nephrologist) called back to report that V51 had spoken with V64, who was currently on vacation. V51 stated that V64 confirmed R8 was only arousable to verbal stimuli during R8's appointment on [DATE]. V51 also stated that V64 told him that R8 had been slumped in R8's wheelchair, R8's respirations were fast and shallow, and R8 was not wearing oxygen at the time of the appointment. On [DATE] at 9:05 AM, V61 Nurse Practitioner (NP) stated R8 had been hospitalized in February 2026 for Congestive Heart Failure, Respiratory Failure, and COPD, and that R8 was intubated during that hospitalization. V61 stated that if V20 documented R8's respirations correctly, a respiratory rate of 44 was much too fast, and one of the providers should have been notified immediately. V61 also stated that R8 should not have been sent out of the facility without oxygen on [DATE], especially considering her recent hospitalizations and diagnoses. V61 stated that because there was an active physician's order for continuous oxygen, R8 should have been wearing oxygen to prevent oxygen saturation levels from dropping below 90%, which may lead to hypoxia, shortness of breath, and fast, shallow breathing. An Emergency Department Physician Note dated [DATE] at 1:53 PM documented that R8 presented to the emergency department with shortness of breath, had an oxygen saturation of 86 percent and was hypoxic upon arrival. The note documented that R8 was diagnosed with Acute Respiratory Failure and a Congestive Heart Failure Exacerbation, was placed on BiPAP, and was admitted to the hospital. 2. R1's Electronic Health Record (EHR) documents that R1 was admitted to the facility on [DATE] for rehabilitation after a fall at R1's assisted living facility that resulted in a left femur fracture. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 requires partial to moderate assistance with transfers and is independent with feeding. This MDS also documents that R1 is cognitively intact. On [DATE] at 9:14 AM, V67 Certified Nurse Assistant (CNA) stated V67 cared for R1 on the night of [DATE] and that R1 was at baseline that night. V67 stated R1 was alert and able to voice R1's needs. V67 stated R1 slept through the night and only woke up during rounds. V67 stated R1 was not in any distress and did not complain of any discomfort that night. On [DATE] at 9:20 AM, V68 Registered Nurse (RN) stated V68 was the nurse who cared for R1 on the day prior to R1's passing on [DATE]. V68 stated that V68 was familiar with R1, having cared for R1 on previous occasions. V68 stated that R1 was stable throughout that day on [DATE]. V68 stated V68 was very surprised the next time V68 returned to work and learned that R1 had passed away. V68 further stated that CNAs are responsible for obtaining residents' vital signs and that V68's role is to document the vital signs provided to her. V68 stated that V68 was unaware that the vital signs documented on [DATE] and [DATE] were the exact same readings both days (Blood Pressure 133/52, Pulse 61). On [DATE] at 8:44 AM, V66 CNA stated that V66 was very familiar with R1 and had been assigned to R1 the night prior to R1's passing on [DATE]. V66 reported that V66 assisted R1 to bed that evening and recalled having a pleasant conversation with R1 as V66 helped R1 get ready. V66 stated that nothing unusual occurred during the shift and that R1 appeared to be at R1's baseline and comfortable when R1 was put to bed. V66 added that V66 was completely surprised when V66 returned to work the following evening and was informed that R1 had passed away. R1's EHR documents that on [DATE] R1 had multiple indicators of a change in condition. R1's EHR documents that on [DATE] at 07:08 AM, R1's blood pressure was obtained with a reading of 98/45 with a pulse of 61 and documented that R1's blood pressure was taken in the left arm while R1 was lying in bed. R1's Medication Administration Record (MAR) dated [DATE] at 7:07 AM documents that R1's blood pressure was 98/45. This MAR documents that V23 held R1's Metoprolol 100 milligrams (mg). R1's physician order includes Metoprolol parameters to hold if Systolic Blood Pressure is less than 120 or heartrate less than 60 beats per minutes. This MAR also documents that V23 held R1's Adolophine 10mg, which had no parameters, but was held and there was no documentation that the physician had been notified that this medication was held. R1's EHR did not include any documentation showing there was any follow-up assessment, monitoring, or notification to R1's doctor regarding R1's hypotensive episode. R1's EHR also showed no Certified Nursing Assistant (CNA) documentation on [DATE] and [DATE] regarding R1's meal consumption. R1's EHR does not show that any skilled assessments or nursing progress notes were completed for R1 on [DATE] and [DATE]. Last skilled documentation on record was [DATE]. R1's EHR documents that R1 refused breakfast at 8:35 AM on [DATE], and this refusal was recorded on the Certified Nursing Assistant (CNA) eating task in the EHR by V60 CNA. R1 experienced a large, loose incontinent bowel movement at 9:09 AM on [DATE], as documented by V60 CNA on the CNA Bowel and Bladder record in R1's EHR. On [DATE] at 10:17AM, V60 CNA stated R1 was pale, lethargic, weak, and refused breakfast on the morning of [DATE] and that R1 complained of not feeling well. V60 CNA stated V60 reported these findings to V23 Licensed Practical Nurse (LPN) at approximately 9:09 AM but stated V60 did not observe any further follow-up to R1's condition after V60 reported it to V23. On [DATE] at 10:00 AM, V62 Nurse Practitioner (NP) stated on [DATE] at 10:12 AM, V62 assessed R1 and noticed R1 was pale, weak, had a dry mouth, and exhibited decreased alertness compared to baseline. V62 stated V62 immediately reported this to V23 and told V23 that R1 was not feeling well and requested nausea medication. V62 stated V62 then called V61 NP and reported V62's concerns related to R1's change in condition. On [DATE] at 9:14 AM, V23 LPN, confirmed that V23 was aware of R1's low blood pressure and that R1 was ill on the day of R1's passing. V23 stated V23 did not physically assess R1 prior to going to lunch at 11:01 AM on [DATE], and instead only visually observed R1 from outside the room because R1 was sleeping and V23 didn't want to bother her (R1). V23 stated V23 did not notify the provider regarding R1's condition, stating that was V23's nursing judgment. V23 also stated V23 administered anti nausea medication, but no documentation of anti nausea medication administration was found in the electronic medical record at the time of review; V23 confirmed the lack of documentation and stated V23 was unsure of the time the medication was given. R1's EHR contains a late entry nursing progress note on [DATE] at 3:10 PM by V23 LPN which stated: V23 checked in on resident to assess pain and nausea. Resident noted sleeping in the bed on her left side. Respirations even and unlabored. Call light in reach. On [DATE] at 9:35 AM, V37 Director of Nursing (DON) stated V23 LPN should have documented the change in R1's condition and notified the physician promptly after V60 CNA reported that R1 appeared more lethargic, pale, and weak. On [DATE] at 8:38AM, V2 Regional Nurse Consultant confirmed the nurses should have assessed, followed up and documented R1's condition. R1's EHR contains a progress note completed by V62 NP dated [DATE] at 10:12 AM documenting that R1 was seen resting in bed, appearing ill. V62 documented that R1 was drowsy but arousable to voice, reported not feeling well, appeared pale, and had a dry mouth. V62 further documents that R1 continued to complain of nausea and fatigue, and V62 advised nursing staff to administer a dose of Compazine, as R1 had not yet requested that morning. V62 documented that R1's vital signs were reviewed and appeared stable, with the exception of a blood pressure of 98/45, noted as low. V62 documented that R1's clinical presentation was discussed with V61 NP, and that laboratory testing and/or further evaluation was recommended. On [DATE] at 8:59 AM, V61 Nurse Practitioner (NP), stated V61 received a call on [DATE] at approximately 10:20 AM from V62 Hospital Nurse Practitioner, who reported concerns that R1 was paler, had a dry mouth, and didn't feel good. V61 stated that when V61 arrived at the facility and was walking past R1's room, R1's family friends stopped V61, appearing visibly upset and telling her they believed something was wrong with R1. V61 stated V61 entered R1's room and immediately observed R1 lying on her left side in bed. V61 stated V61 checked R1 for a pulse and found that R1 had no pulse, was cold, and was unresponsive. V61 stated V61 then immediately went to the office of V38 Assistant Director of Nursing (ADON), and a Code Blue was called. Cardiopulmonary resuscitation (CPR) was initiated. V61 stated that if staff had notified V61 earlier regarding R1's condition, interventions such as laboratory testing, intravenous hydration, or hospital transfer could have been initiated, which had the potential to prevent this outcome. On [DATE] at 10:26AM, V71Oncologist stated that R1 has been seeing him since [DATE] with continued treatment for anemia, cancer of the liver and colon which was diagnosis in [DATE]. V71 stated that while R1 was in the hospital with a fracture, V71 observed R1 in stable/baseline condition when seeing R1 at the end of January. R1 had to discontinue treatment due to admitting to acute rehab and was planning on restarting chemotherapy on discharge from the facility. V71 stated R1's diagnosis was not curable but V71 stated the last time V71 saw R1 she was stable. On [DATE] at 09:46 AM, V62 Nurse Practitioner stated V62 had seen R1 on [DATE] and reported V62's concerns about R1 immediately to V61 Nurse Practitioner and suggested that R1 would benefit from a total work up because of the changes in condition. V62 stated that per V61, V61 will see R1 that day. V62 stated V62 was concerned about the changes in R1's condition enough to call V61 immediately. V62 stated V62 can give an order, but V62 only takes care of pain and bowels, V62 leaves everything else to the facility nurse practitioner or physician. On [DATE] at 10:21 AM, V61 stated V62 called V61 on [DATE] at around 10:20 AM and reported V62's concern about R1's changes in condition. V61 stated V62 asked if V61 can look at R1 that day. V61 put R1 first on the list to see when arriving at the facility. V61 stated V61 was not aware that two blood pressure medicines were held the morning of [DATE] by V23 Licensed Practical Nurse (LPN) due to blood pressure being 98/45. V61 stated V23 LPN did not provide any notification from the facility about R1's blood pressure of 98/45. V61 stated if V23 LPN would have notified V61, V61 would have ordered V23 to encourage R1 to drink more fluids and recheck blood pressure after an hour and go from there. On [DATE] at 12:18 PM, R1 was found unresponsive in bed by V61. Cardiopulmonary resuscitation was initiated, and emergency services were contacted. R1 was subsequently pronounced deceased at 12:33 PM on [DATE]. The facility's Notification of Changes Policy dated [DATE] documents that the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance guidelines for this policy documents that circumstances requiring notification include: 1. Accidents a. Resulting in injury. b. Potential to require physician intervention. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. The facility's Oxygen Administration Policy dated [DATE] documents that oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. Definitions: Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (2.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia. Hypoxia means decreased perfusion of oxygen to the tissues. Policy Explanation and Compliance Guidelines: Oxygen is administered under orders of a physician, except in the case of an emergency. In such case oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 2. Personnel authorized to initiate oxygen therapy include physicians, Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and respiratory therapists. 3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. 12. Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen.

Based on observation, interview and record review, the facility failed to employ a full-time certified dietary manager. This failure has the potential to affect all 83 residents.Findings Include:On 03/23/26 at 10:15am, V17 Dietary [NAME] stated there was not a Certified Dietary Manager (CDM) when asked if there was a CDM.On 03/23/26 at 2:00pm, V43 Corporate Dietary Manager stated the facility employed a CDM V44 who works part time.On 03/24/2026 at 09:15am, V43 Corporate Dietary Manager stated the facility does not have a full time Certified Dietary Manager at this time. V43 stated V44 works every Tuesday, Thursday and Friday.On 03/24/2026 at 09:20am, R15 Resident Council President, stated the facility only has a part-time CDM and V44 is usually unavailable.On 03/24/2026 at 09:25am, Employee Roster review documents V44 CDM as a part-time employee. On 03/24/2026 at 2:27pm, V44 CDM was unavailable for interview due to not being in the facility at this time. V44 did not answer the telephone at the time call was placed.The facility's midnight census dated 3/22/2026 documents that there are 83 residents that reside in the facility. R15's Care plan dated 06/24/2023 documents an admission date of 06/20/2023, care plan documents diagnosis of Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Localized Swelling, Mass and Lump, Essential (Primary) Hypertension, Post-Traumatic Stress Disorder, Gastro-Esophageal Reflux Disease With Esophagitis, Atherosclerotic Heart Disease Of Native Coronary Artery with Angina Pectoris, Myocardial Infarction, Diseases Of The Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism, and Generalized Epilepsy and Epileptic Syndromes. R15's Minimum Data Set, dated [DATE] documents R15 is cognitively intact.

Based on observation, interview and record review the facility failed to follow the menu as printed/posted. This failure has the potential to affect all 83 residents. Findings Include:On 03/23/2026 at 12:10pm, the posted lunch menu in the dining room documents Ravioli bake, Cauliflower, Bread Stick, Apple Orchard Bar and a beverage. On 03/23/2026 at 12:15pm, lunch observation was conducted in the main dining room. Residents received a main course of ravioli bake, Vegetable of the day was to be cauliflower which some residents received, some residents received mixed vegetables due to kitchen running out of cauliflower, no dessert was served on the tray at time of distribution.On 03/23/2026 at 12:20pm, conversations with random residents stated they would have preferred to have the cauliflower over the mixed vegetables and that the kitchen frequently runs out of various foods.The grievance log documents on 03/2/26 a resident and their power of attorney had concerns with missing food items.The grievance log documents on 01/07/26 resident council concern of facility running out of food.The grievance log documents on 01/15/26 a resident filed concern that the kitchen staff stated they run out of food items.Resident council minutes dated 1/7/26 documents the kitchen does not have enough food and runs out of things.On 03/23/2026 at 1:05pm, R11 stated most of the time the kitchen sends different food than what is on the menu.On 03/23/2026 at 1:56pm, R10 stated the menu and what food is served often do not match.On 03/23/2026 menu documents lunch meal as ravioli bake, cauliflower, bread stick, Apple orchard bar and a beverage.On 03/23/2026 at 10:15am, V17 cook stated today's menu is cheese ravioli, cauliflower, bread stick and ice cream. V17 stated there is no apple orchard bar.On 03/25/2026 at 11:25am, V43 Corporate Dietary Manager confirmed on 03/23/25 the lunch meal cauliflower was substituted after running out due to not having enough supply and the apple orchard bar was not prepared and served by staff. On 3/23/26 at 1:37pm, V16 Dishwasher stated that sometime in February that all the residents received for breakfast was a donut and fruit, but V16 is not sure why. V16 stated they ran out of Cauliflower today because they only had one (1) bag, and they offered mixed vegetables as an alternative. V16 stated the kitchen runs out of food and is unable to follow the menu frequently. R11's Care Plan documents an admission date of 07/31/2025, care plan documents diagnosis of Anemia, Essential (Primary) Hypertension, Personal History of Other Venous Thrombosis and Embolism, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, Gout, Localized Edema, Insomnia, Chronic Diastolic (Congestive) Heart Failure, Hyperlipidemia, Morbid (Severe) Obesity Due to Excess Calories, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, and Peripheral Vascular Disease. R11's Minimum Data Set, dated [DATE] documents R11 is cognitively intact.R10's Care plan documents an admission date of 03/05/2026, care plan documents diagnosis of Hyperlipidemia, Essential (Primary) Hypertension, Lichen Simplex Chronicus, Abnormal Levels of Other Serum Enzymes, Other Malaise, Lymphedema, Age-Related Physical Debility, Non-Pressure Chronic Ulcer of Right Calf with Unspecified Severity, Non-Pressure Chronic Ulcer of Left Calf, Cellulitis of Left Lower Limb, and Metabolic Encephalopathy. R10's Minimum Data Set, dated [DATE] documents R10 is mildly cognitively impaired.The facility's midnight census dated 3/22/2026 documents that there are 83 residents that reside in the facility.

Based on observation, interview, and record review the facility failed to hold and serve food at 135* Fahrenheit degrees or above. This failure has the potential to affect all 83 residents.Findings Include:On 03/23/2026 at 12:15pm, three (3) random lunch trays being plated at the serving window for resident consumption had a temperature of the ravioli bake taken at 108 degrees Fahrenheit.On 03/23/2026 at 12:15pm, lunch observation was conducted in the main dining room included the temperatures of random meal trays. One meal tray contained the main course of baked ravioli at a temperature of 95.3 degrees Fahrenheit. Another meal tray containing two (2) hamburger patties on buns, the hamburger meat recorded temperature 79.5 degrees Fahrenheit and the last tray temperature in the dining room contained cauliflower as the vegetable temperature of 86 degrees Fahrenheit.On 03/23/2026 at 12:15pm, V18 Certified Nurse's Assistant confirmed the temperatures of the food trays as the temperatures were being taken on the food trays being served in the dining room to residents.On 3/23/26 at 1:37pm, V16 Dishwasher stated that the food is not usually cold but today it might have been because just before serving the steam table broke down.On 3/25/26 at 11:25am, V43 Corporate Dietary Manager confirmed the steam table was broken on 3/23/26. V43 stated while observing meals the staff would open the doors of the hot cart, remove a food tray and take it to the resident leaving the doors of the hot cart open which allows the food to cool. Food temperature policy dated 11/10/21 documents the policy is to ensure food safety the hot food is cooked to a minimum safe temperature and is held at no lower than 135 degrees Fahrenheit. Page two of the same policy documents hot food holding temperatures are taken and recorded for food on the steam table. Hot food is held on the steam table at 135 degrees Fahrenheit or higher.The grievance log review documents on 3/4/26 that meat needs to be cooked more precisely, on 2/4/26 that meal was unappetizing, the potatoes were cold and undercooked, and the food is coming out cold to rooms and the dining room.Resident Council minutes dated 2/4/26 document the meat is overcooked, and the food is cold.The facility's midnight census dated 3/22/2026 documents that there are 83 residents that reside in the facility.

Based on interview and record review the facility failed to serve the dinner meal during the posted time of 5:30pm to 6:30pm. This failure has the potential to affect all 83 residents.Findings Include:R11's Care Plan documents an admission date of 07/31/2025, care plan documents diagnosis of Anemia, Essential (Primary) Hypertension, Personal History of Other Venous Thrombosis and Embolism, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, Gout, Localized Edema, Insomnia, Chronic Diastolic (Congestive) Heart Failure, Hyperlipidemia, Morbid (Severe) Obesity Due to Excess Calories, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, and Peripheral Vascular Disease. R11's Minimum Data Set, dated [DATE] documents R11 is cognitively intact. On 03/23/2026 at 1:05pm, R11 stated on an unknown date in February that the dinner meal did not arrive until 8:30pm. V29 (R11's) family, at bedside confirmed R11 spoke to V29 in late February about not being served dinner till 8:30pm.On 03/24/2026 at 09:06am, V48 Registered Nurse stated and confirmed there was an unknown date in late February that the dinner meal was not served until after 8:00pm.On 03/24/2026 at 09:08am, V47 Registered Nurse stated on an unknown date in February the dinner meal was served very late due to the kitchen staff calling in.On 03/24/2026 at 09:14am, V37 Director of Nursing confirmed on an unknown date in February the dinner meal was served very late due to the kitchen staff calling in. V37 stated some of the certified nurses' aides went into the kitchen to help prepare the dinner meal.On 03/24/2026 at 11:30am, V43 Corporate Dietary Manager confirmed on 02/25/26 that the evening meal was served late due to kitchen staff shortage due to staff calling in. The grievance log review documents on 02/25/26 the dinner meal was served late.Resident Council minutes dated 1/7/26 at 10:07am documents meals are served late. The facility's midnight census dated 3/22/2026 documents that there are 83 residents that reside in the facility.

Based on interview and record review, the facility failed to ensure staff maintained professional standards of conduct, including accurate, truthful, and timely documentation in the medical record for four (R4, R7, R15, and R20) of four residents reviewed for falsification of records/reports for a total sample of 23 residents.Findings Include:Review of the Point of Care (POC) Audit Report printed on 3/27/2026 documents R4, R7, R15 and R20 were included on the list of residents that have missing documentation for Activities of Daily Living (ADL): Bathing on the POC Audit Report for the period of 1/5/2026 through 3/26/2026.On 3/31/2026 at 10:48 AM, V5 Certified Nurse Assistant (CNA) stated V5 was given a four-page list of residents V5 needs to complete retroactive documentation on. V5 stated V5 was not comfortable going back to document from the past days because V5 does not remember what all happened. V5 stated V5 had to make up information which V5 was not comfortable with. V5 stated V5 was told V5 would be taken off of the schedule, and V5's job will be on the line if V5 does not complete the documentation.On 03/31/2026 at 1:15 PM, V7 CNA stated V7 received a four-page list of residents identifying tasks V7 allegedly failed to document on. V7 stated V7 was instructed to complete documentation retroactively for the period of January 7, 2026, through March 2026. V7 stated V69, Certified Nursing Supervisor, informed V7 that failure to complete the missing charting for the listed residents would result in removal from the work schedule, termination of employment, and potential revocation of V7's CNA license. V7 stated V69 indicated these directives originated from Corporate. On 03/31/2026 at 1:26 PM, V69 Certified Nursing Supervisor stated V3 provided V69 with a list of residents and instructed V69 to distribute the list to CNAs. V69 reported V69 was directed that staff members would be removed from the schedule if the required documentation was not completed. V69 further stated V69 was acting as a middleman in communicating these instructions and reiterated CNAs who failed to complete their charting would be removed from the schedule.On 3/30/2026 at 1:26 PM, V15 CNA stated V15 received a list of residents V15 needs to go back and document the care V15 provided from March 7, 2026, to current date.On 3/30/2026 at 1:33 PM, V8 CNA stated V8 received a list of residents V8 needed to go back, and document care provided all the way back from January 2026. V8 stated V8 was told V8 will be taken off the schedule if V8 does not complete the documentation. V8 stated V8 documented N/A on most documentation because V8 did not have any clue on who V8 was charting on and did not want to lie on the documentation because V8 does not remember what care V8 provided on those days. V8 stated some of the required tasks were showers and meals and other tasks mostly on day shifts. V8 stated when V8 goes back to document, there were other tasks required to complete other than showers.On 3/30/2026 at 1:42 PM, V3 Regional Nurse Consultant stated V3 ran a report of missing documentation and asked V69 Certified Nursing Supervisor to have nursing staff complete the documentation so there were no holes in the report. V3 stated V3 does not know how far back V3 ran the report for. V3 stated V3's expectation was whoever was assigned that day must go back and complete the documentation.Review of the facility policy for documentation in Medical Record with revised date 02/02/2026 documents each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through compete, accurate, and timely documentation. Policy explanation and compliance guidelines documents:Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.Documentation shall be timely and in chronological order.

Based on observation, interview and record review, the facility failed to perform timely testing of residents with respiratory infection symptoms during a known Respiratory Syncytial Virus (RSV) outbreak for two of five residents (R3, R19) reviewed for infection control in the sample of 23 residents.Findings Include:On 3/25/26 at 9:07 am, V38 Assistant Director of Nursing (DON)/Infection Preventionist (IP) stated the facility had been in an RSV (Respiratory Syncytial Virus) outbreak which affected eleven residents. V38 DON/IP also stated that there was a delay in testing some residents because of agency staff using the wrong materials, which V38 caught after returning to work after the weekend.The ongoing Infection Control Log documents the first confirmed case of RSV on 2/20/26.On 3/25/26 at 9:40 am, V2 [NAME] President of Clinical Services stated that the facility policy and Department of Public Health guidance is to test for COVID-19 infection first when a resident presents with respiratory illness, even during the RSV outbreak. V2 then stated that the delay in testing for RSV was because the facility was having trouble getting swabs to test for RSV.1.On 3/24/26 at 9:12 am, R3 was sitting up in a wheelchair in R3's room. R3 appears clean and well groomed. R3 stated R3 hasn't had much of a voice for a week or so since being sick. R3's Laboratory Tests dated 2/24/26 documents R3 was tested for RSV, which was negative.R3's Progress Notes document the following:2/27/26 - R3 tested negative for RSV but is still having congestion.3/2/26 - R3's oxygen saturation is 89%, started on two (2) liters of oxygen and physician notified due to not receiving a response from the physician over the weekend.R3's submitted laboratory test dated 3/2/26 for RSV documents The specimen collected is not acceptable for the test ordered. Please submit a nasopharyngeal swab in a red cap viral transport medium.R3's next Laboratory Test dated 3/3/26 documents R3 tested positive for RSV.2. On 3/24/26 at 9:25 am, R19 was resting in bed and appeared clean and well groomed. There was an EBP (Enhanced Barrier Precaution) sign on R19's room door.R19's Progress Notes dated 2/27/26 documents R19 spiked a fever of 102.1 last night. Denies shortness of breath. Physician notified and awaiting response. R19 was tested for COVID-19 at this time and was negative.R19's Progress Notes dated 3/1/26 documents R19 has wheezing in bilateral upper lobes. Physician notified and chest x-ray ordered. Was tested for COIV-19 again, which was negative. R19 then swabbed for RSV, COVID and Influenza.R19's Laboratory Test documents, the RSV, COVID and Influenza specimen were collected on 3/2/26 with results of a positive RSV test reported to the facility on 3/3/26.The facility's Infection Prevention and Control Program Policy dated 2/10/26 documents the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The designated Infection Preventionist is responsible for the oversight of the program and monitors staff and resident exposures, surveillance and epidemiological investigations of exposures to infectious disease.

Based on Interview and Record Review the facility failed to answer a call light in a timely manner that resulted in a fall with injury for one (R1) resident of three residents reviewed for falls in a sample list of three residents. This failure resulted in R1 rolling from the bed, complaining of pain, requiring transfer to the local emergency room and diagnosed with multiple left and right rib fractures. Findings Include:R1's Progress Note written by V7 Licensed Practical Nurse dated 1/6/26 at 6:15 PM, documents R1 was observed lying face down between R1's bed and the wall. R1's roommate was yelling for help when the Certified Nurse Assistant entered the room and observed resident on the floor. It appeared R1 was reaching for something and rolled out of the bed. The bed was regular height. R1 was turned over carefully and R1's head was placed on a pillow. R1 didn't answer when asked what she was doing. 911 was called as R1 did say she was in pain all over. R1 was transported to a local emergency room Department at 6:40PM on 1/6/26.R1's Emergency Department Notes dated 1/6/26 at 10:58PM document R1 has a nondisplaced right lateral fifth through ninth rib fracture and nondisplaced acute fractures of the anterior left sixth, seventh, eighth and tenth ribs.R1's Minimum Data Set assessment dated [DATE] documents R1 is cognitively intact.R1's Care Plan documents a fall intervention to ensure bedside table is next to R1's bed, where R1 can reach R1's items dated 12/8/25 and to keep call light within reach at all times dated 5/12/2025.On 2/09/26 at 10:38AM, R1 and V12 (R1's Family) stated R1 was transferred to another facility due to this incident. V12 stated R1 put on R1's call light to get someone to help R1 get popcorn off the floor that R1 wanted to eat. R1 stated R1's call light was on for approximately 40 minutes. R1 went to reach for the popcorn and rolled out of bed onto the floor. R1 stated R1's roommate started yelling for help. On 2/09/26 at 11:45 AM, V6 Director of Rehab stated at times the call lights go off for over 30 minutes as there are only two Certified Nursing Assistants on second and third shift at times.On 2/09/26 at 12:15PM, V7 Licensed Practical Nurse, stated there were two Certified Nursing Assistants on the floor and a trainee. V7 stated that R1 was reaching for something on the floor when R1 rolled out of bed. V7 stated, the facility staff try to answer call lights in a reasonable time, but at times facility staff are with other residents or in the dining room. V7 stated that R1 had a pressure relieving mattress for R1's wound and when R1 went to reach for something, R1 most likely slid off the bed.On 2/09/26 at 1:30PM, V4 Registered Nurse stated that at times the staff can't get to the resident soon enough after the call light is activated. V4 stated R1 was also a mechanical lift and had a pressure relieving mattress.On 2/10/26 at 9:30AM, V8 Certified Nursing Assistant stated that there were two certified nursing assistants for 27 residents due to a Certified Nursing Assistant was going with another resident to a doctor's appointment. V8 stated especially at nighttime and during dinner time and bedtime, the call lights can go off for over 20 to 40 minutes. On 2/10/26 at 10:00AM, V2 Director of Nursing stated the facility staff should be answering call lights in a reasonable time frame which would be less than 10 minutes. Facility Call light Policy revised on 1/26/2026 documents the facility will be equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. This policy also documents response times should be a priority.The Facility Incident and Accidents policy revised on 2/2/2026 documents that assuring that appropriate and immediate interventions are implemented, and corrective actions are taken to prevent recurrences and improve the management of resident care.

Based on Observation, Interview, and Record Review the facility failed to prevent esophageal obstruction during medication administration by administering multiple medications at a time for one (R2) resident of three residents reviewed for medication administration on the sample list of three residents. This failure resulted in R2's esophagus becoming obstructed, with an inability to breath, the Heimlich maneuver was performed, and R2 was transferred to the local emergency room for further evaluation. Findings Include:Nursing Progress note dated 1/17/2026 at 8:00 PM documents at approximately 7:45 PM V13 Registered Nurse (RN) was called to room by a Certified Nursing Assistant (CNA) who reported the resident (R2) was not able to breathe. Writer entered room and observed the resident's lips being cyanotic; (R2's) Oxygen level was observed at 64% and the writer asked the resident (R2) if she could breathe and the resident (R2) shook her head side to side indicating no. Writer assessed airway and could not see anything obstructing the airway, the resident (R2) put hands to her throat indicating she was choking. Writer sent CNA to go get another nurse and the crash cart. Writer began performing the Heimlich maneuver on resident (R2), resident then went unresponsive. Writer continued the Heimlich maneuver an additional three times and observed resident (R2) throw up what appeared to be applesauce and undigested food. Resident (R2) was unconscious less than one minute and was able to start answering questions approximately two minutes after regaining consciousness. 911 was activated upon second RN entering the room. Resident (R2) gagged and appeared to swallow and forcibly coughed with a gurgle sound, writer leaned resident onto right side and resident threw up a second time. Writer applied high flow nasal cannula and observed residents' oxygen saturation increase to 96%. Resident (R2) was able to answer questions via her communication board. Resident wrote on her board that I (R2) laid my bed down too fast after having a snack. Resident immediately educated to keep head of bed elevated at minimum 45 degrees and to tuck her chin when she is experiencing difficulty swallowing. Resident (R2) shook her head up and down indicating understanding. Resident wrote she feels better but still feels like Something is in her lungs. EMS/emergency medical service arrived and was given report, copy of face sheet, SBAR (Situation-Background-Assessment-Recommendation), bed hold policy and POLST (Practitioner Order Form Life-Sustaining Treatment) form. Voicemail left for contact on residents (R2's) profile via the other nurse. Writer called and spoke to ER charge at the local hospital and gave an additional verbal report. Writer also called the on-call provider for the facility and notified her of this occurrence. Resident agreeable to going to the hospital for further evaluation. Resident left with EMS on room air at 95% and shaking her head and using her tablet to answer questions for EMS. Resident transferred out at approximately 8:10 PM. Physician answering service notified resident was sent out with voicemail to call the facility back with any further questions.R2's Emergency Department Notes dated 1/17/2026 at 9:31 PM document R2 was seen for choking episode/aspiration.R2's Minimum Data Set assessment dated [DATE] documents R1 is cognitively intact. The GG assessment reports R2 is dependent with transferring, turning, and repositioning. R2 is also set up/supervision with eating. Physician Orders Dated 12/21/2025 documents Speech therapy Clarification: Swallowing evaluation completed on R2. Patient with mild lingual weakness but able to score a seven on the Functional Oral Intake Scale indicating regular texture with thin liquids, however, four minutes status post swallow patient noted to cough stating it was due to texture with thin liquids, however, four minutes status post swallow R2 was noted to cough when R2 consumed anything by mouth, stating it was due to dryness but maybe reflux response based on latency of cough. Speech therapy recommended two times a week for four weeks to address safe swallowing strategies and muscle strengthening.Speech Evaluation Therapy Notes dated 1/15/26 documents that R2 was seen for a swallowing evaluation due to concerns R2 could not swallow multiple pills over the weekend when presented by the agency nurse. R2's able to safely swallow one pill at a time with applesauce. This document also states R2 is concerned about swallowing pills on the weekend when agency staff is present.On 2/10/26 at 8:07AM, R2 wrote on R2's white communication board that V13 Registered Nurse was giving R2 multiple medications, and R2 takes one medication pill at a time with applesauce. R2 stated R2 tried to raise R2's hand at V13 instructing one pill at a time. R2 stated R2 was scared and frightened as V13 left the room due to R2 still swallowing the medication. V14 Certified Nursing Assistant came in to change R2 due to R2 is incontinent of urine. R2 continued that R2 was still trying to swallow the pills (medications) administered by V13 when V14 laid the head of the bed down from an elevated position to a flat position to change R2 and R2 then began choking. R2 stated V13 came back into R2's room where V13 completed the Heimlich maneuver and R2 stated R2 went to the Emergency Room. On 2/10/26 at 2:45PM, V6 Director of Rehab stated R2 prefers one medication pill at a time due to swallowing complications. R2 has been on Speech Therapy since 7/2025 due to R2's swallowing difficulties. V6 stated speech therapy recommendations were recommended to the physician.On 2/11/26 at 3:15PM, V14 Certified Nursing Assistant stated V14 was completing rounds and V13 Registered Nurse had just come out of R2's room. V14 went into R2's room to change R2 due to urine incontinence and noticed R2 started to cough and drool. V14 stated V14 went to lay R2 down to change R2 and R2 started gasping, coughing, and drooling. V14 stated V13 was still outside the room and V14 went and got V13. V13 instructed V14 to go get the crash cart and another nurse.Facility Resident Rights Policy revised on 2/2/26 documents the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. The Policy also documents the resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights. This policy also documents that the resident has the right to be informed of, and participate in, his or her treatment, including: the right to participate in the development and implementation of his or her person-centered plan of care.Facility Medication Administration Policy Revised on 2/2/2026 documents The qualified employee who is giving medication must Position resident to accommodate administration of medication and observe resident consumption of medication.

Based on Interview and record review the facility failed to report to state agency an allegation of misappropriated goods in a reasonable time frame for one (R6) of three residents reviewed for abuse/misappropriation of goods in a sample of three residents. Findings Include: On 1/5/2026 at 2:40PM, R6 reported to V9 Registered Nurse that R6 was looking for R6's cellular device and was unable to locate it after searching through R6's room and in the dining room/common area for the phone. V9 stated at approximately 3:00PM on 1/5/2026, R6's Power of Attorney and the facility Management was informed of R6's missing phone. On 1/5/2026 at 7:34PM, V11 local Police Officer documented V11 took a report over the phone for a theft that occurred at this facility. V11 called and spoke with V10 (R6's) Power of Attorney. V10 stated V10 told V11 that R6 was staying at the facility and received a call from the facility that R6's cellular device with a black case, was missing. V10 gave V11 the Life 360 location for the phone, and it showed the phone was in the road of the 200 block of a local road. It showed this location at approximately 2:13PM on 1/5/2026. V11 documented the location had not been updated for approximately five hours. V11 went out to this location and searched for the phone but could not locate it. On 2/10/2026 at 1:35PM, V10 (R6's) Power of Attorney stated V10 received a phone call from the facility regarding R6's missing iPhone. V10 stated V10 contacted the police department and talked with V1 Administrator and V1 stated the facility has no responsibility related to the missing phone. V10 stated V10 contacted the local Police Department on 1/5/2025 around 7:30PM. V10 stated V10 bought and took R6 a new phone with personal funds and was not reimbursed by the facility. On 2/10/2026 at 2:15PM, V1 Administrator stated V1 never reported R6's missing phone to the state agency. V1 also stated the facility is not liable for misappropriation of goods when residents are in the facility especially if the residents are cognitively intact. V1 stated the facility did not replace R6's phone. The Facilities Abuse Prevention Policy Dated 1/24 documents that the facility affirms the right of the resident to be free from misappropriation of property, deprivation of goods and services by staff or mistreatment. This policy also documents that the facility would investigate, report to the state agency and keep the residents informed of the conclusions of the investigations.

Based on interview and record review the facility failed to replace misappropriated goods in a reasonable time frame for one (R6) of three residents reviewed for abuse/misappropriation. R6 had to replace (iPhone) with R6's own personal money and the facility failed to report this to the state agency. Findings Include:On 1/5/2026 at 2:40PM, R6 reported that R6 was looking for R6's cellular device and couldn't find it. After looking through R6's room and in the dining room for the phone. V9 Registered Nurse stated at approximately 3:00PM on 1/5/2026, V9 notified R6's Power of Attorney and the facility Management of the missing phone. On 1/5/2026 at 7:34PM, V11 Normal Police Officer documented V11 took a report over the phone for a theft that occurred at this facility. V11 called and spoke with V10 (R6's) Power of Attorney. V10 stated V10 told V11 that R6 was staying at this facility and received a call from the facility that R6's cellular device with a black case, was missing. V10 gave V11 the Life 360 location for the phone, and it showed the phone was in the road 200 block of a local road. It showed this location at approximately 2:13PM on 1/5/2026. V11 documented the location and had not been updated for approximately five hours. V11 went out to this location and searched for the phone but could not locate it. On 2/10/2026 at 1:35PM, V10 (R6's) Power of Attorney stated V10 received a phone call from the facility reporting that R6 was missing R6's cellular device. V10 stated she contacted the police department and talked with V1 Administrator and stated the facility stated they have no responsibility related to the missing phone. V10 stated V10 contacted the Normal Police Department on 1/5/2025 around 7:30PM. V10 stated V10 bought and took R6 a new phone. On 2/10/2026 at 2:15PM, V1 stated V1 never reported the missing phone to the state agency and the facility. V1 also stated that the facility is not liable for misappropriation of goods when residents are in the facility, especially if the residents are cognitively intact. V1 stated the facility did not replace R6's cellular phone.The Facilities Abuse Prevention Policy Dated 1/24 documents that the facility affirms the right of the resident to be free from misappropriation of property, deprivation of goods and services by staff or mistreatment. This policy also documents that the facility would keep the resident informed of the conclusions of the investigations.

Based on Interview and record review the facility failed to complete a thorough investigation of misappropriated goods in a reasonable time frame and failed to replace the misappropriated goods for one (R6) resident of three residents reviewed for abuse/misappropriation of goods in a sample of three residents. Findings Include: On 1/5/2026 at 2:40PM, R6 reported to V9 Registered Nurse that R6 was looking for R6's cellular device and couldn't find it after looking through R6's room and in the dining room. V9 Registered Nurse stated at approximately 3:00PM on 1/5/2026, R6's Power of Attorney and the facility management was informed of the missing phone. On 1/5/2026 at 7:34PM, V11 Local Police Officer documented V11 took a report over the phone for a theft that occurred at this facility. V11 called and spoke with V10 (R6's) Power of Attorney. V10 stated V10 told V11 that R6 was staying at the facility and V10 received a call from the facility that R6's cellular device with a black case, was missing. V10 gave V11 the Life 360 location for the phone, and it showed the phone in the road of the 200 block of a local road. It showed this location at approximately 2:13PM on 1/5/2026. V11 documented the location had not been updated for approximately five hours. V11 went out to this location and searched for the phone but could not locate R6's phone. On 2/10/2026 at 1:35PM, V10 (R6's) Power of Attorney stated V10 received a phone call from the facility regarding R6's missing cellular device. V10 stated V10 contacted the police department and talked with V1 Administrator. V1 stated the facility has no responsibility related to the missing phone. V10 stated V10 contacted the local Police Department on 1/5/2025 around 7:30PM. V10 stated V10 bought a new cellular device using personal funds and was never reimbursed by the facility.On 2/10/2026 at 2:15PM, V1 stated V1 never reported the missing cellular phone to the state agency. V1 also stated the facility is not liable for misappropriation of goods when residents are in the facility especially if the residents are cognitively intact. V1 stated the facility did not replace the phone nor did they identify who took the cellular device. The cellular device could have possibly been taken by staff, agency staff or visitors. V1 stated V1 didn't believe V1's staff would take the phone because V1 knows her staff.The Facilities Abuse Prevention Policy Dated 1/24 documents that the facility affirms the right of the resident to be free from misappropriation of property, deprivation of goods and services by staff or mistreatment. This policy also documents that the facility would investigate, report to the state agency, and keep the resident informed of the conclusions of the investigations.

Based on interview and record review, the facility failed to answer call lights in a timely fashion for three of three residents (R2, R7, R10) reviewed for call lights in the sample list of eleven.Findings Include:Grievance logs dated October 2025, November 2025 and December 2025 all document residents having to wait extended times for help with various activities.Resident Council Minutes dated 12/3/25 document 13 residents attended the meeting and documented staff need to answer call lights quicker.R2's Medical Record reviewed 12/30/25 documents R2 admitted to the facility on [DATE] from a local hospital with Diagnoses of Weakness, Right Sided Hemiparesis, Cognitive Decline, B12 Deficiency, Back Pain, Right Lower Extremity Pain, Microscopic Hematuria, Diabetes Mellitus, Hypertension, Hyperlipidemia, Cerebral Vascular Accident, and Multiple Sclerosis. R2's medical record does not contain an admission assessment or admission note from a licensed nurse from time of arrival until discharge. On 12/30/25 at 10:20am V4, R2's Family, stated that R2 did not have a call light but rather a call bell that was rang several times and went without any staff members answering the sound of the bell.On 12/30/2025 R7's Care Plan dated 11/26/25 documents R7's admission to the facility on [DATE] with the following diagnoses: Aphasia Following Cerebral Infarction, Dysarthria Following Cerebral Infarction, Apraxia Following Cerebral Infarction, Pulmonary Hypertension, Atrial Fibrillation, and Benign Prostatic Hyperplasia. The Minimum Data Set, dated [DATE] documents R7 is cognitively impaired.On 12/30/25 at 11:20am R7 stated the call light system works, though once activated it has taken anywhere from 30min to two hours to get a response from staff.On 12/30/2025 R10's Care Plan dated 11/27/25 documents R10's admission to the facility on [DATE] with the following diagnoses: Abnormal Levels of Other Serum Enzymes, Lichen Simplex Chronicus, Malaise, Hyperlipidemia, Muscle Wasting and Atrophy, Specified Disorders of Muscle and Lack of Coordination. R10's Minimum Data Set documents R10 is cognitively intact.On 12/30/25 at 1:00pm R10 stated call light response time can vary but have been as long as two hours.On 1/2/26 at 12:45pm V16, Corporate Nurse, stated staff should answer the call light in under 10 minutes.On 1/2/26 at 1:05pm V19, DON, stated staff should answer the call light in under 10-15 minutes to meet resident needs. The Call Lights: Accessibility and Timely Response policy dated 2/06/25 documents: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 9. Process for responding to call lights: a. Response times should be a priority.

Based on interview and record review, the facility failed to provide showers for three (R1, R3 and R6) of five dependent residents reviewed for activities of daily living out of a sample list of eleven.Findings Include:R1's current Medical Record documents R1's admission to the facility on [DATE] with the following diagnoses: Acute Osteomyelitis Right Ankle and Foot, Weakness, Chronic Atrial Fibrillation, and Chronic Kidney Disease Stage Four. R1's Care Plan includes a focus regarding ADL deficits initiated 04/11/2025. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact.On 12/30/2025 at 9:42 AM R1 stated he received a bed bath last night with water staff retrieved from another area of the facility. R1 stated he had not received a shower or bed bath for approximately two weeks prior to last night's bed bath. R1 described his bed bath water as lukewarm. R1 stated the hot water has not been working for a couple of months and that the lack of hot water is the entire uptown hall. R1 stated the other half of the facility called Downtown has hot water for use.R3's current Medical Record review documents R3's admission to the facility on [DATE] with the following diagnoses: Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Acute and Chronic Respiratory Failure with Hypoxia, and Type Two Diabetes Mellitus with Diabetic Neuropathy. R3's Care Plan includes a Care Plan focus regarding R3 having an ADL self-care performance deficit related to Fatigue, Impaired balance and Limited Mobility that was initiated 02/21/2024.R3's MDS dated [DATE] documents R3 is moderately cognitively impaired.On 12/30/2025 at 9:52 AM R3 stated she does not get two showers a week every week. R3 stated she gets showers that are warm to touch.R6's Current Medical Record review documents R6's admission to the facility on [DATE] with the following diagnoses: Fracture of Upper and Lower End of Left Fibula, Repeated Falls, and Disorders of Muscle. R6's Care Plan dated 12/18/25 documents a Care Plan focus regarding ADL self-care performance deficit related to upper and lower left fibula fracture initiated 12/18/2025.On 12/30/2025 at 10:13 AM R6, with the use of a dry erase board and marker, wrote the facility has been experiencing lack of hot water, on her hall, for over a month. R6 communicated she is taken to another part of the facility to shower where there is hot water available for use. R6 communicated she doesn't feel that she gets enough showers at this facility.On 1/2/2026 at 1:30 PM V16, Corporate Nurse, stated residents are to be receiving two showers weekly and not all residents are getting the showers as required. V16 stated V16 was unable to provide correct documentation of dates the residents' received showers.The Activities of Daily Living (ADLs) policy dated 2/10/2025 documents: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.Care and services will be provided for the following activities of daily living:1.Bathing, dressing, grooming and oral care.3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal hygiene and oral hygiene.

Based on interview and record review the facility failed to assess a resident after an unwitnessed fall and failed to assist a resident off the floor following an unwitnessed fall for one (R3) of three residents reviewed for Quality of Care and Dignity on a sample list of five residents. Based on interviews with the family, this resident suffered psychosocial harm as a result of the resident being left on the floor.Findings includeR3's Electronic Medical Record (EMR) documents that R3 had Alzheimer's Disease with early onset and Adult Failure to Thrive.R3's Minimum Data Set (MDS) dated [DATE], documents R3 had cognitive impairment with disorganized thinking, and inattention with altered levels of consciousness that fluctuated. This MDS also documents that R3 was not capable of making her own decisions and that R3 was dependent on staff to get from a sitting to standing position.R3's admission fall risk assessment dated [DATE] documents that R3 was at risk for falls.R3's Care Plan dated 10/23/25, documents that R3 was at risk for falling related to dementia, side effects of medication, and a terminal condition.R3's Care Plan dated 10/30/25, documents that R3 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's disease with interventions to supervise resident as needed.On 11/25/25 at 12:40 PM, V18 Certified Nurse Assistant (CNA) stated V18 sat right outside of R3's room the night of R3's unwitnessed fall. V18 stated V18 went on her lunch break sometime during the middle of the night and when she returned V19 CNA told her that R3 was found on the floor in R3's room. V18 CNA stated she reported this to V7 Registered Nurse (RN) and V7 RN told V18 CNA that R3 likes to be on the floor and that the family said it's ok. V18 CNA stated V7 RN never went to R3's room and assessed R3.On 11/25/25 at 1:11 PM, V19 CNA stated that she found R3 on the floor and reported it to V7 RN and V7 RN told V19 CNA to leave R3 and the floor. V19 CNA stated V7 RN did not go to R3's room to assess R3 after being found on the floor.On 11/25/25 at 2:51 PM, V7 RN stated she was the nurse on duty at the time of R3's fall. On 11/20/25 V7 RN went on lunch break around 12:50 AM and when V7 returned V19 CNA told her that R3 was found on the floor. V7 RN stated that V8 Licensed Practical Nurse (LPN) told V7 RN in shift report that R3 would sometimes put herself on the floor and that it would not be considered a fall. V7 RN stated V7 made a mistake in not documenting the unwitnessed fall. V7 RN stated she did not assess the resident as V7 RN did not consider this a fall.On 11/25/25 at 10:23 AM, V22 Laundry Aide stated she found R3 on the floor around 6:15 AM on 11/20/25 and that there was a pillow behind R3's back and R3's head was propped against the wall.On 11/25/25 at 11:03 AM, V23 Housekeeper stated she saw R3 lying on the floor with her head leaning against the wall and dresser on the morning of 11/20/25. On 11/25/25 at 11:13 AM, V20 Activities Aide stated she recalls that on the morning of 11/20/25 her coworkers told her to go find help because R3 was found on the floor. V20 Activities Aide stated she told a nurse and CNA (unsure of their names) and they did not do anything.On 11/25/25 at 11:20 AM, V21 Activity Director stated V23 Housekeeper came to V21 Activity Directors office on the morning of 11/20/25 and stated R3 was lying on the floor and needed help. V21 Activity Director stated she went to R3's room found her lying on the floor partially on a fall mat, not covered up, with a pillow behind her back, and R3's head was leaning against the wall.On 11/25/25 at 10:35 AM, V11 Licensed Practical Nurse (LPN) stated she was the nurse coming on duty the morning R3 was found on the floor. V11 LPN stated V1 Administrator came to V11 LPN and asked V11 LPN why R3 was on the floor. V11 LPN stated V7 RN did not tell V11 LPN that R3 was found on the floor during the night. On 11/24/25 at 2:36 PM, V17 CNA stated she overheard V1 Administrator on the morning of 11/20/25 loudly addressing staff after finding R3 lying on the floor saying, what if this was your family member that was left lying on the cold floor?On 11/25/25 at 9:49 AM, V1 Administrator stated she found R3 floor in R3's room around 6:55 AM. V1 Administrator stated R3 was partially lying on a fall mat, not covered, and was not arousable. V1 stated this was unacceptable that the nurse should have assessed R3 immediately when the unwitnessed fall was reported and gotten R3 up off the floor and into her bed. On 11/25/25 at 2:43 PM, V24 (R3's) Husband tearfully stated if R3 had the ability to communicate on 11/20/25 when R3 was found on the floor, R3 would have been anxious, pissed off and questioning how she got on the floor and why she was left there. The facility's Resident Right's Policy dated 2/12/25 documents that the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. This policy documents the following:2. Exercise of rights. The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative. 5. Respect and dignity. The resident has a right to be treated with respect and dignity, including: the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents.9. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview, and record review the facility failed to ensure wheelchair pedals were in place prior to propelling a resident in a wheelchair for one of three residents (R1) reviewed for falls on the sample list of three. This failure resulted in R1 falling from the wheelchair onto the tile floor and suffering a subarachnoid hemorrhage that required an overnight hospital stay. Findings Include: R1's Care Plan dated 05/09/2025 documents R1 is diagnosed with Dysphagia, Unspecified Psychosis, Dysarthria following Cerebral infarction, Hemiplegia, Muscle Weakness, Seizures, Major Depressive disorder, Unsteadiness on Feet, Other abnormalities of gait and mobility, lack of coordination, History of Falling, unspecified Dementia, and Diabetes. R1's Care Plan dated 05/09/2025 documents R1 is at risk for falling related to weakness. R1's care plan does not document R1 as dependent for wheelchair mobility or interventions for R1 for refusing to use foot pedals during transfers/propelling by staff. R1's Physician Order Sheet dated June 2025 documents R1 was prescribed an anti-platelet medication in of February 2025. R1's Minimum Data Set documented as completed on May 8, 2025, documents under section C completed on April 30, 2025, that R1 is cognitively intact. Section GG completed on May 8, 2025, documents that R1 uses a wheelchair and requires substantial/maximal assistance for transfers, bed mobility, and activities of daily living. V2's, (Director of Nursing (DON)), Progress Note dated 5/8/2025 at 10:37 AM documents on 5/7/25 at 4:31 PM R1 was in the dining room on the floor on R1's left side. The same note further documents R1 was in her wheelchair, being transported by an activity aide (V7) to her room to be changed prior to the fall. V10's (Registered Nurse) Progress Note dated 5/8/2025 at 05:39 AM documents R1 was admitted to the intensive care unit for subarachnoid hemorrhage. R1's After Visit Summary dated 5/8/25 at 1:55 PM from the local hospital documents R1 was admitted to the hospital on [DATE] after a ground level fall and that a Computed Tomography scan of R1's brain documented a small acute subarachnoid hemorrhage over the right frontal lobe anteriorly and a large left frontal subcutaneous hematoma. On 5/28/25 at 09:45 AM R1 was sitting in the common area in her wheelchair with foot pedals attached to the wheelchair. R1 had a half dollar sized raised hematoma on the left side of her forehead. R1 was only alert to person and place. On 5/28/25 at 11:45 AM V7, Activity Assistant, stated V7 was propelling R1 in the wheelchair from the table in the dining room to take R1 to her room to be changed due to being incontinent of urine and R1 put her feet on the floor while R7 was propelling the wheelchair and R1 fell forward from the wheelchair and hit her head on the floor. V7 stated R1 did not have foot pedals on the wheelchair and is dependent on staff to propel R1 around the facility. On 5/28/25 at 10:34 AM V3 Occupational Therapy, stated every wheelchair issued has foot pedals. V3 stated R1 has had foot pedals for the wheelchair for a long time but that they are not often used. V3 stated R1 has been known to refuse foot pedals on occasion. On 5/28/25 at 11:38 AM V8, Certified Nursing Assistant, stated R1 does not self-propel the wheelchair. V8 stated V8 does not recall R1 having foot pedals prior to the fall of 5/7/25. V8 stated R1 now has foot pedals attached to the wheelchair. On 5/28/25 at 11:40 AM V9 Certified Nursing Assistant, Stated R1 did not have foot pedals prior to the documented fall of 5/7/25 and did not self-propel wheelchair. V9 stated staff propelled R1 around the facility. V9 confirmed it was possible for R1 to have fallen and hit her head at any time due to the non-use of foot pedals. On 5/28/25 at 1:30 PM V2 Director of Nurses (DON) confirmed V7 was propelling the wheelchair when R1 fell and the wheelchair R1 was using did not have foot pedals on at the time of the fall. On 06/02/2025 at 11:45 AM V11, Certified Nurse Assistant, stated R1 has not propelled herself in a very long time and is dependent on staff for mobility in the wheelchair. The facility's Fall Prevention Program dated 02/12/2025 documents the program's purpose is to assure the safety of all residents in the facility and is to include measures which determine the individual needs of each resident by assessing the risk of falls, implementing appropriate interventions to provide necessary supervision, and using assistive devices as necessary. A Fall Risk Assessment should be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. Safety interventions should be implemented for each resident identified at risk. Section J. documents to Provide additional interventions as directed by the resident's assessment, including but not limited to: 1. Assistive devices.

Based upon observation, interview and record review, the facility failed to ensure for the safety and supervision of a resident with a history of self-harm and attempts at suicide. These failures affect one (R1) of three residents reviewed for behavioral health services on the sample list of three. R1 put a plastic bag tightly over R1's head resulting in emergency transport to the hospital, previously R1 was found on 5/20/24 with the call light cord wrapped around her neck. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 5/20/24 when R1 was found with the call light cord wrapped around R1's neck. R1 had continued access to self-harm items resulting in another attempt on 7/10/24. On 7/31/24 at 12:15 PM, V1 Administrator was notified of the Immediate Jeopardy situation. The surveyor confirmed by interview and record review that the immediacy was removed on 8/5/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and Quality Assurance monitoring. Findings include: R1's medical record documents the following: 5/21/2022 R1's medical record shows R1 was seen in the hospital for self-harm attempts. On 5/23/2022 R1's care plan was updated with behaviors of attention seeking with attempts to self-harm (suicidal ideations). This care plan states R1 is to have all corded accessories removed from room for safety and to have a call bell instead of corded call light. R1's 6/01/2023 Psychiatric visit note documents R1 was seen for a follow up for mood disturbance. The note lists diagnoses of BPSD (Behavioral and psychological symptoms in dementia) including hallucinations, depression, and suicide intention threats in the setting of UTI (urinary tract infection). R1's 5/20/2024 R1 was found by staff with call light cord wrapped around her neck as documented in nursing progress note dated 5/20/24 which states that around 12:25am R1 had gotten herself up to bathroom and back to bed. R1 had put the bathroom call light on but when V13 (C.N.A/ Certified Nursing Assistant) entered the room, R1 was already back in bed. V13 noticed R1 had the call light cord wrapped around her neck. V13 called for writer. V13 removed the cord, no injury from this act by R1. When R1 was asked why she wrapped the cord around her neck. R1 stated to kill myself, I want to die. V2 (Director of Nursing), R1's medical doctor and POA (power of attorney) notified and R1 sent out for psychiatric evaluation. (No new interventions were documented on R1's care plan or noted in her medical chart as a result of this incident.) R1's 5/26/2024 psychiatric visit note documents R1 was found by staff with her call light wrapped around her neck and that she has a history of this behavior in the past. Staff stated they removed R1's call light at that time and gave her a bell to use. R1 has been increasingly more irritable including having verbal arguments with roommate. R1's 7/10/2024, R1 was sent to hospital after placing plastic bag over head, while at the nurse's station, in an attempt to self-harm as found in hospital emergency department nurse note. This note states R1 presented to ED (emergency department) via EMS (emergency medical service) with police escort for complaints of suicidal ideations. R1 states she tried to wrap a call light cord around her neck and tied a garbage bag around her throat and staff had to poke holes in it to take it off. R1 told EMS she didn't want to breathe anymore. Per EMS report, pt's (patients) bp (blood pressure) was low 90's over 60's with a MAP (mean arterial pressure) of 66- IV (intravenous) established en-route and fluids given. R1's 7/14/24, hospital discharge records stated that R1 presented to local ED via ambulance for suicide attempt at 6:37pm on 7/10/24 and was held on a psych hold with 1 to 1 observation until discharge back to facility at 7:07 pm on 7/14/24. R1's care plan with a print date of 7/24/24 has new intervention entered on 7/20/24 stating all plastic garbage bags removed from resident's room. On 7/24/24 at 12:15pm R1 observed sitting in dining room in wheelchair, R1 stated she does not feel her normal self today but is okay. R1 states she doesn't recall any hospitalization and that I must have the wrong person. R1 asked if she would like to talk to me later and she stated yes. On 7/24/24 at 1:45pm resident lying in bed in R1's room. R1 stated I remember you. R1's room is the very last room, next to exit door furthest away from nursing station. Observed mounted TV above R1's head and R1's roommate's call light cord attached at wall behind R1 bed and in reach of R1. On 7/29/24 at 9:45am in R1's room TV mounted over the bed with looped unsecured cord hanging down above the head of R1's bed. A reading lamp and radio with cords was sitting on the bedside. The cords were not secure and were accessible to R1. One large plastic bag was on the floor by R1's bed and another large plastic bag was on the bedside table. A plastic bag was in the trash bin under the sink. There were multiple plastic grocery bags on the roommate's side of room and within R1's reach. A call light cord was attached to the wall above head of bed between R1's bed and the roommate's bed. R1 able to reach up and grab roommates call light. During this survey R1 was noted to be propelling self around the facility without difficulty in her wheelchair. On 7/29/24 at 11:25am, V12 (Psychiatric Physician Assistant; PA-C) stated that R1 attempted suicide in May of this year by wrapping a call light cord around her neck. V12 states she was told the call light was removed and R1 given a bell but did not inform her that R1 had a roommate or that there were still corded items in the room. V12 states that subsequently on 7/10/24 R1 placed a plastic bag over her head to stop breathing per R1. V12 states she saw R1 on 7/18/24 and R1 stated she felt ignored and was attempting to get attention. V12 states these attempts should be taken seriously by staff as any attempt could result in death as R1 has a long history of self-harm behaviors. Facility policy titled Behavioral Health Services dated 12/5/2022 states that employees should be educated for meeting the behavioral health needs of the residents. This education would include behavioral interventions. This policy does not document who is responsible for training the staff as well as who is responsible for implementing and monitoring these interventions. Facility policy titled Suicide Prevention with an implemented date of 5/1/22 states the facility is to act quickly and appropriately if a resident expresses any thoughts of suicide. On 7/29/24 at 9:55am V8 (housekeeping) stated she is aware of R1's restrictions to not have corded call light or trash bags in room. V8 also indicated she has inquired more than once to upper management regarding R1 having a private room as R1 has access to roommate's belongings including plastic bags, corded accessories, and corded call light. On 7/29/24 at 10:20, V1 (administrator) states he was alerted that R1 had put a bag over her head in front of the nurse station and certified nurse and nurse responded immediately to remove the bag. V1 states a call was placed to 911 to have R1 sent to the hospital. V1 stated R1 was conscious but unresponsive to staff. On 7/29/24 at 10:45am V6 (LPN/Licensed Practical Nurse) stated she witnessed R1 at the nurse station with a plastic bag over her head attempting to pull bag tight around her neck. V6 states she witnessed certified nursing assistant (C.N.A./Certified Nursing Assistant) rip open plastic the bag on R1's head. V6 states she is not aware of R1 having any prior attempts of self-harm. On 7/29/24 at 11:16 AM, V2 Director of Nursing stated R1 has a diagnosis of Parkinson's Disease. V2 stated due to her (R1's) Parkinson's Disease her gait is limited. She (R1) has behaviors of self-harm. In May she was found with a call cord around her neck. We took hers out. Additional corded items were removed. R1's roommate has a call light that is attached to the table. There should be no cords in her room or garbage sacks. V2 stated she went in on Friday and there were no cords in her room. V2 stated the housekeeper told me today that there were incontinence brief bags in her room. V2 stated the CNAs put it there as a makeshift garbage sack. It should not be in there. On 7/29/24 at 11:45am V9 (certified nursing assistant; C.N.A.) and V10 (C.N.A.) that are assigned to R1's hall stated they were not aware of any precautions for R1. V11 (RN/Registered Nurse) assigned to R1 stated she knew nothing as it's her first day as agency nurse. On 7/29/24 at 12:36 PM, V3 (SSD/Social Service Director) stated she heard about R1 putting the call cord around her neck but cannot recall how or when. V3 states it was discussed in morning meeting which included therapy, V1, V2, V5, and V8 present. The intervention was to remove all corded items out of R1's room including corded call light as they were identified as a hazard to R1. V8 would have removed these items, The same people also concluded after R1's attempt with a plastic bag, that garbage bags be removed from room as they also are a hazard for R1. V3 states that R1 can toilet without assistance most of the time. On 7/29/24 at 12:53 PM, V5 LPN MDS CPC stated that we discussed R1's putting the cord around her neck. The interventions of corded accessories not being in her (R1) room and a call bell instead of a corded call light was already on her care plan. There has been a lot of room moves. V5 stated it was most likely not removed from the new room. V5 stated they educate staff in multiple ways including in-services and mass email. V5 does not have documentation of any education. On 7/29/24 at 1:24 PM, V2 Director of Nurses stated R1 was found with the cord wrapped around her neck. V2 stated there was an intervention already in place for R1 to not have any corded accessories or call light in room. V2 stated there was a call light in the room when she wrapped the cord around her neck 5/19/24. V2 stated she sends out emails to staff about facility and resident updates but has no verification method in place. V2 indicates the C.N.A.'s have access to the resident's electronic Kardex for individual resident interventions but there is no alert to notify them of any change made. V2 states the floor nurses are responsible for updating C.N.A.'s on any resident care plan changes but she has no way of knowing if this was done. V2 states there was word of mouth education but denies having documentation. On 7/29/24 at 2:26pm, V13 (certified nursing assistant) stated that on the evening/overnight shift of 5/19/24- 5/20/24 she was working on the east hall when the nurse alerted her that R1 had wrapped the call light cord around her neck. V13 states R1 did not appear to be in distress or show any signs of change in behavior after incident. V13 states that floor nurse had the cord removed for R1's neck at the time V13 entered R1's room. V13 states she did not see any marks on R1's neck nor heard her coughing or complaining of having any respiratory issues. V13 states the nurse had R1 on 15 min checks and that V13 personally removed R1's call light from her room and gave her a bell to use. V13 confirmed it was R1's personal call light and not her roommate's call light she removed. V13 stated R1 was residing in the same room she currently resides in at the time of the incident. On 7/29/24 at 2:33pm V14 (RN) states on the evening/overnight shift of 5/19/24- 5/20/24 she was entering R1's room to administer R1's medications when she saw R1 sitting on her bed pointing at her neck where V14 states R1's call light was wrapped around it. V14 states R1 was conscious and did not appear to be having breathing difficulty at any time. V14 states she immediately removed the cord from R1's neck and after making sure R1 was not harmed, she placed her on 15 min checks and called and notified the DON. The Immediate Jeopardy that began on 5/20/24 was removed and the deficient practice corrected on 8/5/24 when the facility took the following actions to remove the Immediacy and correct the noncompliance, confirmed by surveyor on 8/5/24 between 9:00AM and 2:30PM through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. 7/29/24 R1 was moved to a private room by V8. R1' s room had all potential items of [NAME]-harm items removed including a call light cord (replaced with bell in place to alert staff of need), and plastic bags from R1 's garbage can. V8 also secured all corded items in R1 's room to prevent self-harm. 2. 7/31/24 V2 (director of nursing) added a task to R1 's MAR (medication administration record) for R1' s nurse to ask R1 every shift if they have any thoughts or plan of self-harm. If R1 states self-harm, then R1 will be placed on 1:1 with facility staff, notified physician, POA or emergency contact and sent to the emergency department for psychiatric evaluation and deemed by physician R1 is no longer a risk for self-harm. 3. On 7/31/24 the IDT reviewed the suicide prevention policy. 4. 7/31/24 thru 8/5/24, Administrator provided all staff in-service regarding R1 's interventions to prevent self-harm and attempts at suicide, Self-Harm binders that include triggers and interventions for residents that are high risk for self- harm and their locations. Staff are educated on the Suicide Prevention Policy. If resident has plan for self-harm the staff will follow the Suicide Prevention policy. 5. On 7/31/24, V3 social services director, reviewed all residnets for self-harm behaviors and will screen all new residents for self-harm behaviors moving forward.7/31/24, V3 (Social Services) reviewed the PHQ9 assessments, trauma informed care assessments and history for all residents at risk for self-harm/suicide and interventions put in place for those identified. 6. 8/1/24 V3 (Social services) created a Self-Harm binder for residents with a history of self-harm including identified triggers, interventions and the Suicide Prevention policy that is located at the nurses' stations, front office, activities and dietary office. V1 (Administrator) educated social services to review the care plan for self- harm interventions and notify the housekeeping department of the interventions prior to a room move. V1 (Administrator) educated housekeeping supervisor that social services will review the care plan for self-harm interventions and will notify the housekeeping department of the interventions prior to a room move. 7. 8/1/24 V1 (Administrator) provided education to IDT to review 24/72-hour notes to assess for changes in behavior and possible self-harm. 8. 8/1/24 V1 (Administrator) started audit to monitor three staff each week for four weeks for staff understanding of the policy and procedures for Suicide prevention, the self-harm binders including triggers and interventions for residents at risk for self-harm. Monitoring will be reviewed by the QA Committee until such time consistent substantial compliance has been achieved as determined by the committee. 9. On 8/5/24, V1, V2, V3, V16 and V17 all verified through interview that education was received and new interventions and procedures are in place. The facility presented an abatement plan to remove the immediacy on 8/1/24 at 4:38 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions and the facility presented a revised abatement plan on 8/2/24 at 10:49 AM and the survey team accepted the abatement plan on 8/5/24 at 9:20 AM.

Based on interview and record review the facility failed to ensure a severely cognitively impaired resident (R1) did not exit the facility unnoticed (elopement). The facility failed to reassess and develop a plan of care for a resident with a known history of exit seeking behaviors, wandering, and supervision needs during emergency procedures. These failures affect one (R1) resident reviewed for elopement on a sample list of three residents. These failures resulted in R1 exiting the facility in the late afternoon on 5/31/24, unsupervised, being found 17 hours later in a grassy area next to a creek. R1 had potential for serious injury and/or death due to poor safety awareness in negotiating city streets/traffic and environmental hazards including a crossing four lanes of traffic to arrive at a nearby creek with dense brush, rugged terrain in the dark. This failure resulted in an Immediate Jeopardy. An Immediate Jeopardy situation was identified on 6/20/24. The Immediate Jeopardy was identified to have begun on 5/31/24 when the facility failed ensure that a resident (R1) did not exit the facility unnoticed (elopement) and failed to reassess and develop a plan of care for a resident with a known history of exit seeking behaviors, wandering, and supervision needs during emergency procedures. On 6/20/24 at 9:11AM, V1 Administrator was notified of the Immediate Jeopardy situation. While the immediacy was removed on 6/24/24, the facility remained out of compliance at a Severity Level 2 while the facility continues to educate the staff on increasing supervision and implementation of interventions to prevent potential harm to a resident who is displaying exit seeking behaviors, training staff to assess residents upon admission and with changes in behavior for elopement risk and care plan documentation, training staff to ensure that exit doors are monitored during fire drills and that a process is developed to ensure safety of at risk residents. Findings include: The facility's Elopement and Wandering Resident's Policy dated 2/1/2020 documents that the facility ensures that resident who exhibit wandering behavior and /or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility's final report to the State Agency documents that on 5/31/24 at approximately 5:04PM a fire alarm drill was initiated. When the fire alarm was silenced, an exit door was heard alarming and R1 was found to be missing from the facility. Staff initiated a search for R1 both on the interior and exterior of the facility without success. An undated timeline provided by the facility documents that on 5/31/24 at 5:39PM, V1 Administrator called 911 to notify the authorities of a missing resident. The undated timeline provided by the facility further documents that R1 was missing from the facility from 5/31/24 at approximately 5:10PM until 6/1/24 at 10:04AM (17 hours) when law enforcement found R1 and took him to a local hospital for evaluation and treatment. R1's Brief Interview for Mental Status dated 4/28/24 documents R1 as severely cognitively impaired. R1's Minimum Data Set, dated dated dated [DATE] documents R1 as independent with mobility. R1's elopement assessment dated [DATE] documents R1 as high risk for elopement. R1's progress notes dated 3/26/24, 4/17/24, 4/21/24 document exit seeking behaviors requiring redirection, including exiting the building and walking around the facility to his bedroom window. R1's care plan with reviewed date of 2/26/24 does not address R1's wandering behaviors or high risk of elopement. R1's Order Summary Report dated 6/17/24 documents the following diagnoses: dementia, transient cerebral ischemic attack, type 2 diabetes, dehydration, chronic kidney disease, Picks disease, malnutrition. A map provided by the facility documented where R1 was found on 6/18/24 at 10:00AM. On 6/18/24 at 10:08AM when walking from the facility to the location, it was approximately three blocks from the facility, across a four-lane street, behind a fraternity building in a low lying, brushy, grassy area next to a creek without any barricade. Additionally, this area had a metal fire pit littered with empty cans and trash. On 6/17/24 at 9:15AM, V1 Administrator stated on 5/31/24, R1 was out of the building overnight for 17 hours and was found 3 blocks away from the facility. V1 further stated that he believed that R1 eloped from the facility via the therapy room doors on the Uptown [NAME] Hall, near where R1 resided in (room number) because R1 was last seen on camera at 5:06PM near the therapy room. V1 Administrator also stated that R1 thought that his wife lived in the apartments that are visible from the therapy room. On 6/17/24 at 9:15AM, V1 Administrator stated R1 had a personal alarm but that the personal exit alarms only work on the front door. On 6/17/24 at 1:00PM, V7 Registered Nurse (RN) stated on the evening of the elopement, R1 was hovering around the exit doors that day and that several staff tried to redirect R1. At approximately 5:00PM, V7 RN saw V1 Administrator redirect R1 toward the Uptown [NAME] Hallway, near the nurse's station, approximately 6 feet from the therapy room. At the time of the fire alarm, there were no nurses at the nurse's station on the Uptown [NAME] Hallway. V7 RN then stated she seen R1 attempt to exit the facility four or five times at least from various doors throughout the facility. On 6/17/24 at 9:50AM, V3 Licensed Practical Nurse stated seen R1 wandering and looking out the doors frequently. V3 said that R1 would try to leave the facility to go to where he thought his wife lived across the street. On 6/17/24 at 10:10AM, V5 Registered Nurse stated R1 had a history of wandering throughout the facility and out the front door. On 6/17/24 at 10:25AM, V6 Administrative Assistant stated she would often see R1 looking out the front door. On 6/18/24 at 11:55AM, V18 Maintenance Director stated that the only door alarming after the fire alarm was silenced was the therapy room exit door, one of ten exit doors in the facility. On 6/18/24 at 3:53 PM, V19 Regional Nurse Consultant stated he was not the one that found R1 that third shift found R1 but R1 was found alone in a grassy area, wet as it had rained that previous night and that R1 had defecated himself and indicated he was hungry. V19 stated he could not understand how R1 was able to leave facility and get to area found on own as he would have to cross a heavily traffic area. The Immediate Jeopardy that began on 5/31/24 was removed on 6/24/24 when the facility took the following actions to remove the immediacy: 1. The (departure alert system)/Door Check Audit dated 6/1/24 documents V29 [NAME] President of Clinical Services checked the facility's exit doors for alarm functioning, and the employee entrance did not alarm. This Audit does not document the conference room exit door alarm was checked for functioning. On 6/20/24 at 2:15 PM V17 Regional Director of Operations reviewed the audit dated 6/1/24 and confirmed the audit does not document that the conference room exit door alarms was checked as part of the facility wide audit. V17 stated V17 will have another facility wide door alarm audit conducted. The (Departure Alert System)/Door Check Audit dated 6/22/24 documents all of the facility's exit doors were checked for alarm functioning. On 6/24/24 at 11:53 AM V29 stated the employee entrance door did not alarm during V29's door audits completed on 6/1/24. V29 stated the door alarm was reactivated when the facility conducted a fire drill on 6/3/24. 2. The (departure alert system)/Door Check Audit dated 6/1/24 documents V29 checked the front door alarm with the (departure alert system) and it was functioning. On 6/24/24 at 11:53 AM V29 stated on 6/1/24 V29 tested all residents' (departure alert systems) at the front entrance. 3. The (departure alert system) Audit dated 6/1/24, and signed by V29 [NAME] President of Clinical Services, documents the device functioning was tested for all residents who use this device (R2-R8, R10, R11). On 6/24/24 at 11:53 AM V29 stated on 6/1/24 V29 checked the functioning of all residents' (departure alert system) with the transmitter. 4. On 6/1/2024 V2 Director of Nursing (DON) and V21 Minimum Data Set (MDS) Coordinator conducted an audit to ensure a current Wandering Risk Assessment was completed for all residents with a (departure alert system). R1's-R11's (residents identified to be at risk for elopement) Wandering Risk Assessments document a completion date of 6/1/24. 5. R1's-R6's and R8-R11's care plans were updated on 6/3/24 to include risk for elopement, interventions, and supervision needs during disaster drills. R7's care plan documents interventions dated 6/24/24 to keep R7 in direct sight to ensure safety during disaster/fire drills and to provide comfort and basic needs when R7 begins to wander. On 6/20/24 at 1:15 PM V2 DON confirmed V2 and V21 conducted a care plan audit on 6/3/24 for residents using (departure alert system) and/or high risk for elopement (R1-R11). V2 confirmed R7's care plan was not updated until 6/14/24 to include interventions for direct supervision during disaster/fire drills and provide comfort measures and basic needs when wandering. 6. The (departure alert system) Audit dated 6/1/24, completed by V29, documents all residents using this device were audited to ensure daily device checks for functioning were recorded on the resident's Treatment Administration Record (TAR). R1's-R11's TARs documents (departure alert system) device checks were completed every shift as of 6/1/24. This was confirmed with V29 on 6/24/24 at 11:53 AM. 7. On 6/17/24 at 1:05 PM V15 Social Services Director verified that elopement books are updated weekly beginning on 6/1/24 and last updated on 6/12/24. On 6/27/24 these books were observed at each of the nurse's stations and the front reception desk. 8. Door alarm and (departure alert system) audits were initiated daily beginning on 6/20/24 and completed by V18 Maintenance Director. The (departure alert system)/Door Check Audits dated 6/20/24 and 6/24/24 do not document an audit was conducted for all of the facility's exit doors, including the conference room door, until 6/22/24. On 6/20/24 at 1:00 PM all of the facility's exit doors were observed to be alarmed and functioning, verified with V18. On 6/24/24 at 10:05 AM V18 confirmed V18 conducts the daily door alarm audits and confirmed all of the facility's exit doors should be included as part of the daily check. 9. On 6/1/2024, V1 Administrator in-serviced V15 Social Service Director and V21 MDS Coordinator regarding assessing all residents quarterly who wander/exit seek and with any changes in behavior, the Interdisciplinary Team (IDT) will review 24- and 72-hour notes to assess for changes in behaviors and possible completion of Wandering Risk Assessment. This was confirmed by V15 on 6/20/24 at 12:12 PM and V21 on 6/20/24 at 11:55 AM. The Focused Audit Tool with date range of 6/1/24-6/21/24 document three residents were reviewed each week for elopement risk assessment update, elopement interventions implemented, one to one in place if required, care plan updated with interventions, and door alarm checks. 10. On 6/3/24 an all staff in-service was conducted by V1 Administrator and V2 DON on Elopement, checking doors to ensure that exit doors are alarmed at all times, checked by staff daily and anytime electricity is interrupted to ensure alarms are on and in working order, R1's care plan interventions to provide one to one and diversional activities, identifying residents at risk for elopement, and providing adequate supervision for those at risk to prevent elopement. The In-Service Education/Meeting Report dated 6/3/24 documents V2 DON gave an all-staff in-service on Elopement and lists employee signatures. On 6/20/24 between 12:00 PM and 1:30 PM V23 LPN, V22 Certified Nursing Assistant, V25 Housekeeper, and V7 Registered Nurse were unsure of the steps taken for residents at risk for elopement during disaster drills, including one to one monitoring. On 6/20/24 at 1:13 PM V26 Housekeeper stated V26 had not received any training on elopement or fire drills, and V26 was unsure what steps would be taken for residents at risk for elopement during fire/disaster drills. On 6/20/24 at 1:08 PM V25 Housekeeper stated V25 was unsure which resident were at risk for elopement and was unsure where to find this information. On 6/24/24 at 9:13 AM V19 Regional Nurse Consultant stated all staff were re-educated on 6/20/24. On 6/24/24 between 9:13 AM and 1:00 PM V2 and V19 provided documentation of staff sign off sheets or text/communication verifying receipt of education. This documentation was reviewed and verified for all of the facility's staff, completed on 6/20/24. The facility's daily assignment sheets dated 6/20/24-6/23/24 document V36-V39 LPNs worked in the facility and there is no documentation that these staff received the training prior to 6/24/24. On 6/24/24 at 1:25 PM V2 DON confirmed there is no documentation that V36-V39 received this training prior to 6/24/24. On 6/24/24 V2 DON and V35 Scheduler stated they will coordinate to ensure agency staff are trained prior to working in the facility. V2 stated all new employees will receive this training as part of new employee orientation, provided by V1 Administrator or V2, prior to working the floor. 11. On 6/3/24 the facility held a Quality Assurance Performance Improvement (QAPI) meeting with the IDT to discuss elopement risk and resident safety during disaster drills/training. The Root Cause Analysis dated 6/3/24 documents a review of R1's elopement. On 6/20/24 at 12:41 PM V2 stated the entire management team attended the QAPI meeting on 6/3/24, we reviewed R1's incident and we conducted a root cause analysis. 12. The facility conducted a fire/disaster drill on 6/21/24 at 1:15 PM, completed by V18 Maintenance Director. On 6/24/24 at 9:22 AM V3 LPN and on 6/24/24 at 9:25 AM V23 LPN confirmed residents at risk for elopement were assigned/provided one to one monitoring during the fire drill on 6/21/24. 13. R1's Care plan dated 6/3/24 documents the care plan was updated on 6/3/24 with an intervention for one to one monitoring and diversional activities, completed by V21 MDS Coordinator. 14. R1's Wandering Risk assessment dated [DATE] documents R1 is considered high risk, completed by V5 RN. 15. R1's Nursing Note dated 6/3/24 at 1:35 PM documents a departure alert system was placed on R1 when R1 returned from the hospital. 16. R1's Nursing Note dated 6/3/24 at 10:40 AM documents one to one monitoring was initiated for R1, completed by V1 Administrator. 17. R1's Care Plan dated 6/3/24 documents this care plan was updated with an intervention for one-to-one monitoring during disaster drills. The facility submitted an abatement plan to remove the immediacy on 6/20/24 at 10:22 AM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions on 6/20/24 at 10:57 AM and 11:32 AM. The facility resubmitted the abatement plan on 6/20/24 at 11:04 AM and 11:51 AM. The survey team accepted the abatement plan on 6/20/24 at 12:27 PM.

Failures at this level required more than one deficient practice statement. A. Based on interview and record review the facility failed to accurately transcribe hospital discharge medication orders for a resident (R37) with a seizure disorder, ensure medications were available for administration, and ensure contracted nurses have access to the backup medication supply. These failures resulted in R37 missing 13 doses of medications to control seizures: 9 doses of Divalproex Sodium, 2 doses of Levetiracetam and 2 doses of Carbamazepine; being hospitalized experiencing continued seizures and requiring intravenous seizure medication. R37 is one of three residents reviewed for hospitalization s in the sample list of 47. The Immediate Jeopardy began on 9/7/23 when R37's hospital discharge orders for Divalproex Sodium were transcribed incorrectly. V1 Administrator was notified of the Immediate Jeopardy on 9/19/23 at 3:27 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 9/25/23, but noncompliance remains at a severity Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: a.) On 09/17/23 at 9:52 AM R37 stated R37 was hospitalized in June 2023 for seizures and R37's seizure medications were adjusted. R37 stated R37 had a history of seizures and was unsure why R37 started having seizures again. R37 stated R37's physician told R37 that it is important to take R37's seizure medications within an hour of the scheduled time. On 9/19/23 at 9:31 AM R37 stated R37 has had a seizure disorder since 17/[AGE] years old, and prior to May 2023 R37's seizures were controlled with medications. R37 stated R37 admitted to the hospital in May 2023 from R37's home and R37's Divalproex dosage was adjusted due to R37's Divalproex level being low. R37 was supposed to discharge to the facility on [DATE] and had another seizure during transport. R37's Hospital Progress Note dated 6/4/23 documents R37 had a seizure on 5/17/23 and R37's Depakote (Divalproex) was increased. R37 was discharged on [DATE] and enroute had an unresponsive episode and returned to the hospital. This note documents Neurology was consulted, R37's Depakote level was 46.8, and R37's Depakote was increased to 1000 mg (milligrams) three times daily. R37's Hospital Discharge Orders dated 6/7/23 documents Divalproex Sodium Extended Release take 1000 mg by mouth every 8 hours. R37's June 2023 Order Summary Report documents orders dated 6/7/23 to administer Carbamazepine 200 mg by mouth twice daily for seizures, Divalproex Sodium Delayed Release 500 mg two tablets (1000 mg) by mouth twice daily for seizures (not Extended Release 1000 mg three times daily as noted on the hospital discharge orders), and Levetiracetam (Keppra) 1000 MG by mouth twice daily for seizures. There is no documentation that the facility identified the Divalproex transcription error. R37's Nursing Notes document the following: R37 admitted to the facility on [DATE] at 2:30 PM. On 6/12/2023 at 1:45 PM pharmacy reported that only a 3-day supply of R37's medications had been provided due to insurance, and the pharmacy was unsure if anyone at the facility was made aware of this. This note documents pharmacy will rerun the insurance and send a 30-day supply of R37's medications. On 6/12/2023 at 2:48 PM (over 6 hours after the scheduled time of 8:00 AM) the pharmacy was contacted regarding R37's Divalproex, Ranolazine, Carbamazepine, and Levetiracetam being out of stock, the last dose of the Levetiracetam was taken out of the (electronic emergency medication dispensing system), and the medications were requested to be delivered STAT (immediately). On 6/12/2023 at 3:21 PM scheduled Keppra and Carbamazepine was removed from (electronic emergency medication dispensing system), and the facility was awaiting the delivery of R37's other scheduled medications to arrive from the pharmacy. On 6/12/2023 at 7:30 PM R37's medications were delivered from the pharmacy. On 6/14/2023 at 2:40 AM R37 complained of nausea and general malaise (tiredness) and was transferred to the hospital. The electronic mail dated 9/18/23 3:50 PM from V37 Pharmacy Registered Nurse to V16 Chief Nursing Officer documents there were no removals of Divalproex from the facility's (emergency medication supply system) and includes a form which documents that Levetiracetam 250 mg eight tablets and Carbamazepine 200 mg two tablets were removed from the facility's (emergency medication supply system) on 6/12/23 at 10:32 AM. The Pharmacy Packing Slip dated 6/7/23 documents six tablets of Carbamazepine 200 mg, twelve tablets of Divalproex 500 mg, and six tablets of Levetiracetam 1000 mg (a three-day supply of these medications) were delivered to the facility for R37 on 6/8/23. The Pharmacy Packing Slip dated 6/12/23 documents sixty tablets of Carbamazepine 200 mg, 180 tablets of Divalproex Sodium Delayed Release 500 mg, and sixty tablets of Levetiracetam 1000 mg were delivered to the facility for R37 on 6/12/23. There is no documentation that any other doses of these medications were dispensed from pharmacy or obtained from the facility's emergency supply between 6/7/23 and 6/12/23. R37's June 2023 Medication Administration Record (MAR) documents Divalproex Sodium Delayed Release 1000 mg, Carbamazepine and Levetiracetam were scheduled to be administered twice daily at 8:00 AM and 4:00 PM from 6/8/23-6/13/23. This MAR documents these medications were administered on 6/11/23 by V38 Agency Registered Nurse (RN), but there is no documentation as to where these medications were obtained from. This MAR documents Divalproex was administered on 6/12/23 at 8:00 AM, but there is no documentation as to where this medication was obtained from. R37's Progress Note dated 6/12/23 recorded by V21 Physician documents R37 reported having seizures since age 17, which have been worse lately and R37 was hospitalized recently for seizures. This note documents R37 reported this morning that R37 had two brief seizures. This note documents Really need to watch the frequent seizures. (R37) is on multiple seizure medications. R37's Progress Note dated 6/13/23 at 9:20 AM recorded by V17 Nurse Practitioner documents R37 had repeated seizures yesterday, there was an issue with R37 not getting R37's seizure medications yesterday, and R37 has received all doses of seizure medications now without further seizures. This note documents Seizure Disorder- last seizure 1 day ago likely due to lapse in doses. Continue antiepileptic meds (medications). (R37) is on several. Seizure precautions. Monitor closely. R37's emergency room Note dated 6/14/23 at 2:46 AM documents R37 presented with concern for seizure with seizure disorder and R37 requested laboratory tests for seizure medications. This note documents R37 reported having nausea and vomiting once this evening and was unable to take R37's seizure medications, and R37 had chest pain that improved after nitroglycerine administration. R37 reported having problems with not receiving R37's seizure medications at the facility due to insurance. This note documents R37 reported that two days ago R37 had seven seizures and tonight R37 had multiple seizure like episodes including tremors to R37's hands. R37's Hospital Progress Note dated 6/15/23 documents (R37) here with frequent seizures after not getting her AED (Antiepileptic Drugs) Grand mal seizures: consulted neurology on IV (Intravenous) antiepileptics per Neurology recommendations, continue the seizure precautions. -Valproic acid level below therapeutic level, Tegretol WNL (Within Normal Limits). R37's Valproic Acid-Depakote level collected on 6/14/23 at 3:52 AM was 37.8 micrograms per milliliter (normal range 50-100). R37's Hospital Discharge Summary with admitted [DATE], documents R37 received intravenous Divalproex beginning on 6/14/23. On 9/18/23 at 12:46 PM V18 RN stated there were issues with pharmacy only sending a limited supply of R37's medications when R37 first admitted to the facility. V18 stated on the morning of 6/12/23 V18 obtained R37's scheduled seizure medications from the facility's (electronic emergency medication system). V18 stated there were concerns that R37 had missed doses of R37's seizure medications and R37 voiced concern that R37 would have seizures. V18 stated V18 ordered R37's medications from the pharmacy that day. V18 stated V18 questioned whether R37 missed doses of these medications since agency nurses were working during that time, and those nurses do not have access to the facility's (electronic emergency medication system). On 9/18/23 at 1:04 PM V11 Care Plan/Minimum Data Set Coordinator stated the facility has a backup system to obtain medications when unavailable, and if the medication is not available then the nurses are to contact the pharmacy to request a STAT delivery. V11 stated the nurses are to follow/implement hospital discharge medication orders. V11 reviewed R37's June 2023 MAR and 6/7/23 hospital discharge orders and confirmed R37's Divalproex Sodium order was incorrectly transcribed to be given twice daily instead of three times daily as ordered. On 9/19/23 at 1:06 PM V38 Agency RN stated V38 thought V38 borrowed R37's medications from another unidentified resident. V38 was unable to state what medications/doses were borrowed and the resident that these medications were borrowed from. V38 stated R37 was out of R37's medications on 6/11/23 and V38 knew that R37 needed the medications. V38 stated V38 thought V38 reported this to an unidentified staff member. V38 stated V38 was unsure of the procedure for when medications are unavailable, and V38 did not notify the pharmacy or access the facility's emergency medication system to obtain R37's medications. V38 stated V38 was not trained on this process. On 9/18/23 at 2:30 PM V16 Chief Nursing Officer stated R37's order sent from the hospital on 5/18/23 documents to administer Depakote 1000 mg twice daily. V16 confirmed the discharge orders from 6/7/23 were not transcribed correctly. V2 Director of Nursing stated agency nurses can ask the facility nurses to access the facility's emergency medication dispensing system to obtain medications. On 9/19/23 at 12:32 PM V16 stated the nurse (V38) may have borrowed seizure medications from another resident to give to R37 on 6/11/23. V16 stated it is acceptable to borrow noncontrolled medications from other residents and V16 would expect the doses to be returned to the resident once delivered. V16 stated sometimes there are issues with insurance and pharmacy delivering medications causing residents to go a couple days without medications. On 9/19/23 at 1:38 PM V16 confirmed there is no documentation as to what medications and dosages were borrowed for R37 or from which resident the medications were borrowed from. V16 stated the facility does not have a policy on borrowing medications. On 9/21/23 at 1:08 PM V16 stated the floor nurses review and transcribe the hospital discharge orders and the facility is now implementing that a second check of the orders will be done. On 9/18/23 at 1:19 PM V17 Nurse Practitioner stated the facility notified V17 that R37 missed doses of R37's seizure medications in June 2023. V17 stated V17 was unsure how many doses of medications were missed, and that it was believed to be a pharmacy delivery issue. V17 confirmed R37 had seizures noted in V17's note on 6/13/23. V17 stated R37's seizures could have been due to missed doses of seizure medications, electrolyte abnormality, or infection. V17 stated Grand Mal seizures put a resident at risk for deconditioning/overall decline, aspiration, and death. On 9/19/23 at 9:55 AM V22 Pharmacist stated six tablets of Carbamazepine, twelve tablets of Divalproex, and six tablets of Levetiracetam were dispensed from the pharmacy for R37 and delivered to the facility on [DATE] at 4:39 AM. V22 confirmed this amount was a three-day supply that would be depleted after 6/10/23. V22 stated the only medications pulled from the facility's electronic medication supply system between 6/7/23 and 6/12/23 was two tablets (two doses) of Carbamazepine 200 mg and eight tablets (two doses) of Levetiracetam 250 mg on 6/12/23 at 10:32 AM. V22 stated no doses of Divalproex Sodium, and no additional doses of Carbamazepine were dispensed from the facility's emergency supply or delivered from the pharmacy after 6/8/23 until 6/12/23. V22 stated the pharmacy delivered R37's 180 tablets of Divalproex, 60 tablets of Levetiracetam, and 60 tablets of Carbamazepine on 6/12/23 at 7:32 PM. V22 stated the pharmacy did not receive any contact from the facility regarding these medications and reordering after 6/7/23 until 6/12/23. V22 stated V22 does not understand why the facility did not pull these medications from the facility's emergency medication system on 6/11/23. V22 stated if medications are not available to administer, the facility is supposed to notify the pharmacy so that a backup pharmacy can be contacted to deliver the medications STAT. V22 stated the facility's emergency medication system contains Depakote Extended Release, which is not the same as Delayed Release that is ordered for R37, and the facility would need to obtain an order to interchange these medications. V22 stated if these medications are being used for seizures, we instruct patients to take the medications as ordered and avoid missing any doses. V22 stated if used for seizures, missing multiple doses of these medications could put the resident at increased risk for having a seizure. The facility's Medication Reordering policy dated as reviewed 12/21/22 documents the facility will provide or obtain pharmaceutical services for routine and emergency medications to be obtained timely. This policy documents the nurses should observe when there are less than six doses of medications remaining and reorder the medications and medication carts should be cross matched weekly on Thursdays. This policy documents medications should be acquired/administered timely, and medications needed for emergency/STAT situations will be maintained in a limited quantity by the pharmacy and sealed in an emergency container. The facility's Medication Errors policy dated as reviewed 1/4/23 documents a medication error includes a medication not being administered as ordered or per manufacturer's specifications. This policy documents mediations will be administered as ordered, medication errors will be evaluated based on the resident's condition, if the medication requires therapeutic blood levels, and the frequency of the error such as repeated omissions of medication. The Immediate Jeopardy that began on 9/7/23 was removed on 9/25/23 when the facility took the following actions to remove the immediacy: 1.) V2 Director of Nursing completed chart audits for all residents and Medication Audit Reports on 9/19/23, 9/20/23, 9/21/23, 9/22/23, 9/23/23, and 9/24/23 to ensure medications were administered and no pharmacy issues were reported. 2.) On 9/19/23 the facility implemented the Admission Checklist to be completed for all admissions and includes three separate nurses reviewing/verifying orders and medication ordering/delivery. These were completed for all new admissions and readmissions between 9/19/23 and 9/25/23. 3.) On 9/19/23 V2 Director of Nursing completed an audit of all facility nurses and login credentials to access the facility's backup medication system. V2 Director of Nursing and V16 Chief Nursing Officer notified pharmacy to request login credentials for nurses, and all nurses had login credentials (including PRN nurses) as of 9/19/23. V2 confirmed there were currently no agency staff nurses. 4.) V2 in-serviced all of the facility's nurses on the new process for transcribing medication orders, the facility's Pharmacy policy, and the facility's Medication Reordering policy. On 9/26/23 at 9:15 AM V2 confirmed all of the nurses had received this training by 9/25/23. 5.) On 9/19/23 V16 trained V2 on the facility's responsibility to provide essential medications to residents, ensuring all nurses have login credentials to access the facility's emergency backup medication system, medication transcription double check process, and auditing medication administration daily with the Medication Administration Audit Report. 6.) On 9/19/23 the facility developed and implemented an audit tool to ensure all medication orders are transcribed correctly, medications are administered, and nurses have credentials to access the backup medication system and the results of the audits will be reviewed during the facility's Quality Assurance meeting. Audits were completed by V2 daily between 9/19/23 and 9/24/23. On 9/19/23 at 12:22 PM V2 stated V2 completes the audits at least five times per week and the audits will continue for at least the next 12 weeks. V2 stated the facility has not had a Quality Assurance meeting after 9/19/23, and the results of the audits will be reviewed during the next scheduled meeting. B.) Based on observation, interview, and record review the facility failed to administer insulin as ordered resulting in a significant medication error for one (R1) of three residents reviewed for hospitalization s in the sample list of 47. Findings include: b.) R1's Hospital Discharge Orders dated 9/7/23 document to check R1's blood glucose level twice daily and to administer Lantus (insulin) 8 units each night. R1's Nursing Notes document R1's Lantus as on order on 9/7/23 and 9/8/23, and to be ordered on 9/11/23. R1's September 2023 Medication Administration Record (MAR) does not document R1's Lantus was administered as ordered on 9/7, 9/8, and 9/11/23 referring to R1's nursing notes, and does not document that R1's blood glucose was checked twice daily until 8:00 PM on 9/12/23 when R1's blood glucose was 475. On 9/21/23 at 1:08 PM V16 Chief Nursing Officer confirmed a checkmark on the resident's MAR indicates the mediation was administered. On 9/21/23 at 1:20 PM V16 Chief Nursing Officer provided a vial of R1's Lantus that included a label with a dispensed date of 9/7/23. V16 confirmed the medication was available and the nurses should have administered the medication as ordered.

Based on observation, interview and record review, the facility failed to maintain a resident's nutritional and hydration status to prevent a significant weight loss and dehydration. The facility failed to: follow physician orders for monitoring enteral feeding (via gastrostomy tube) intake amounts for a resident who has care orders for nothing by mouth and ensure for placement of the resident's abdominal binder. The facility also failed to follow up with the physician and implement dietary recommendations or notify the Registered Dietician and/or Physician of the inability to obtain the recommended enteral feedings in a timely manner. The facility failed to obtain weights timely for an accurate/baseline nutritional assessment to be completed and to ensure residents enteral feeding was being administered as ordered. These failures affect one of two residents (R78) reviewed for nutrition on the sample list of 47. These failures resulted in R78 sustaining a significant weight loss and being admitted to the hospital with Diagnoses of Hyponatremia due to Dehydration, Acute Kidney Injury from Dehydration/Sepsis, along with Severe Protein Calorie Malnutrition. Findings Include: R78's ongoing Census documents R78 was readmitted to the facility on [DATE]. R78's June 2023 Physician Orders document an order for NPO (nothing by mouth) and Jevity 1.2 {Enteral Feeding} at 65 ml/hr (milliliters/hour) continuously for nutrition (via gastrostomy tube). R78's Progress Notes by V25 RD (Registered Dietician) document the following: 6/24/23 -V25 had to request a weight for R78's assessment as one had not been obtained. 6/29/23 - V25 observed Jevity 1.2 at 65 ml/hr and a water flush of 250 ml QID (four times a day) running per order. R78 is thin, chronically ill, and meets the guidelines of malnutrition AEB (as evidenced by) reduced fat/muscle mass, and bony prominences. 7/6/23 - R78 is NPO for nutritional status, is a tube feed with flushes. R78 has lost weight and is a re-admit from hospital stay, returning from hospital as an enteral feed. 7/13/23 - R78's weight is 135.7 pounds (a 13% weight loss in two months). Blood Glucose levels have been running high since returning from the hospital. Recommend discontinuing the Jevity 1.5 and current water flushed and switch to Glucerna 1.5 when available to support glucose control. Glucerna 1.5 at 65 ml/hr x 20 hrs with a Water flush of 255 ml QID. 7/25/23 - Glucerna is on backorder so consider switching to an available brand of formula if Glucerna remains unavailable; Diabetic Source or Nestle to infuse at 65 ml/hr x 24 hrs with a water flush of 250 ml QID. These would be equivalent to the Glucerna recommendation. Current weight 134.6 pounds (a loss of an additional pound). 7/27/23 - Glucerna 1.5 to start at 6:00 pm today {14 days after recommendation made}. 8/3/23 - Current weight 126 pounds {down an additional 8.5 pounds} (7% weight loss in one month and 19% in 3 months). Observed Glucerna 1.5 infusing at 65 ml/hr and fluid at 255 every 6 hours. Consider increasing fluids due to elevated laboratory values and weight change per physician discretion. 8/17/23 - Current weight is 126 pounds and is considered undesirable. Recommendations are to: Increase Glucerna 1.5 to 70 ml/hr x 20 hr with a water flush of 230 ml every 4 hrs (6 times/day). This provides 1400 cc (cubic centimeters), 2100+160=2260 kcal (kilocalorie's), 116 gm (gram) protein, 1063+1380= 2443 cc/day or 1 kcal:1 cc ratio. Add Juven {Nutritional Supplement} 1 packet bid (twice a day). Discontinue Juven 1 packet daily. Add weekly weights through September 20, 2023. R78's ongoing Progress Notes do not document that V25 RD, V17 NP (Nurse Practitioner), or V31 Physician were notified of R78's ordered Glucerna Enteral Feeding not being obtained and initiated in a timely manner. R78's September 2023's Physician Order Sheet documents the following orders: Juven Packet {Nutritional Supplement} 1 package a day, Glucerna 1.5 at Rate of 65 ml/hr for a total Feed Volume of 1300 mL via G-Tube from 5 pm - 1 pm, 255 ml water flush QID, and record the enteral feed volume delivered every day. This order sheet also documents R78 is to wear an abdominal binder at all times to prevent R78 from pulling on the gastrostomy tube. V25's recommendations from 8/17/23 for the changes in enteral nutritional and hydration rate are not transcribed and initiated and neither is the increase in Juven. On 9/17/23 at 9:35 AM, R78 was lying in bed with Glucerna 1.5 infusing at 65 ml/hr with a water flush running at same time. The enteral feeding/flush mixture was leaking and R78's gown and sheet were saturated with feeding. R78 was not wearing the ordered abdominal binder. On 09/17/23 at 11:27 AM, R78's Glucerna and water flush continues to be leaking, and R78 does not have the ordered abdominal binder in place. The saturated area of bedding and gown is much larger than at 9:35 am. At this time, V13 RN (Registered Nurse) stated V13 will look at R78's gastrostomy tube explaining, it sometimes leaks. V13 also stated that R78's intakes are to be documented on the MAR (Medication Administration Record). R78's August and September 2023 MAR (Medication Administration Record) do not document the volume of enteral feeding received daily. On 9/19/23 at 8:08 AM, R78 was lying in bed without the ordered abdominal binder. R78's enteral feeding and hydration pump was not running and was alarming as the bottle of enteral feeding was empty, so nothing was being administered. On 9/19/23 at 9:22 AM, R78 continues to lay in bed, with no feeding being administered, and no abdominal binder in place. The feeding/hydration pump is still alarming. At this time, V15 ADON/ Wound Nurse stated R78 is to have the abdominal binder on at all times. On 9/20/23 at 9:30 AM, V2 DON (Director of Nursing) stated if a resident receives enteral feedings, V25 RD is contacted so an evaluation can be done within 24 hours. Residents should be weighed at the time of admission and then as ordered. V2 also stated nurses on the unit follows up on the dietary recommendations or V2 will send them off to the Physician/NP for signature but V15 ADON (Assistant Director of Nursing)/Wound Nurse, is the person responsible for monitoring weights and following up on the recommendations. Once the recommendations are signed by the physician, the nurses are to transcribe and implement the orders. On 9/20/23 at 9:33 AM, V15 ADON/Wound Nurse, reviewed R78's medical record and confirmed R78 did not have a weight upon re-admission, and it was not obtained until July 2023, therefore V25 could not complete a nutritional assessment within 24 hours of R78 being admitted to the facility. V15 also confirmed V25's recommendations from 8/17/23 were never implemented and explained, V15 doesn't know what happened to the recommendations or if they were ever sent to the physician because nothing is scanned into the electronic medical record. V15 stated it is V15's responsibility to follow up on those recommendations and doesn't know why V15 didn't do it, 'I should have. On 9/20/23 at 10:34 AM, V25 RD confirmed R78 did not have a current weight on 6/24/23, so V25 had to request one in order to complete R78's nutritional assessment. Once it was obtained, V25 completed the evaluation on 7/6/23 which documents a weight of 135.7 pounds, a 13% weight loss in 2 months. V25 explained due to R78's weight loss and elevated blood glucose levels, V25 recommended switching to Glucerna 1.5. V25 also stated with the Jevity, 1.2, R78 should have been able to maintain R78's weight but since R78 was not, the increased calories in Glucerna should help in maintaining R78's weight. V25 confirmed the facility had a delay in obtaining the Glucerna so on 7/25/23, V25 gave additional formula's that could be used instead of continuing with Jevity 1.2. V25 stated the facility had not reached out to V25 regarding the delay in obtaining the recommended formula. V25 confirmed R78 continued to have significant weight loss of another 7% in 1 month and 19% in 3 months, so on 8/17/23, V25 recommended increasing the Juven {Nutritional Supplement} to twice a day and increasing the feeding to Glucerna 1.5 at 70 ml/hr x 20 and recommending weekly weights for closer monitoring. V25 explained, with those recommended changes, R78 would be receiving more than the recommended calories to maintain R78's weight. V25 was not aware that those recommendations were never implemented. On 9/20/23 at 11:11 AM, V32 Environmental Services confirmed a delay in obtaining the Glucerna 1.5 and stated it was ordered on 7/14/23 but was not received until 7/27/23 {13 days later}. On 9/20/23 at 12:47 PM, V17 NP (Nurse Practitioner) stated the facility generally forwards V25's recommendations to V17 to sign off on them, then implements them. V17 stated V17 never received the recommendation from 8/17/23 to increase R78's feeding rate, or supplements but would not have declined the recommendation as V25 is the expert in that region and if that is what V25 calculated for R78's nutritional/hydration needs to maintain weight, that is what should be ordered and administered to maintain R78's weight. V17 stated, I can't think of any reason why R78 would still be losing weight if R78 was getting the feeding as ordered. V17 stated V17 has also not been notified of R78's continued weight loss, or that there was a delay in obtaining the Glucerna 1.5. but that the facility should have notified V25 to see if there was another formula that could have been used. R78's Progress Notes dated 9/19/23 documents R78 was admitted to the hospital. R78's Hospital History and Physical dated 9/19/23 by V29 Hospital NP documents upon assessment, R78 has Acute Hyponatremia due to Dehydration and AKI (Acute Kidney Injury) due to Dehydration/Sepsis along with a chronic medical condition of Severe Protein Calorie Malnutrition. R78's Historical Laboratory tests document on 5/22/23, R78's BUN (Blood Urea Nitrogen) level was 28, normal results are 7-28. On 8/3/23, R78's BUN level was 81 and Sodium Level was 143, normal results are 138-147. Then upon admission to the hospital on 9/19/23, R78's BUN level was 116 and Sodium level was 152. The Facility Hydration Policy dated 4/1/21 documents, the facility offers each resident sufficient fluid, consistent with resident needs, to maintain proper hydration and health. The dietician will assess hydration as part of the comprehensive nutritional assessment within 72 hours of admission, annually and upon significant change in condition. The facility Nutritional Management Policy dated 12/5/22 documents the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Nursing staff shall obtain the resident's height and weight upon admission and subsequently in accordance with facility policy. A comprehensive nutritional assessment will be completed by a dietician within 72 hours of admission, annually and upon significant change in condition. The dietician will estimate the resident's calorie, nutrient, and fluid needs. The physician will be notified of significant changes in weight, intake, or nutritional status. Nutritional recommendations made by the dietician will be followed up with the physician/practitioner for orders per facility policy.

Based on observation, interview and record review, the facility failed to transcribe and implement physician orders to promptly send a resident to the hospital with a change in condition and failed to recognize a change in condition for one of two residents' (R78) reviewed for skin conditions on the sample list of 47. This failure resulted in a delay of hospitalization /treatment for R78. Upon admission to the hospital for worsening Gangrene of the right foot/toe, R78 was diagnosed with Osteomylitis and Sepsis due to Osteomylitis requiring Intravenous Antibiotics, an above the knee popliteal bypass grafting and amputation of the third right toe. Findings Include: On 9/17/23 at 10:13 AM, R78 was lying in bed. R78's right third toe was black, to the base of the toe, with red skin coloring at the base of the toe, on the top of the foot extending approximately 2 cm (centimeters). On 9/17/23 at 12:21 PM, V5 (R78's Friend/Emergency Contact) stated R78 has already lost R78's left big toe due to an infection and now the facility staff are saying R78 needs a toe on the right foot removed. On 9/17/23 at 3:29 PM, V6 (R78's Family) stated V6 received a phone call on 9/7/23 at 8:00 pm from an unidentified nurse, saying R78's right third toe is looking like it needs amputated and that a podiatrist would be out either Monday or Tuesday {9/11 or 9/12/23} to look at it. V6 explained on 9/14/23, after not receiving any updates, V6 called the facility and spoke with an unidentified nurse who stated she was not aware of R78's condition and checked R78's chart and said that nothing was documented on it, so it must have been a mix up with another resident. V6 explained today {9/17/23} when V6 was at the facility, V6 looked at R78's foot and R78's toe is completely black, and it was red on top of the foot near the toe. V6 stated V6 reported the toe condition to V13 RN (Registered Nurse) and V13 replied that the toe might completely fall off on its own and that if it looked red past the black, R78 would need hospitalized . V6 reported to V13 that the foot looked red to V6 and V13 responded okay but did not look at it or do anything. R78's Progress Notes dated 9/7/23 document R78 has a diabetic wound to the right third toe with the peri-wound skin being cyanotic. V20 Wound Physician recommends R78 be seen by vascular surgery and podiatrist. There is no other wound documentation/descriptions documented in the Progress Notes through 9/17/23. R78's Wound Physician Notes by V20 document the following: 8/31/23 - does not document any right third toe wounds 9/7/23 - R78 has a Full Thickness Diabetic Wound of the Right Dorsal Third Toe measuring 2 cm (centimeters) by 1.5 cm by not measurable that is covered in 100% thick adherent black necrotic tissue. Additional information: dorsal distal toe black with loss of nail and distal plantar aspect of toe is cyanotic. Suspect this is a result of ischemia. R78 is non-ambulatory and has been in a reclining wheeled chair so it is unlikely to have been injured otherwise. R78 had a BLE (Bilateral Lower Extremity) angiography on 4/28/23 that showed an occluded right SFA (Superficial Artery) but three vessel runoff; likely microvascular disease is causing the ischemia of third toe. Schedule appointment with podiatry. 9/14/23 - R78 has a Full Thickness Diabetic Wound of the Right Dorsal Third Toe measuring 2.5 cm by 2 cm by not measurable that is 100% covered in a thick adherent black necrotic tissue (eschar). Special Instructions for dry gangrene of toe: Apply betadine to the right third toe. R78 will require amputation vs (versus) autoamputation. If R78 develops erythema around the wound, then R78 would need sent out to hospital but otherwise R78 can wait for outpatient podiatry consultation for possible surgical amputation of the toe. R78's September 2023 Physician Orders documents an order on 9/18/23 to apply betadine every shift to the third right toe. There is no order transcribed to send R78 to the hospital if erythema develops. On 9/19/23 at 8:30 AM, V15 ADON (Assistant Director of Nursing)/Wound Nurse entered R78's room to complete the ordered toe treatment. R78's right third toe is black with the foot being red up to the ankle, compared to two cm on the top of the foot two days ago. The blackness of the toe now extends onto the plantar part of the foot approximately 0.2 cm and the top of the foot has dark/dusky discoloring approximately 1 cm. V15 explained R78 is being followed by V20, who recommended R78 be seen by vascular surgery and podiatry but that R78 hasn't been able to get in yet to be seen. V15 completed the ordered treatment and verified that the foot is red, and the blackness is spreading stating that the toe started with a small black area and has expanded to this point in a couple of weeks. On 9/19/23 at 10:12 am, V15 stated V15 was not aware of the order to send R78 out to the hospital if the toe/foot developed erythema and stated on 9/15/23, the last time V15 seen R78's right foot, it was not red and there is nothing documented in the Progress Notes about it being red. V15 explained, if that is an order, and it was red over the weekend, then R78 should have been sent to the hospital, so V15 will contact V20 for recommendations. R78's Progress Notes dated 9/19/23 document V20 consulted about redness to top of R78's right foot. V20 indicates the redness is from progressing ischemia and has ordered R78 to be sent to the ER (emergency room ) for vascular evaluation as R78's appointment with the vascular surgeon is over a week away. V17 NP (Nurse Practitioner) also notified. On 9/19/23 at 11:20 AM, V20 Wound Physician stated the facility just called V20 this morning to report the changes to R78's toe/foot and V20 asked for the facility to send R78 out to the hospital. V20 explained V20 is concerned with the ischemic changes to the toe and that R78 was going to need the toe amputated but now that the blackness is spreading, R78 needs seen because it could be the difference between losing a toe vs the entire foot. V20 stated the facility should have called the primary care physician over the weekend with the changes to the toe when the redness was noticed two days prior on 9/17/23. R78's Hospital History and Physical dated 9/19/23 by V29 Hospital NP documents R78 is being admitted for worsening right foot/toe gangrene/Osteomylitis. Assessment shows: Sepsis present on admission due to Osteomylitis, Severe PVD (Peripheral Vascular Disease) with right third toe Gangrene and Osteomylitis. R78 started on IV (Intravenous) Zosyn {Antibiotic} and Vancomycin {Antibiotic}. R78's WBC (White Blood Cell Count) in the hospital on 9/20/23 documents a level of 17.25, normal range is 4-12. R78's Vascular Surgeon Notes 9/19/23 by V30 Vascular Surgeon documents R78 came to the ER (emergency room ) with reports of Gangrenous, Cellulitis of the distal right foot, third toe. Assessment and Plan: PVD (Peripheral Vascular Disease) with Cellulitis, Gangrene of right third toe/foot. R78 has known superficial femoral artery occlusion. Will treat the Gangrene and Cellulitis and R78 may need an above the knee popliteal bypass grafting to restore blood flow to the right leg. R78's Podiatric History and Physical dated 9/19/23 by V40 documents R78 presents with a new finding of gangrene on the right lower extremity with Cellulitis. R78 was seen by V30 Vascular Surgeon who is considering a possible bypass. Basically, there is some odor to the toe. There is a little bit of moisture. The distal end is dry, though. At this point, will let the Cellulitis settle down for a day or two with antibiotics and then taking off the right third toe would be reasonable. Will make sure Vascular is okay with us proceeding with the amputation. Probably on Thursday, 9/21/23, we will plan for a toe amputation of the right third toe, it might even include the metatarsal head. R78's Palliative Care Progress Note dated 9/25/23 documents R78 had the right third toe amputated and a right femoral above knee bypass completed. The Facility Wound Treatment Management Policy dated 9/19/23 documents it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The effectiveness of treatments will be monitored by nursing staff, DON (Director of Nursing) and Wound Nurse through regular assessment of the wound, based on treatment and progress. The Facility Physician/Practitioner Orders Policy dated 1/1/20 documents a physician/practitioner may include, but is not limited to, a resident's attending physician, wound clinic physician, nurse practitioner, or specialist. Orders received in writing or via fax, the nurse in a timely manner will call the attending physician and verify the order and follow facility procedures for verbal or telephone orders including noting the order and transcribing to the medication or treatment record.

Based on observation, interview and record review, the facility failed to implement residents' pressure relieving interventions to prevent the development of pressure ulcers, and report pressure ulcers to the nurse so a treatment order could be obtained. This failure affects one of two residents (R139) reviewed for pressure ulcers on the sample list of 47. This failure resulted in R139 developing four, stage two pressure ulcers. Findings Include: R139's MDS (Minimum Data Set) dated 9/1/23 documents R139 is alert and oriented and requires extensive assistance of one staff for transfers. R139's Skin Risk assessment dated [DATE] documents R139 is at risk for breakdown. R139's Care Plan dated 9/1/23 documents R139 is at risk for skin breakdown due to decreased mobility with interventions to administer all preventative measures as ordered by the physician and monitor for effectiveness, educate and encourage resident to reposition/allow staff to reposition frequently to decrease risk of impaired skin integrity, observe skin condition with ADL (Activities of Daily Living) care daily and report abnormalities, chambered air type cushion to wheelchair, and turn and re-position frequently. On 9/17/23 at 10:18 AM, R139 was sitting up in a wheelchair on a thin gel cushion. R139 stated R139's butt is red and sore. R139 explains staff get R139 up around 7:00 am for breakfast then leave R139 sitting until after lunch {more than six hours}. R139 stated staff won't lay me down between times, they tell me it's good for me to stay up. On 9/17/23 at 1:30 PM, R139 remained sitting up in the wheelchair and stated staff still have not laid R139 down after requesting to be laid down several times and R139's buttocks is hurting worse. On 9/18/23 at 9:54 AM, R139 was sitting up in a wheelchair on a thin gel cushion stated R139 did not get laid down yesterday until 1:50 pm {6 hours and 50 minutes after being gotten up into the wheelchair}. R139 also stated R139 was gotten up around 7:00 am again today and has requested to be laid down due to R139's buttocks hurting really bad. On 9/18/23 at 11:10 AM, R139 was lying in bed on a regular mattress, on R139's back. R139 stated R139 was placed in bed around 10:30 am, {3.5 hours after being gotten up into the wheelchair}, and that R139's buttocks is still hurting, even after being able to lay down. R139's Skin Observation Tool dated 9/16/23 by V4 LPN (Licensed Practical Nurse) does not document any pressure ulcers or redness. On 9/18/23 at 12:17 PM, V13 RN (Registered Nurse) stated R139 does not have any open areas on the buttocks that V13 is aware of. V13 also stated, V13 knows that staff try to keep residents up for meals, but don't know if R139 is one that they tell can't lay down or not. At this time, V14 CNA (Certified Nursing Assistant) stated facility staff encourage residents to be up for meals. V14 also stated V14 is not sure if V14 told R139 yesterday {9/17/23} that R139 needed to stay up for lunch or not. V14 stated R139's buttocks is red and open and that V14 did not report that to anyone because it has been like that for a while and V14 assumed the nurses already knew. V13 denied knowing R139's buttocks is red and open. V13 left R139's room to get V15 ADON (Assistant Director of Nursing)/Wound Nurse. V13 and V15 then entered R139's room and pulled down R139's pants to check R139's buttocks, which revealed an unblanchable dark red/purple in color area which V15 measured as 12.1 cm (centimeters) by 19.0 cm, extending across bilateral buttocks. Within the dark red/purple area, R139 has three superficial open areas to the right-side measuring: 5.4 cm by 1.3, 0.2 by 0.4, and 1.2 cm by 1.2 cm and one superficial open area to the left side measuring 4.1 by 2.0 cm. V15 described the open areas all as stage 2 and the red area as stage 1 pressure areas. V13 and V15 both confirmed that resident sitting in chair for more than 6 hours at a time, could cause the pressure ulcers and explained R139 needs to be turned and repositioned every 2 hours. V15 also stated V15 will also have to look at the type of wheelchair cushion R139 is using, because it is not was is care planned to be used. R139's September 2023 Physician Order Sheet does not document a treatment for R139's pressure ulcers until 9/18/23. On 9/18/23 at 3:07 PM, V15 stated a head-to-toe assessment should be completed weekly and with any new skin issues, and that CNA's should report any new skin issues to the nurse immediately upon finding it, so the nurse can notify the physician for treatment orders. V15 also stated, if a resident is wanting to be laid down, staff should lay them down and not tell them that they need to stay up for the meal. The Facility Pressure Injury Prevention and Management Policy dated 12/6/22 documents the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Pressure Ulcer/Injury refers to localized damage of the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Licensed nurses will conduct a full body skin assessment on all residents upon admission, readmission, weekly and after any newly identified pressure injury. Findings will be documented in the medical record. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task. Evidence-based interventions for prevention will be implemented for all residents who hare assessed at risk or who have a pressure injury present. Interventions will be documented in the care plan and communicated to all relevant staff.

Based on record review and interview the facility failed to protect the resident's (R53) right to be free from verbal and mental abuse by another resident (R10). R53 and R10 are two of four residents reviewed for abuse on the sample list of 32. Findings include: R10's Physician Order Summary Report dated 12/16/22 documents the following diagnoses: Unspecified Dementia Unspecified Severity Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. R10's Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview of Mental Status score of 8 out of 15 indicating severe cognitive impairment. The same MDS documents R10 ambulates with limited assistance of one staff member and can stabilize self without staff assistance when walking. The same MDS documents R10 had verbal behavioral symptoms directed towards others '(e.g., threatening others, screaming at others, cursing at others)' one to three days a week. R10's Care Plan dated 11/18/22 includes the following: Focus, (R10) is/has the potential to be physically aggressive related to Dementia, poor impulse control, and cognition decline. Goal, (R10) will not harm self or others through the review date, 01/06/23. Interventions, (R10) triggers for physical aggression are consistent verbal outburst towards other residents (and) receiving negative comments to questions. The resident (R10) is de-escalated by keeping other residents with verbal behaviors at a safe distance ensuring spatial boundaries. R10's staff documentation Point of Care Response History behavioral tracking, documents R10 had Aggressive Language on 12/3/22, 12/04/22, 12/09/22 and 12/14/22. R53's Minimum Data Set (MDS) dated [DATE] documents R53's Brief Interview of Mental Status score as 15 out of a possible 15, indicating R53 has no cognitive impairment. R53's same MDS documents R53 requires physical assist of two people with ambulation. On 12/15/22 during group meeting between 10:45 am and 11:45 am, R53 stated My (R53) roommate (R10) called me (R53) a jackass last evening and said she (R10) was going to bash my head in and kick my butt. I (R53) told a CNA (Certified Nursing Assistant, unidentified) and she went to (V10, Licensed Practical Nurse/LPN). The nurse (V10, LPN) went to the DON (V2, Director of Nursing), (see interview below, V3, LPN Supervisor on-call was notified not V2, DON). My roommate (R10) scared me. I (R53) was afraid to go to sleep. The DON moved (R10) to another room. (R10's) (unidentified relative) came in this morning and apologized (to R53). On 12/15/22 at 12:00 pm V1, Regional Clinical Support, Registered Nurse confirmed R53 and R10 were involved in a resident-to-resident situation that occurred 12/14/22. R53's General Progress Note dated 12/14/22 at 6:44 pm signed by V10, LPN documents the following: Resident (R53) c/o (complained of) her (R53's) roommate (R10) made threatening statement to her (R53), including physical violence. Resident's roommate (R10) removed from the room to an empty room on the hallway for the evening. Nurse Manager (V3, LPN) on call notified via phone. On 12/16/22 at 12:40 pm R10 stated I don't know what happened with some other person here. I can't say one way or the other. R10 raised R10's voice and stated loudly I might have said something, I can't remember. On 12/16/22 at 12:45 pm V3, Licensed Practical Nurse stated I was the supervisor on call that night. (V10, LPN) called me and said there was an altercation where (R10) threatened (R53) with bodily harm. I directed staff to put (move) (R10) in the empty room down the hall. I called the DON (V2, Director of Nursing) after supper. I did recognize this as potential abuse and I reported immediately to the DON (V2), our designated Abuse Prevention Coordinator. The facility Initial Report was provided by V1, Regional Clinical Support, Registered Nurse. The initial report documents R10 allegedly verbally abused was intentional toward R53 because R53 would not take R10 to the bathroom. The facility policy Abuse, Neglect and Exploitation dated 06/08/20 documents the following: Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Definitions: 1. The Abuse coordinator in the facility is the Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect or exploitation immediately to: Administrator or designee Other Officials in accordance with State Law State Survey and Certification agency through established procedures 2. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual deliberately, not that the individual must have intended to, inflict injury or harm. 3. Verbal Abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. 4. Sexual Abuse is non-consensual sexual contact of any type with a resident. 5. Physical Abuse includes, but not limited to hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. 6. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s).

Based on interview and record review the facility failed to protect the residents' right to be free from physical abuse by other residents for two of four residents (R1 and R4) reviewed for abuse in a sample list of five residents. This failure resulted in R1 sustaining skin tears and multiple bruises to (R1's) right forearm and R4 sustaining bruises and abrasions to (R4's) head and face when they were physically assaulted by R2 and R3. Findings include: 1. R1's Order Summary Report printed 11/28/22 includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired and depends on staff for assistance with activities of daily living (ADLs). R1's Care Plan updated 11/14/22 documents (R1) is at potential risk for abuse related to dependency on staff. R2's Order Summary Report printed 11/28/22 includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS dated [DATE] documents R2 is moderately cognitively impaired. R1's Progress Note dated 11/14/22 at 4:42PM documents (R1) was struck on the arms and possibly the head and shoulders by (R2) with the stick part of a (toilet) plunger. Residents were immediately separated. Director of Nursing was notified. Power of Attorney and Medical Doctor were notified. Physical assessment done. (R1) noted to have discoloration to Right Forearm along with two skin tears. (R1) kept in close observation. R2's progress notes 8/1/22 to 11/28/22 document numerous episodes of verbally threatening statements directed at staff and or resistance to care/refusal of ordered medications. However, interventions for Verbal outbursts and potential to be physically aggressive were not included in R2's Care Plan until 11/18/22. On 11/28/22 at 11:30AM V3, Registered Nurse, (RN) stated I was working when (R2) hit (R1) with the toilet plunger handle. I have no idea why the plunger was even in the room, (V4) Certified Nurse's Aide (CNA) called out to me. I got there when (V4) was taking the plunger from (R2). (V4) had gotten (R1) away from (R2). (R1) had two fresh bleeding skin tears and several new bruises on the right forearm. (R2) is frequently resistive to care and has been known to strike staff. So far as I know this is the first time, she has physically struck another resident. I took care of the injuries and sent (R2) out for a psych (psychological) evaluation. On 11/28/22 at 11:40AM V4 stated I was walking down the hall (11/14/22) when (R2) had her back to me. I saw she had something in her right hand that looked like a wooden stick and was swinging it to (R1) who was facing me. I saw the stick strike (R1) several times on the right forearm and R1 was bleeding. I got (R1) to safety and took the stick, which turned out to be a toilet plunger, from (R2). I had called (V3) and she came right away. (R1) told me she had also been hit in her head and shoulders, but there were no marks there. (R2) frequently curses and threatens staff and will hit staff at times, but that is the first I have seen (R2) hit another resident. 2. R3's Order Summary Report printed 11/28/22 includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Minimum Data Set (MDS) dated [DATE] documents R3 is mildly cognitively impaired. R3's Care Plan updated 11/18/22 documents yells out and refuses care. However, interventions for potential to be physically aggressive were not included until 11/18/22. R4's Order Summary Report printed 11/28/22 includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Minimum Data Set (MDS) dated [DATE] documents R4 Is severely cognitively impaired and requires staff assistance with activities of daily living (ADLs). At potential risk for abuse was not included in R4's Care Plan until 11/18/22. The facility's State Report dated 11/17/22 documents (V5) Certified Nurse's Aide (CNA) stated On 11/17/22 (V5) was in room to get vitals. (R3) allowed (V5) to get some (Vital Signs) but wouldn't let (V5) finish. (V5) got (R4's) vital signs and left the room. (V5) turned to come back into the room saw (R3) pushing a bedside table into (R4). The curtain was pulled between the two beds. After the table made contact with (R4) (R4) walked around the curtain and (R3) pushed the bedside table. It flipped over hitting (R4). On 11/28/22 at 12:00PM V5 stated I was trying to get vital signs and (R3) hit me. I went to help (R4) in the other bed. (R3) screamed and shoved the table into (R4) through the curtain. I sat (R4) on the bed and (R3) shoved the bedside table at (R4) so hard it flipped up and hit (R4) in the head, face and chest. (R4) had black eyes and bruises and a scrape on her face for days. (R3) is often aggressive. (R3) throws things at staff and other residents. Just a few days before that I saw (R3) throw a box of tissues at (R5). The box wasn't full, and it didn't hurt (R5). On 11/28/22 at 1:10PM V2 Director of Nursing (DON) confirmed the incidents involving R1 and R2 and R3 and R4. V2 stated (R1) had skin tears and bruises on her right forearm and R4 had bruises on both temples and black eyes. V2 also stated some residents flush a lot of tissue and that was why we had the plungers in the room. They have been removed to where they are not accessible to the residents. The facility's policy Abuse, Neglect, and Exploitation revised 6/8/20 states Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion, and physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. This policy further states Physical abuse includes, but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment.

Based on observation, interview and record review, the facility failed to provide adequate staff during cares, per plan of care, to prevent a fall from bed and thoroughly investigate a fall for R36. The facility failed to document an investigation including a root cause analysis for an accident involving R245 and another resident, which resulted in minor injury. R36 and R245 are two of four residents reviewed for falls and accidents on the sample list of 37. This failure resulted in R36 rolling off the bed, during incontinence cares, and sustaining an impacted fracture of the left femoral neck. Findings Include: 1.) The facility Fall Prevention Policy dated 9/7/21 documents each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. On 3/14/22 at 9:58 AM, R36 was sitting up in a wheelchair and stated, a girl was changing me (R36), and I (R36) rolled out of bed. The floor isn't too soft, let me tell you. R36's Care Plan dated 12/17/21 documents R36 has an ADL (Activities of Daily Living) self-care performance deficit related to [CONDITION(S)] following Cerebral Infarction affecting the left non-dominant side and has a history of falls, weakness, and a left above knee amputation. This care plan also documents R36 is at risk for falls due to having a history of falls, impaired balance/poor coordination, involuntary movements, and seizures. R36's MDS (Minimum Data Set) dated 12/22/21 documents R36 requires extensive assistance of two staff for bed mobility and toileting and has mildly impaired cognition. R36's Progress Notes dated 2/28/22 by V20 RN (Registered Nurse) documents a {unidentified} CNA (Certified Nurse Assistant) came to V20 to report that R36 had rolled off the bed while being changed and was on the floor. V20 went into R36's room to find R36 lying on R36's back, against the wall, between the windows and the bed. R36 stated that R36 rolled out of bed while being changed. R36 complained of pain, rated it a 9 on a scale of 1-10, to the left hip and pain to the back of the head. A large bump was observed to the back of the head. R36 was sent to the emergency room for evaluation. R36's ER (emergency room ) Notes dated 2/28/22 by V16 Physician documents R36 is in the ER with complaints of left sided leg pain, at the distal end of femur, just above where R36's previous amputation was performed. R36 also presents with a large hematoma to the posterior aspect of the head without active bleeding or laceration and left sided chest wall tenderness. A CT scan (Computed Tomography) of the chest, abdomen and pelvis was completed and revealed an Impacted fracture of the left femoral neck. V17 Physician who read the CT scan documented the impacted fracture appears acute and correlates with (R36's) active symptoms. R36's Post Fall Review dated 2/28/22 contained a witness statement from V13 CNA that documents V13 transferred R36 to the bed upon R36's request due to R36 needing to be changed. Once R36 was in bed, V13 instructed R36 to roll over so V13 could provide cares. By that time, R36 was on the edge of the bed. V13 instructed R36 not to roll anymore because R36 would fall but before V13 realized it, R36 was falling out of bed. On 3/16/22 at 12:05 PM V13 CNA stated V13 was the only CNA assisting R36 on 2/28/22, when R36 rolled out of bed. V13 stated V13 was aware that R36 required two assist with bed mobility however none of the other CNA's were willing to assist V13 get R36 in bed, and R36 needed changed so V13 decided to provide cares independently. V13 stated R36's bed was positioned approximately 2.5-3 feet off the floor {waist height on V13}. V13 stated after R36 was in bed, R36 wiggled onto R36's side Before I (V13) knew it, (R36) rolled overreaching for something on the bedside table and next thing I (V13) know, (R36) rolled further and fell . V13 stated V13 tried catching R36 by grabbing R36's shirt and amputated leg but couldn't keep R36 from falling. V13 stated had V13 had assistance, the other staff would have been on the opposite side of the bed and been able to stop R36 from falling out of the bed. V13 stated V13 was coached after the incident, by V13's agency, about not providing cares independently for residents who require two assist and that V2 DON (Director of Nursing) also educated V13 that two staff were required when providing cares to R36. V13 again stated that V13 was aware that R36 required two assist but nobody wanted to help me. On 3/16/22 at 12:43 PM, V2 DON confirmed R36 sustained a fractured left hip from rolling out of bed. 2.) R245's Progress Note dated 3/1/2022 at 1:53PM documents Housekeeping staff reported to this nurse that resident told her another resident ran over her foot with their wheelchair. This nurse went to assess resident who was in the hallway in her wheelchair, with her back to the wall, and her feet in the middle of the hallway. Resident asked about what happened, and she showed this nurse her right foot. She said it was her toes. This nurse assessed, noting resident has discoloration of the Right Lower Extremity which appears to be from long term [CONDITION(S)] and blood flow issues, as it is cooler to touch and a purple tint to the skin. Resident able to move all toes, and pulse palpable. Skin remains intact. Resident encouraged to turn her chair parallel to the wall, so her feet would not be exposed as much to passersby. Resident agreed and this was done. Resident informed that she could also utilize the lounges in the facility as well. Fax sent to provider office, and phone call made to resident representative. Will continue to monitor for injury/pain. On 3/15/22 at 11:00AM when complete investigation documentation was requested from V2, Director of Nursing V2 stated We monitored (R245) after it was reported to us. It wasn't a fall, so I didn't get any statements from staff or identify a root cause. The facility's policy Accidents and Supervision dated 12/1/20 states The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Definitions: 'Accident' refers to any unexpected or unintentional incident, which results in injury or illness to a resident.

Failures at this level required more than one deficient practice statement. A.) Based on observation, record review and interview, the facility failed to obtain and initiate orders for a [CONDITION(S)] (bilevel positive airway pressure) machine for one of six residents (R67) reviewed for respiratory care on the sample list of 37. This failure resulted in worsening respiratory function, which required increased oxygen use for R67. B.) Based on observation, record review and interview, the facility failed to secure a portable oxygen cylinder tank, prevent contamination of oxygen tubing, and failed to change out visibly soiled oxygen tubing, mask, and suction canister for two of six residents (R13, R34) reviewed for oxygen on the sample list of 37. Findings Include: a.) On 3/14/22 at 10:28 AM, R67 was lying in bed with oxygen running at 6 Liters/NC (Nasal Cannula). R67's skin was ashen in color. R67's oxygen tubing was lying on the floor. R67 had a [CONDITION(S)] Machine sitting on top of a small refrigerator, next to R67's bed. The mask and tubing for the [CONDITION(S)] Machine were uncovered. R67 gasped for breath when trying to talk, waiting several seconds and taking multiple breaths between words. R67 stated it was hard to talk due to not being able to breath. R67 also stated R67 got the [CONDITION(S)] machine a couple of weeks ago but that R67 has never used it due to nobody teaching R67 how to. R67's Medical Record Documents R67 was admitted to the facility on [DATE] and then hospitalized from 2/6/22 - 2/11/22. R67's Hospital Consult Note dated 2/10/22 by V31 Pulmonologist documents R67 is in the hospital due to Hypoxemic Hypercarbic Respiratory Failure. This note documents R67 has a known history of Lung Disease, severe malnutrition and deconditioning, along with being bedridden for 8 months, and now displaying profound Cachexia. This note also documents R67 has been hospitalized multiple times, approximately once a month for the last three months. V31 discussed trying a [CONDITION(S)] at night to improve (R67's) Hypercarbia and R67 agreed to try it. V31's Recommendations due to R67's Hypercarbic Respiratory Failure is limit oxygen to maintain saturations greater than 89 in less than 95%, and nocturnal [CONDITION(S)] to help ventilation and help bring down CO2 {Carbon [MEDICATION(S)]). R67's March 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 3/14/22, these orders do not contain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R67's Progress Notes document continued breathing difficulties after R67's return from the hospital: 2/25/22 - Nurse Spoke with V32 Physician regarding R67's request to increase oxygen to 6 Liters. R67 is sating at 84% on 5 Liters of oxygen via NC (Nasal Cannula) but when oxygen is bumped down to 4 Liters, R67 is sating at 90%. V32 stated to continue at 4 Liters for now and that V32 would come to see R67 the following day. R67 educated to take some deep breaths in through the nose and out through the mouth. Will continue to monitor resident at this time. 2/25/22 - V32 Physician called back and gave orders to put R67's oxygen on at 6 Liters via NC at this time. High flow concentrator and high flow NC brought to R67's room and set up for resident at this time. R67 stated I (R67) am feeling better already. R67 reminded to take slow deep breaths in through the nose and out through the mouth. Progress noted dated 3/1/22 by V34 ADON (Assistant Director of Nursing) - R67 noted to have ongoing complaints of wanting R67's oxygen turned up to 7 Liters and is asking staff to do so for R67. R67 given extensive education at this time regarding chronic pulmonary dysfunction, and the use of oxygen. Discussed the depression of the drive to breathe with higher levels of oxygen Liters Per Minute, causing lower oxygen saturations, and perpetuating the shortness of breath felt. R67 is having denial of this and needing multiple explanations with different wording. R67 educated on sitting up for lung expansion, deep breathing/pursed lip breathing techniques, and need for carbon [MEDICATION(S)] to be expelled from the lungs. R67 taught to sling accessory muscles with a pillow for any discomfort caused by deep breathing exercises. An incentive spirometer was given, and instructions given written and verbal. R67 refused to try it at this time but stated R67 would later. R67 also laid self-back flat in the bed, despite education to sit up when feeling short of breath. Will continue to encourage and educate as needed. On 3/16/22 at 9:27 AM, V11 Corporate Nurse stated it appears that R67 returned to the facility from the hospital with the [CONDITION(S)] but didn't have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/16/22 at 10:05 AM, V2 DON with V11 Corporate Nurse present clarified that the [CONDITION(S)] for R67 did not return from he hospital with R67 but instead got delivered to the facility for R67 after R67 returned to the facility. V2 stated staff should have followed up with V 31 Pulmonologist and/or V32 Physician at that time to obtain and implement the orders for the [CONDITION(S)]. At this time, V2 stated V2 called V32 (R67's Physician) yesterday to tell of the [CONDITION(S)] error and get an order. V2 also called V31 Pulmonologist, to get clarification as to if R67 needs to have oxygen running concurrently with the [CONDITION(S)] at night but is still waiting for V31 to return the call. b.1.) R13's MDS (Minimum Data Set) dated 12/8/21 documents R13 requires supervision with set up for ADL's (activities of daily living). R13's Care Plan dated 12/10/21 documents R13 using oxygen PRN (as needed) due to [CONDITION(S)] (Chronic Obstructive Pulmonary Disease). On 3/14/22 at 10:18 AM, R13 was sleeping in R13's wheelchair. R13's oxygen concentrator was on and running however the tubing and NC (Nasal Cannula) were lying on the floor. There was a portable oxygen cylinder tank standing in the corner of the room, next to the closet, that was not in a cart nor secured in any way. On 3/14/22 at 11:43 AM, V2 DON (Director of Nursing) stated V2 stated the oxygen cylinder should be secured for safety. On 3/14/22 at 12:44 PM, R13 was sitting up in R13's wheelchair with R13's oxygen tubing draped across the bed and lying on the floor. R13 stated R13 removes and applies R13's own oxygen but that facility staff have never told me (R13) to put it in a bag when I'm not wearing it. On 3/14/22 at 3:40 PM, R13 was sitting up in the wheelchair with oxygen running at 4 Liters/NC. R13 stated nobody had changed the set up and that it is the same tubing and NC that was attached to the machine earlier. The facility Oxygen Safety Policy dated 4/27/21 documents, staff, residents, and families will be educated on oxygen safety precautions in accordance with their roles and responsibilities related to the use and storage of oxygen. Cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full or empty. The facility Oxygen Administration Policy dated 5/10/21 documents oxygen is administered to resident who need it, consistent with professional standards, comprehensive person-centered care plans, and the resident's goals and preferences. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. b.2.) R34's Order summary dated 3/16/22 includes the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/14/22 at 12:52 PM R34 was lying in her bed with oxygen tubing and [CONDITION(S)] ([CONDITION(S)]) collar in place. The collar was attached to a portable ventilator (receiving only [CONDITION(S)] level of support) supplying 30% oxygen and respiratory support as ordered. There was a portable suction machine in place at bedside. The tubing was not dated as to last time changed. The suction canister was full of green thick liquid. The tubing and collar were covered in patches of yellow green secretions. It was difficult for R34 to speak, but she was able to state they don't change the tubing and suction container for weeks at a time. I don't like that. R34's Minimum Data Set, dated dated dated [DATE] documents R34 is moderately cognitively impaired and able to make needs known. On 3/16/22 at 11:30AM V2 Director of Nursing stated, The [CONDITION(S)] collar and tubing and the suction tubing and container should be changed weekly or if they are dirty. The facility's policy [CONDITION(S)] Care dated 12/1/20 states The facility will ensure that residents who need respiratory care, including [CONDITION(S)] care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. The facility's policy Oxygen administration dated 5/10/21 states Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include: a. Follow manufacturer recommendations for the frequency of cleaning equipment filters. b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. c. Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. Use only sterile water for humidification. d. If applicable, change nebulizer tubing and delivery devices every 72 hours or per facility policy and as needed if they become soiled or contaminated. e. Keep delivery devices covered in plastic bag when not in use.

Based on observation, interview and record review the facility failed to treat a resident's pain by failing to obtain and administer ordered narcotics for one or three residents (R1) reviewed for pain in the sample list of five. R1 suffered excruciating pain due to the facility failing to administer pain medication. Findings include: The facility's undated Pain Management policy documents, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. In order to help a resident, attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. [for example] after a fall, change in behavior or mental status, new pain or an exacerbation of pain). c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. R1's Admission Record documents R1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Care Plan with an initiation date of 11/14/21 documents, Risk for pain as evidenced by verbalization of pain with an intervention to administer pain medication per Physician orders. R1's Order Summary Report printed on 12/14/21 documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This report also documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This report also documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/13/21 at 2:10 PM, R1 stated that R1 is miserable in pain. R1 grimaced as R1 tried to move in bed. R1 stated that R1 received [MEDICATION(S)] around 5:00 AM this morning and the nurse told R1 that R1 only had four [MEDICATION(S)] pills remaining until the pharmacy brings more in the morning. R1 stated the nurse told R1 someone should have ordered the [MEDICATION(S)] and did not order it. R1 stated that R1 is trying to hold off on getting more pain medication so R1 can make it through the night. R1 stated it has been 9 hours since R1 had [MEDICATION(S)] and is in a lot of pain. R1 stated R1's pain is in the abdomen and the left leg. R1 rated R1's pain at this time between a 9 and 10 out of 10 with 10 being the worst. R1 stated R1 runs out of [MEDICATION(S)] frequently. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/13/21 at 3:11 PM, V4 Registered Nurse states that V4 just gave R1 two [MEDICATION(S)]'s. R1's medication card containing the [MEDICATION(S)] Acetaminophen ([MEDICATION(S)]) 5-325mg contained two tablets left in the card. The medication card dispense date is 12/9/21. V4 stated that R1's [MEDICATION(S)] is coming tonight, usually around 3:00 AM. V4 stated R1 gets it ([MEDICATION(S)]) every 4 hours. V4 stated that they have it ([MEDICATION(S)]) in the contingency box (emergency backup supply). V4 stated the pharmacy is using the old prescription for one tablet every four hours. V4 stated when V4 reordered the [MEDICATION(S)] the pharmacy did not have the prescription for the 2 tablet by mouth every 4 hours. V4 stated the last time V4 talked to the pharmacy they said they had 56 tablets of [MEDICATION(S)] they had to consume. V4 stated if they have a new e-signed (electronic signed) prescription they can change it. On 12/13/21 at 3:20 PM, V2 Director of Nursing stated the nurses can pull [MEDICATION(S)] from the back up supply if needed. On 12/14/21 at 9:26 AM, V5 Licensed Practical Nurse stated R1's [MEDICATION(S)] came in this morning. R1's Narcotic count sheet documents R1 received two [MEDICATION(S)] 5-325mg at 7:35 AM. R1's [MEDICATION(S)] prescription card stated take 1-2 tablets po (by mouth) q(every) 4 hours prn (as needed) for pain. Dispense date of 12/13/21 with 28 tablets left. R1's previous narcotic count sheet documents R1 was given the last two [MEDICATION(S)] at 7:30 PM on 12/13/21. According to the narcotic count sheets R1 went 12 hours without receiving pain medication that is ordered every four hours as needed. V5 confirmed that is when R1 received [MEDICATION(S)]. On 12/14/21 at 10:39 AM, R1 stated that R1's pain was really bad last night. R1 stated that R1 told the nurse about R1's pain but the nurse told R1 that R1 had no more [MEDICATION(S)] but R1 could have Tylenol. R1 stated that Tylenol does not help with R1's pain. On 12/14/21 at 11:15 AM, V1 Administrator stated when a resident runs out of pain medications V1 expects the nurse to get medication out of the backup supply. On 12/14/21 at 11:20 AM, V2 stated regarding to R1 running out of, [MEDICATION(S)] the night nurse should have gotten [MEDICATION(S)] from the back up supply and if there were any problems the nurse should have called the on call physician. V2 stated that V2 re-educated the nurse on using the backup supply.

Based on interview and record review, the facility failed to prevent resident to resident physical assault for 2 of 3 residents (R2 and R3) reviewed for physical abuse.This failure resulted in R2 and R3 being involved in a verbal altercation that escalated to R3 pushing R2 on the forehead resulting in R2 being sent to the hospital, then returning to the facility fearful of R3. Findings include: R2's undated Face Sheet documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This same Face Sheet documents R2 has a Power of Attorney for Healthcare and Financial matters as V11 R2's family member. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 points indicating severe cognitive impairment. R2's Care Plan does not document any focus area, goal nor interventions for R2's risk for being abused. R2's Clinical Mobility assessment dated [DATE] documents R2 as using a wheelchair for mobility most of the time and requires one staff member for standing. R3's undated Face Sheet documents an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 3 out of 15 possible points indicating severe cognitive impairment. The same MDS documents R3 requires one staff member assist for walking in room and in corridor. R3's Care Plan documents a focus area dated 6/7/21 has verbal aggression due to poor impulse control. This same Care Plan documents an intervention dated 5/24/21 to increase staff rounding due to increased agitation. R3's Nurse Progress Note dated: 6/12/21 at 3:28 PM documents R3 was re-directed by staff to not enter another resident's family visiting area, when R3 became angry with staff and stated I will choke you until you are no longer breathing. 6/14/21 at 2:56 PM documents resident (R3) becoming increasingly agitated wandering the hallways asking staff when he (R3) gets to go home. Resident demanding to go home. Attempts to re-direct were unsuccessful. 6/21/21 at 6:06 PM documents verbally aggressive with staff and verbalizing a dislike of all female staff. Continues to be agitated after family visit. Currently sitting in a chair at the nurses stations making rude comments to the staff that walk past him (R3). 6/27/21 at 3:44 PM documents resident (R3) agitated and ambulating in the hallway. Attempted to re-direct but resident (R3) continues to be agitated. On 7/2/21 at 3:30 PM V1 Administrator, stated R2 and R3 are both alert residents with low BIMS scores. V1 stated R2 uses a wheelchair for mobility and R3 is ambulatory. V1 stated R2 and R3 were both in the hallway by the nurse's station on 6/29/21. R2 was on the telephone with V11, R2's wife. R2 said something to R3 which agitated R3, so R3 used his middle three fingers and pushed on R2's forehead causing R2's head to be pushed back. V1 stated at that point, the staff returned R2 to R2's room. V1 stated V9 Resident Assistant was assigned to R3 for one to one supervision during this time. V1 stated R3 was provided one to one supervision during second shift (2:00 PM-10:00 PM) every day, but one to one supervision was not provided from 6:00 AM -2:00 PM nor from 10:00 PM - 6:00 AM daily. V1 stated R3 did not have any prior relationship with R2 before entering facility. V1 stated unknown as to why R2 and R3 do not get along. V1 stated there have been no further altercations between R2 and R3 or R3 with any other residents since 6/29/21. On 7/3/21 at 8:10 AM V1 Administrator stated any staff member assigned as a 'one to one' with a resident is expected to stay with that resident the entire assigned time. V1 stated R3 is 'pretty re-directable'. V1 stated in the case of R2 and R3's physical altercation, my (V1) expectation would be that the staff step in before another resident gets hurt. The staff should have intervened between R2 and R3 so that this unfortunate incident never would have occurred. On 7/2/21 at 4:30 PM V9, Resident Assistant (RA) was assigned to be one to one with R3. V9 stated one to one means that I (V9) don't have any other duties. I (V9) am supposed to stay with him (R3) and try to re-direct him (R3) when he (R3) tries to leave the building. He (R3) is on one to one's for his (R3) exit seeking behaviors. He (R3) tries to leave all the time. He (R3) gets mad when we (staff) don't let him (R3) leave. R2 and R3 had been yelling at each other, using profanities, flipping the middle finger at each other. I (V9) told V10 Registered Nurse (RN) that R2 and R3 were verbally arguing. She (V10) told me to monitor them (R2 and R3). R2 and R3 don't like each other. They (R2 and R3) have had several occasions where they (R2 and R3) yell obscenities at each other. This time, R3 was taunting R2. He (R3) told R2' I (R3) am going to kick your ass while flipping R2 off. R2 and R3 were yelling back and forth at each other some more. R3 then walked over to the nurse's station where R2 was on the phone with V11, R2's wife. R3 then yelled at R2 I'll fu***** kill you b****! I am going to kill you, you mother f*****! R3 then used his three middle fingers to push against R2's forehead, moving R2's head in a backward motion. V9 stated R2 started shouting after being hit by R3 He hit me! He hit me! V9 stated after R3 hit R2 I (V9) redirected R3 to walk in the opposite direction as R2 and reported this physical abuse to V10 Registered Nurse (RN). I (V9) am not going to get in the middle of two grown men fighting. On 7/3/21 at 10:45 AM R2 stated that guy (R3) yells at me all the time. I (R2) just mind my business. I (R2) don't bother anybody. He (R3) hit me in my head. (R2 demonstrates the same action described earlier using R2's three fingers). R2 stated he (R3) said he was going to kill me! I had to go to the hospital to get away from him (R3). R2 stated I hope he (R3) never comes back here. I am scared of him (R3). I hope he (R3) doesn't hurt me again. On 7/6/21 at 12:35 PM V30 Nurse Practitioner (N.P.) stated during in person visits, R2 had been very appropriate, calm and not offensive to staff or others. V30 stated that the facility had reported increased agitation since the 6/29/21 episode which sent R2 to the emergency room two times (6/30 and 7/4). V30 stated a urinalysis was obtained this week due to increased agitation and was unremarkable. V30 stated R2 has progressive dementia and is not able to process decision making or make appropriate decisions. V30 stated the mental anguish that R2 suffered by R3's death threats and physical abuse could cause increased agitation, increased confusion and increased combativeness which he (R2) has shown an increase in this past week. His (R2) behaviors are most likely due to the abuse he (R2) suffered by the other resident (R3). The facility policy titled 'Abuse, Neglect and Exploitation' revised 6/8/2020 documents the following: Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to facility staff and other residents. The abuse coordinator in the facility is the Administrator. Report allegations of suspected abuse, neglect or exploitation immediately to: Administrator, other officials in accordance with state law and State survey certification agency through established procedures. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 'Willful' means the individual deliberately, not that the individual must have intended to, inflict injury or harm. When suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. The facility will make efforts to protect all residents after alleged abuse, neglect and/or exploitation. When abuse, neglect or exploitation is suspected, the employee should respond to the needs of the resident and protect them from further incident, notify Abuse Coordinator immediately and notify the attending physician and the resident's family/legal representative.

Based on observation, interview, and record review, the facility failed to properly secure R1's wheelchair during transport resulting in R1's wheelchair tipping over backwards and R1 falling to the floor of the transport vehicle. This failure resulted in R1 sustaining multiple abrasions to R1's head, hands, arms, and uncontrolled bleeding to R1's right foot requiring emergency medical intervention. Findings include: R1's Physician Order's on 10/27/2020 document [DIAGNOSES REDACTED]. The facility Fall Guide on 10/22/2020 documents R1 is at high risk of injury from a fall due to recent surgery and use of blood thinners. R1's Progress Notes on 10/22/2020 at 1:35PM, documents R1 tipped over backwards in R1's wheelchair while being transported in the van of the facility's transportation provider to a medical appointment on 10/22/2020. The same notes document R1 returned from the appointment with abrasions to R1's head, right knee, bilateral hands, and R1 had also bitten R1's tongue and had blood in R1's mouth. The record further documents facility staff contacted emergency medical services to transport R1 to the hospital emergency department due to uncontrolled bleeding and chest pain. The Emergency Medical Patient Report, dated 10/22/2020, documents R1 had multiple injuries to R1's knees, hands, right foot, and the back of R1's head, and R1 had head, back and chest pain due to R1's fall on 10/22/2020. The same report documents R1's foot was bleeding heavily, and the facility reported to the ambulance they were unsure how much blood R1 had lost. The Hospital Emergency Medical Communication form, dated 10/22/2020, documents R1 had heavy bleeding and the Emergency Department Report, dated 10/22/2020, documents the facility transport van accelerated and R1 fell backwards in R1's wheelchair striking the back of R1's head and R1 was jarred hard. The same records document R1 foot was spraying blood. On 10/25/2020 at 1:50PM, R1 reported falling over in R1's wheelchair inside of the transportation van when the van accelerated around a corner. On 10/26/2020 at 11:20AM, R1 reported the transportation provider returned to the facility after R1's fall and injuries on 10/22/2020 stating, He (the van driver) probably should've taken me to the hospital. On 10/26/2020 at 10:13AM, V8 (Licensed Practical Nurse) reported assessing R1 after R1's return to the facility on [DATE]. V8 noted R1's injuries with R1 stating, They tipped me over & I hit my head. V8 noted abrasion and hematoma to the back of R1's head, bilateral hand abrasions, and foot bleeding. V8 also noted R1's metal intravenous fluid wheelchair pole was bent forward. On 10/26/2020 at 2:42PM, V3 (R1's representative) stated (R1) told V3 his wheelchair was not secured, the seat belt was not fastened, R1 tipped over backwards in the wheelchair and hit his head. V3 stated R1 was very upset over the incident and worried if it would happen again. V3 stated R1 reported severe pain in back, right foot and head. The Facility Fall guide (10/20/2020) does not identify any root cause of R1's fall, any evaluation of R1's wheelchair, evaluation of the transport van used to transport R1 on 10/22/2020, or any targeted interventions to prevent subsequent falls for R1. On 10/27/2020 at 9:28AM, V2, Director of Nursing (DON), stated the facility had not evaluated R1's wheelchair. On 10/27/2020 at 11:41AM, V1, Administrator, stated the facility had not evaluated the transportation van related to R1's fall on 10/22/2020. V2 stated root cause analysis unable to be completed due to van driver on the lamb (unavailable).

Based on observation, interview, and record review, the facility failed to prevent the development and worsening of pressure ulcers, monitor pressure ulcers, perform physician ordered weekly skin assessments, and obtain and follow treatment orders for residents. This failure affects two of three residents (R5 and R9) reviewed for pressure areas on the sample list of nine. This failure resulted in R5 developing and worsening unstageable pressure areas, and R5 being hospitalized [MEDICAL CONDITION] related to pressure ulcers. Findings include: 1. R5's medical record documents: Diagnosis: [REDACTED]. R5's Minimum Data Set (assessment), dated 9/25/19, documents R5 requires extensive assistance of staff with bed mobility, dressing and toilet use, and total dependence of staff with transfers and locomotion. This same MDS documents R5 is always incontinent of bowel and bladder and Yes is checked under - is this resident at risk of developing pressure ulcers/injuries. R5's care plan, with a revision date of 7/2/19, documents: Focus: (R5) has potential for pressure ulcer development related to immobility. Interventions: Follow facility policies/protocols for the prevention/treatment of [REDACTED]. R5's Wound Evaluation and Management Summary, dated 11/20/2019, documents, Exam: Groin/Buttock coccyx wound resolved with 0.5 cm x 0.5 cm of recent [MEDICATION NAME] visible midline distal sacrum more consistent with recent MASD (moisture associated skin damage) fissure that has healed. Other Diagnosis: [REDACTED]. There is a 0.5 cm x 0.5 cm area of indentation with thin [MEDICATION NAME] indicating recent healing likely several days ago based on appearance. Treatment: house barrier cream q (every)shift and prn (as needed) after incontinence to buttocks. R5's medical record documents, 12/1/2019 at 11:24 PM, Noted with skin care at HS (hours of sleep) res (resident) has a 2 cm (centimeter) open area on coccyx with several tiny open areas surround the coccyx. area was draining a serous pink. Cleansed with wound cleaner and abt (antibiotic) umg (ointment) applied with (guaze pad) and covered with a (waterproof) drsg. (physician) faxed for TX (treatment) orders. R5's Skin Observation Tool form documents, site: Coccyx, type: pressure, length: 2 cm, width: 2cm, depth: 0.2 cm, stage: two. R5's Treatment Administration Records (TAR's) documents: start date: 11/19/19, wound to coccyx: cleanse and apply barrier cream, monitor for s/s (signs and symptoms) of infection/worsening every shift for wound care at 6:15 AM, 2:15 PM and 10:15 PM. R5's TAR's, dated (MONTH) 2019, fails to document new physician ordered treatments from 12/1/19 to 12/4/19 after the development of R5's stage 2 pressure area to the coccyx. R5's progress notes document on 12/2/2019 at 5:19 PM, New order received to refer to wound clinic and turn and reposition every two hour. R5's Wound Evaluation and Management Summary, dated 12/4/2019 at 7:00 AM, documents, Focused Wound Exam (Site 1), Unstageable (due to Necrosis) Sacrum (coccyx area). Etiology (quality) Pressure. MDS 3.0 Stage Unstageable Necrosis. Duration > (greater than) 1 days. Wound Size (Length x Width x Depth): 4 x 3 x Not Measurable cm. Exudate: Moderate Serous. Thick adherent devitalized necrotic tissue: 75 %. Additional wound detail: patient with febrile illness now, thought to be UTI (urinary tract infection). Focused Wound Exam (Site 2). Unstageable DTI (Deep Tissue Injury) of the Left Buttocks. Etiology (quality) Pressure. MDS 3.0 Stage Unstageable DTI with intact skin. Duration > 1 days. Wound Size (L x W x D): 1.5 x 2.5 x Not Measurable cm. Focused Wound Exam (Site 3), Unstageable DTI of the Right Buttock. Etiology (quality) Pressure. MDS 3.0 Stage Unstageable DTI with intact skin. Duration > 1 days. Wound Size (L x W x D): 1 x 0.7 x Not Measurable cm. R5's progress notes document: 12/4/2019 at 8:54 AM, Resident noted to be hot to touch at time of wound MD (physician) rounds. Resident moaning and crying out at being turned. Spoke with cart nurse, call was placed to (physicians office) for orders due to [MEDICAL CONDITION], reading of HI on glucometer meaning over 500. Call received back from (physician) received orders to call 911 and send to ER (emergency room ) for evaluation and treatment, no coverage for [MEDICAL CONDITION] to be given prior to sending out. Resident left facility at 8:57 AM. R5's Hospital History and Physical, by V28 (Hospital Physician), dated 12/4/19, documents, History of present illness: Patient began having altered mental status about three days ago. This included a fever of about 102 as well as sleeping a lot throughout the day. Associated symptoms include a fist sized bed sore described as an ulcer on the sacrum. Assessment/Plan:[MEDICAL CONDITION], possibly secondary to UTI (Urinary Tract Infection) or ulcer wound on sacrum. R5's Hospital History and Physical documents: test 12/4/19 at 11:16 AM, urine color: yellow, urine appearance: cloudy, urine bacteria: mod (none seen). R5's medical record documents, 12/4/2019 1:42 PM, Received urine culture results (no significant growth identified). R5's Hospital Nursing Assessment, completed by V29 (Hospital Registered Nurse), documents on 12/4/19, Pressure ulcer present, midline coccyx, Type: pressure, length: 5.7 cm, width: 2.8 cm, depth: 0.3 cm, Pressure Ulcer Classification: full thickness, Pressure ulcer stage: unable to stage, (pressure injury to the coccyx is covered with moist necrotic tissue that is tan with some darker brown soft eschar, wound is acutely tender). Right medial buttock, Type; pressure, Length: 1.4 cm, Width: 0.8 cm, Pressure Ulcer Classification: full thickness, Pressure ulcer stage: deep tissue injury, (area of dark purple discoloration to the right medical buttock which is non blanchable, site is acutely tender). Left medial buttock, Type: pressure, Length: 1.3 cm, Width: 2.2 cm, Pressure Ulcer Classification: full thickness, Pressure ulcer stage: deep tissue injury, (area of dark purple discoloration which is non blanchable to the left medial buttock, site is acutely tender to patient). R5's hospital discharge summary, dated 12/10/19, documents, discharge position: skilled nursing facility. Patient presented [MEDICAL CONDITION] due to UTI (Urinary Tract Infection) and Pressure Ulcer coccyx infection, grew polymicrobial. Hospital Course: (R5) presented to ED (emergency department) with altered mental status the past three days. Patient was not conscious on initial presentation. Patient's daughter stated the patients condition had been getting worse throughout past three days. Patient also had an ulcer on her coccyx that the daughter described as roughly the size of a fist. Patient was treated for [REDACTED]. R5's Specimen Report documents: Source: coccyx, ordered: wound abscess, queries: other specimen description wound sacral. Collected: 12/4/19. Wound Culture Final Result: Organism #1: [MEDICATION NAME] Faecalis, Organism #2: Morg. [NAME]ii ssp morganii, Organism #3: Proteus mirabilis. On 12/11/19 at 1:46 PM, R5 had a 1.7 cm x 0.6 cm area to right buttock, area was not open but had a dark red/black center, a 0.2 cm x 0.3 cm open area to the left buttock with a pink center, and open area to coccyx/ sacrum measuring 4.3 cm x 2.4 cm with yellow slough to the entire wound bed with another area directly below measuring 1.7 cm x 0.6 cm. On 12/11/19 at 2:48 PM, V23 (Registered Nurse, Previous Wound Nurse) stated, R5 has a history of pressure ulcers. On 12/11/19 at 2:55 PM, V2 (DON) stated staff use their nursing judgement when a wound is identified and apply a treatment, notify the doctor and the wound nurse. Barrier cream is our standing order as a preventative, if the open area is a stage two or higher then barrier cream would not be appropriate and the staff should get an order for [REDACTED]. On 12/11/19 at 3:02 PM, V2 (DON) stated, R5's treatment orders did not change after R5's developed a stage 2 pressure ulcer on 12/1/19. Staff continued to apply the barrier cream to R5's open pressure area. R5's physician was not notified that R5's open area had worsened after 12/1/19 and R5 had developed two additional areas. R5 was not seen by the wound doctor until 12/4/19, and was later sent to the hospital 12/4/19. On 12/11/19 at 3:05 PM, V2 (DON) stated, Staff should have followed up with R5's physician for a new treatment order for the open area identified on 12/1/19. If the nursing staff noticed a change or worsening of the wound or if the current treatment was not effective the physician should have been notified until R5 could have been seen by the Wound doctor. 2. R9's Face Sheet document R9 was admitted to the facility on [DATE]. R9's Admission Progress Note, dated 10/31/19, by V23, RN (Registered Nurse)/Previous Wound Nurse, documents R9 was admitted to the facility with [DIAGNOSES REDACTED] to the left foot. [DEVICE] applied to the left foot and a dry dressing to the right foot. R9's Minimum Data Set (MDS), dated [DATE], documents Brief Interview for Mental Status (BIMS) score of 14, which indicates R9 as cognitively intact. This same MDS documents R9 as requiring extensive assistance of two staff for bed mobility. This same MDS documents that R9 is at risk of developing pressure ulcers. R9's Physician order [REDACTED]. This POS documents the following physician orders: skin observation tool to be completed weekly, pressure ulcer risk assessment to be completed weekly for four weeks, then monthly unless condition changes such that warrants assessment more often. Apply an absorbent occlusive dressing to the right and left inner buttocks. Change every 3 days, [DEVICE] to the left foot wound with pressure settings: 125 mm/ Hg (millimeters of Mercury) continuous suction. Change the vacuum dressing three times a week and as needed. Monitor the [DEVICE] every shift to ensure proper functioning. Pressure Ulcer Risk Assessments, dated 10/31/19, 11/7/19, and 11/14/19, document R9 is at moderate risk for skin breakdown. There is no Pressure Ulcer Risk Assessment for 11/21/19. R9's Skin Observation Tool, dated 11/20/19, documents new pressure ulcers to R9's right and left inner buttocks. There was no description or staging of any pressure ulcers. There were no other Skin Observation Tools completed in R9's medical record. Wound Assessment Details signed by V27, Wound Physician, document the following: 11/27/19 - R9's right and left foot wounds increased in size, nursing home has not changed vac {vacuum} in six days. 12/5/19 - Stage IV Pressure ulcer of the left heel. On 12/11/19 at 9:35 AM, V11, RN, entered R9's room to complete R9's ordered treatments. V11 removed the dressings to R9's coccyx and left buttocks pressure ulcers. Per V11, R9's coccyx wound measures 3.8 cm (centimeters) long by 2.1 cm wide. This wound was covered in soft white tissue with uneven wound edges, slight noticeable depth and moderate amount of yellow drainage. R9's skin surrounding coccyx pressure wound and left buttock pressure wound was dark red. The pressure ulcer to R9's left buttocks was also covered in white slough. V11 stated R9 had obtained both the left buttock pressure wound and the coccyx pressure wound at facility. At the time, left foot wound had a [DEVICE] dressing covering the wound, and the machine was set at 120 mm Hg. The [DEVICE] machine had three settings to choose from: 70 mm/Hg, 120mm/Hg, and 150 mm/Hg. On 12/11/19 at 9:45 AM, V11 stated R9's coccyx wound had declined and now appears larger and has white tissue covering the wound that it did not have before. V11 stated R9 has had the same [DEVICE] machine and set on 120 mm/Hg since admission. On 12/11/19 at 12:30 PM, V2 stated when a resident is identified to have a new or worsening pressure ulcer, staff should assess the wound, measure the wound, notify the resident's physician and Power of Attorney should be notified and orders obtained. V2 also stated the nurse should obtain a consult for a wound physician. V2 stated nurse should complete the skin observation tool and pressure ulcer risk assessment upon admission, with any new wound or worsening of any wound. V2 stated skin audits and skin observation tool should be completed weekly. V2 stated nurses should carry out and follow physician orders. V2 stated nursing staff should have notified V27 of the [DEVICE] settings not being accurate. The Facility Policy titled Prevention of Pressure Ulcers/Injuries, revised (MONTH) 2019, documents the following: Purpose: The purpose of this procedure is to provide information regarding indentification of pressure ulcer/injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment 1. Assess the resident on admission for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. 4. Inspect the skin on a daily basis when preforming or assisting with personal care or activities of daily living. a. identify any signs of developing pressure injuries b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) c. Wash the skin after any episodes of incontinence, using pH balanced skin cleanser d. moisturize dry skin daily e. reposition resident as indicated on the care plan. Mobility/Repositioning 2. At least every hour, reposition residents who are chair-bound or bed-bound with the head of the bed elevated 30 degrees or more. Monitoring 1. Evaluate, report and document potential changes in the skin 2.Review the interventions and strategies for effectiveness on an ongoing basis. The Facility Policy titled Pressure Ulcer/Injury Risk Assessment, revised (MONTH) (YEAR), documents the following: General Guidelines 6. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. Steps in the Procedure 3. Conduct a comprehensive skin assessment with every risk assessment. c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. 4. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. a.The interventions must be based on current, recognized standards of care. b. The effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Documentation The following information should be recorded in the resident's medical record utilizing facility forms: 1. The type of assessment conducted. 2.The date and time and type of skin care provided, if appropriate. 3. The name and title (or initials) of the individual who conducted the assessment. 4. Any change in the resident's condition, if identified. 5. The condition of the resident's skin (i.e. the size and location of any red or tender areas), if identified. 10. the signature and title (or initials) of the person recording the date. 11. initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted. 12. documentation in the medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated. The Facility Policy titled Wound Care, revised (MONTH) 2010, documents the following: Documentation The following should be recorded in the resident's medical record: 1. The type of wound care given. 2.The date and time the wound care was given. 3. The position in which the resident was placed. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.

Based on interview and record review the facility staff neglected to operationalize their policy on a safe mechanical lift transfer for one of three (R1) residents reviewed for transfer in a sample of 6. This resulted in R1 sustaining a spiral [MEDICAL CONDITION] femur. Findings include: The facility Lifts and Injury-Reducing Devices manual dated (MONTH) (YEAR) documents A two person lift is required when using lift equipment. The facility policy Patient Protection Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention documents Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental an anguish, or emotional distress. The facility incident report dated 5/7/2018 documents R1 was transferred on a sit to stand (mechanical) lift by V8 Certified Nurse Aide (CNA). R1 was sliding off the edge of the bed and subsequently fell with R1's foot caught under the sit to stand lift. R1's hospital x-ray dated 5/8/2018 at 9:44AM documents an oblique spiral [MEDICAL CONDITION] femur with up to a 15 millimeter displacement of the distal fracture fragment. On 5/29/2018 at 9:50AM, V3 (Orthopedic Physician) stated A spiral fracture requires a twisting motion with torque. I feel the injury occurred when (R1) was lowered to the floor and (R1's) foot caught on something, which created a twisting motion. A true pathological fracture has a tumor involved. (R1) had no tumor. On 5/29/2018 at 1:27PM, V8 stated I used the sit to stand lift to transfer R1 from the wheelchair to bed by myself on 5/7/2018. (R1) slid off the bed onto the floor in a sitting position. I know I was to have another staff person help me with all mechanical lift transfers, but I did the transfer by myself. V8's personal file has the Facility Lift Free document stating Our policy is that there is always a two person lift even using mechanical lifts. Work rule critical /type A- Remember you must comply with all health and safety rules, including rules prohibiting unsafe conduct or unsafe acts which jeopardize the health and safety of self or others or results in serious injury. This document was signed by V8 and dated 4/20/2018. On 5/30/2018 at 12:05PM, V5 (CNA) stated V8 attempted to transfer (R1) earlier in the shift by (V8's) self. V8 had (R1's) feet off the (sit to stand) lift platform with legs straddling the platform and (R1) hanging from the sling. I took two other CNA's in and retrained (V8) how to properly use the lift and reported this to the nurse (V6). On 5/29/2018 at 11:07AM, V6 (Nurse) stated I remember (V5) telling me (V8) was transferring (R1) by (V8's) self and I heard (V6) re-educate (V8) how to properly utilize the sit to stand lift. I also reinforced with (V8) never to transfer a resident with a sit to stand or sling lift by (V8's) self, there always must be two staff present for (mechanical) lift transfers. On 5/29/2018 at 10:30AM, V1 (Administrator) stated It is the facility policy that all mechanical lift transfers require a two person (staff) transfer. V8 was a new employee and only worked at the facility for about two weeks before this incident occurred and V8 resigned.

Failures at this level required more than one deficient practice statement. A. Based on interview and record review the facility failed to ensure safe mechanical lift transfer for one (R1) of three residents resident reviewed for transfers in a sample of six. This failure resulted in R1 sustaining a spiral fracture to the right femur. B. Based on interview and record review the facility failed to assess residents post fall for three of three residents (R1, R2 and R3) reviewed for falls in a sample of six. Findings include: a.) R1's facility face sheet dated 5/29/2018 documents a [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documents R1 is cognitively intact requiring extensive assistance of two for transfers. The facility Incident Report dated 5/7/2018 at 11:20PM documents a Certified Nurses Aide (V4) was attempting to put R1 to bed using a sit to stand mechanical lift. V8 Certified Nurse Aide stated V8 could only get R1 to the edge of the bed. R1's feet started to slide. R1's foot was caught in the sit to stand lift and R1 fell to the floor. R1 complained of pain on the inner right femur; later R1 complained of pain on the outer right femur. R1 was assisted to bed using a sling mechanical lift. Ice packs were applied to R1's thigh. On 5/29/2018 at 10:30AM, V1 (Administrator) verified R1 was transferred by V8 with the sit to stand lift alone. R1 is a two person sit to stand lift transfer. On 5/29/2018 at 11:07AM V6 (Nurse) stated (V8, Certified Nurse Aide) came out of R1's room into the hallway yelling for help. When I entered (R1's) room (R1) was laying on the floor. (R1's) foot was caught under the sit to stand machine with the foot twisted to the side. I gently removed (R1's) foot from under the sit to stand. (R1) was complaining of pain in the outer thigh, trembling and shaking. (V8) per facility rule should never have transferred (R1) by (V8's) self. I notified the on-call Nurse Practitioner (not sure who it was) and also the family. On 5/29/2018 at 12:05PM V5 (Certified Nurse Aide, CNA) stated when I entered (R1's) room after (V8) told me (R1) was sliding off the bed, (V6) nurse was in the room. (R1) was on the floor between the bed and the sit to stand machine leaning to the left cry out in pain. (V8) told me (V8) tried to transfer (R1) to bed by (V8's) self. I had already re-educated (V8) earlier in the shift on a proper sit to stand transfer and never to transfer a resident alone. On 5/29/2018 at 9:50AM, V3 (Orthopedic Physician) stated A spiral fracture requires a twisting motion with torque. I feel the injury occurred when (R1) was lowered to the floor and (R1's) foot caught on something, which created a twisting motion. A true pathological fracture has a tumor involved. (R1) had no tumor. R1's hospital x-ray dated 5/8/2018 at 9:44AM documents an oblique spiral [MEDICAL CONDITION] femur with up to a 15 millimeter displacement of the distal fracture fragment. The facility Lifts and Injury-Reducing Devices manual dated (MONTH) (YEAR) documents A two person lift is required when using lift equipment. b 1.) R1's facility incident report dated 5/7/2018 documents a lift transfer fall with a fractured right femur. R1's clinical record had no documented post fall assessment. On 5/30/2018 at 10:00AM, V3 (Assistant Director of Nursing) verified that the post fall assessment was not completed. V3 stated I do the post fall assessments and I did not do one for this fall. 2.) R2's Facility incident reports documented the following information: dated 3/29/2018 at 3:00PM - found on floor in a supine position with back of body up against the closet; 4/7/2018 at 7:30PM - Noted on floor of room injuries include a skin tear on elbow and abrasion on the knee; 4/21/2018 - Patient rolled self out of the bed onto the floor while bed was in the lowest position; and 5/26/2018 - resident on the floor, prior to the incident resident was in bed. Resident (R2) very confused, yelling for the police and combative with care, grabbing staff in the arm. R2's clinical record has no documented post fall assessment for the falls of 3/29/2018, 4/21/2018 or 5/26/2018. The assessment for the 4/21/2017 was completed on 4/27/2018 per V3 on 5/30/2018 at 10:00AM. V3 also verified the other two were not completed. 3.) R3's Facility incident reports dated 5/18/2018 documents the following information: 5/18/2018 - resident stated R3 developed a cramp in legs and tried to sit up and slid out of bed and 5/21/2018 - resident slipped out of bed onto the floor. R3's clinical record had no documented post fall assessments for 5/18/2018 or 5/21/2018 This information was verified by V3 on 5/30/2018 at 10:00AM. The facility Fall Policy dated 2011 documents a post fall evaluation of the patient is to be completed timely following a fall. Upon completion of the evaluation, the physician is notified and new orders are documented, noted, and implemented.

Based on interview and record review the facility failed to control a residents pain related to a fracture for one of three residents (R1) reviewed for pain in a sample of six. This failure resulted in R1 experiencing unrelieved pain for twelve hours then subsequently being admitted to the hospital with [REDACTED]. Findings include: R1's facility face sheet dated 5/29/2018 documents a [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documents R1 is cognitively intact. On 5/29/2018 at 10:00AM R1 stated I had a pain level of ten plus (scale of one to ten) in my right thigh, after I fell during the transfer. They put me in bed and put an ice pack on my right thigh. It was several hours later when they gave me a pain pill and the next day before I was sent to the hospital. The pain remained a ten plus even after the pain medication. On 5/29/2018 at 11:30AM, R6 (R1's roommate) stated I heard (R1) fall. (R1) hit the floor hard. (R1) was crying and in a lot of pain after the fall. I don't know why they did not sent (R1) to the hospital right away. (R1) was crying and whimpering in pain the rest of the night. R1's progress notes dated 5/7/2018 at 11:17 PM documents at 9:15PM, R1 slid out of the sit to stand and hit the floor buttocks first. R1 complained of pain in the right inner thigh area and later the outer thigh area also. R1's progress note dated 5/8/2018 at 1:26 AM documents a portable x-ray was ordered. At 1:34AM, R1 had Tylenol 650 milligrams every six hours for pain as needed ordered and administered. The 9:17AM, progress note documents patients right leg turned inward, complaining of severe pain. (R1) did not want anyone to turn or change (R1). Received orders to send to the local emergency room for evaluation and treatment. Family notified of transfer. R1's Medication Administration Record [REDACTED]. R1's Physician order [REDACTED]. On 5/30/2018 V2 (Director of Nursing) verified the x-ray was not ordered STAT (immediately), therefore the x-ray would have been done the next day. R1's hospital x-ray dated 5/8/2018 at 9:44AM documents an oblique spiral [MEDICAL CONDITION] femur with up to a 15 millimeter displacement of the distal fracture fragment. On 5/29/2018 at 11:07AM, V6 (Nurse) stated I was on duty the night that (R1) fell . I put an ice pack on the inner and outer right thigh and later (about two hours after the fall) I gave Tylenol for pain. (R1) was trembling and whimpering after the fall complaining of pain. I called the Nurse practitioner on call. I did not get an order to send (R1) to the hospital for evaluation. I think (R1) should have probably went out for x-rays and treatment right away. I can't send a resident to the hospital without an order. I did not notice bruising at the time of the fall. I did remove the right foot from under the lift. The foot was turned sideways and caught under the lift platform.(R1)has a high pain tolerance and doesn't complain, but I could tell (R1) was in pain because of the trembling and whimpering. On 5/30/2018 at 10:30AM, V2 (Director of Nursing) stated We do need an order to send a resident to the hospital, but we can use nursing judgement and send a resident and then get the order. I was notified the night (R1) fell . I did ask about sending (R1) out or at least getting x-rays. The x-ray should have at least been ordered STAT. (R1) was sent out to the emergency room the next day before the x-ray was done. I would have sent (R1) out to the emergency room for evaluation right away if I was the nurse on duty. On 5/30/2018 at 12:05PM, V5 (Certified Nurse Aide) stated The night (R1) fell (R1) was crying and yelling in pain. (R1) appeared in a lot of pain the rest of the shift. I work until 11:00PM. (R1) fell about 9:15PM. On 5/29/2018 at 9:50AM, V3 (Orthopedic Physician) stated A displaced spiral fracture is very painful. Tylenol would more than likely not control the pain.

Based on observation, record review and interview, the facility failed to ensure two staff members were present for repositioning a patient in bed for one of three residents (R1) reviewed for repositioning, in a sample of three. This failure resulted in V3 (Certified Nursing Assistant) pulling R1 up in bed by R1's right arm/shoulder causing an anterior dislocation of the right shoulder requiring multiple internal reductions and eventual surgical repair. Findings include: The facility policy, titled Lifts and Injury-Reducing Devices Manual (9/2017), documents Repositioning. Friction-reducing devices, including the MaxiSlide, are available to assist in the repositioning process. All repositioning in beds is performed by at least two employees. The Electronic Medical Record documents R1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R1's admission Plan of Care, dated 12/29/17, identifies R1 as having Impaired Functional Mobility and a ADL (Activities of Daily Living) Self Care Deficit related to disease process and physical limitations, requiring gait training, neuromuscular re-education and therapeutic activity and exercise to improve mobility. The 12/29/17 Plan of Care also identifies R1 as requiring assistance to restore function in transferring from one position to another and advises staff to transfer R1 with the use of a mechanical lift and two staff members. A Minimum Data Set assessment, dated 1/06/18, identifies R1 as having no cognitive impairment or short/long term memory loss. A State Report, dated 1/02/18, documents, On Jan. 1, (YEAR), (R1) was attempting to push himself up in his bed. CNA (Certified Nursing Assistant) was walking by and resident called out for assistance. CNA states resident had knee bent and was using leg to move up in the bed and was stuck on his shoulder. CNA attempted to lift resident under the right shoulder and heard a 'pop'. Nurse on duty was called to the the room for assessment. Assessment revealed mild pain in the right shoulder with ROM (Range of Motion), hand grasp strong and no redness or bruise at the shoulder. POA (Power of Attorney) and MD (Medical Doctor) notified and resident sent to ED (Emergency Department) for evaluation. ED report states dislocation of the right shoulder. The State Report further documents, after a 1/05/18 appointment with V4 (Orthopedic Surgeon), (R1) scheduled to have shoulder surgically relocated and an anchor to be placed due to inability of shoulder to remain in place. The Emergency Department Note Report, dated 1/02/18, documents R1 presented with a complaint of right arm injury which occurred when he was being repositioned in his bed, when he felt a pop, felt his right shoulder was dislocated. The Emergency Department Note Report concludes, X-ray of the right shoulder showed anterior dislocation, with humeral head noted inferior to the coracoid process. The right anterior dislocation was reduced as described above. Patient was premedicated with [MEDICATION NAME]. Initial attempts was successful, however, after x-ray was performed the shoulder dislocated again. Second attempt of reduction performed and showed successful reduction through x-ray. Patient felt better and was able to move right shoulder without difficulty. Shoulder immobilizer was applied. Patient was (discharged ) home stable advised to follow up with Orthopedic Doctor. The follow up notes from the Orthopedic Doctor, dated 1/05/18, document R1's right shoulder continues to be very unstable, with the ability to dislocate during abduction of the arm and instructs staff to have R1 wear an immobilizer at all times and to NOT initiate any range of motion exercises. On 4/24/18 at 2:22 p.m., R1 was sitting in his wheelchair with his right arm secured in a immobilizer. R1 stated he is currently unable to use his right arm, and has been unable to use it since he was injured on 1/01/18. R1 stated he was admitted to the facility (12/29/17) for therapy related to worsening of his [MEDICAL CONDITION]. R1 stated at the time of his admission, he was unable to reposition himself in the bed independently and had weakness on his right side. R1 stated, prior to the incident (1/01/18), he was always repositioned with two staff members, not just one. R1 stated, on the night of the injury, he asked a CNA for help to be repositioned back up towards the head of the bed. R1 stated the CNA put his arm under his right arm to pull him up towards the head of the bed and R1 immediately heard a pop. R1 stated he has had two different Orthopedic Surgeons since the injury, attempt to get the right shoulder back into the socket, but due to the rotator cuff being injured it would not stay in place. R1 stated he had to have his right shoulder surgically placed back into the socket, by (V5 - Orthopedic Surgeon), approximately 5 weeks ago. On 4/24/18 at 11:08 a.m., V3 (Certified Nursing Assistant) stated he was working the evening of 1/01/18, when at approximately 9:00 p.m., R1 called out for assistance to be repositioned in bed. V3 stated R1 had slid down towards the foot of the bed and was uncomfortable. V3 stated he independently pulled R1 up towards the head of the bed, as R1 used one leg to help push himself, when V3 heard a pop from R1's right shoulder. V3 stated, my arm was under (R1's) arm when moving (R1), but I didn't use much pressure. V3 stated R1 was usually a two person assist for repositioning, but we were short of staff that day and I didn't want to wait for help. V3 stated he normally would have tried to get additional staff assistance. On 4/24/18 at 11:58 a.m., V2 (Assistant Director of Nursing) indicated he was the Nurse on shift when R1's 1/01/18 injury occurred. V2 stated V3 had reported he was trying to pull R1 up in the bed, and on the three count when V3 pulled R1 up, V3 heard a pop from R1's shoulder. V2 stated upon assessment, R1 had an obvious deformity of the right shoulder. V2 stated he did conduct the initial interview with V3, for the investigation into R1's injury, but did not question V3 about exactly how he was repositioning R1. V2 stated, based on R1's injury he assumed V3 hooked his arm under R1's arm to pull him up into the bed, which is an improper method for repositioning a patient.

Based on record review and interview the facility neglected to provide prompt medical care following changes in condition for one of three residents (R1) reviewed for an acute change in condition in the sample of three. Failure to provide prompt medical care resulted in R1 developing excruciating pain resulting in disorientation, falling, and requiring hospitalization for the treatment of [REDACTED]. Findings include: The facility's Patient Protection Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation policy dated 11-3-16 documents, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. R1's Electronic [DIAGNOSES REDACTED]. This same record documents R1 was admitted to the facility for therapy to return to home following a Spinal Fusion. R1's BIMS (Brief Interview for Mental Status) dated 9-27-17 documents R1's BIMS score is a 15 indicating R1 is cognitively intact. R1's physician's orders [REDACTED]. Carvedilol 3.125 mg one time daily and 6.25 mg at bedtime for Hypertension (Hold if (R1's) B/P (Blood Pressure) is systolic less than 110 or diastolic is less than 50 and call MD). [MEDICATION NAME] ER (Extended Release) 30 mg one time daily for Hypertension (Hold if (R1's) B/P (Blood Pressure) is systolic less than 110 or diastolic is less than 50 and call MD). Losartan Potassium 25 mg daily for Hypertension (Hold if (R1's) B/P (Blood Pressure) is systolic less than 110 or diastolic is less than 50 and call MD). [MEDICATION NAME] ([MEDICATION NAME]) 2 mg every three hours as needed for pain. R1's Medication Administration Records dated 9-20-17 to 9-27-17, document R1's Carvedilol 6.25 mg 8:00 p.m. dose was held on 9-22-17, 9-24-17, and 9-28-17 due to (R1's) blood pressure being below the parameters. R1's Physical Therapy Encounter Note dated 9-26-17 at 1:30 p.m., documents R1 felt dizzy, was having difficulty talking, unable to tolerate therapy, and had a blood pressure of 98/38. This same note documents the therapy session was discontinued and (R1's) low blood pressure was reported to E4 (Licensed Practical Nurse/LPN). R1's Electronic Medical Record does not include a nursing assessment of R1 or treatment for [REDACTED].>change in condition. R1's Incident Report dated 9-27-17 at 10:45 a.m., documents R1 fell out of the chair while in the facility van. R1's Incident Report dated 9-27-17 at 11:00 a.m., documents R1 was found on the floor in the bathroom at the doctor's office (Z1/Surgeon). This same report documents Z1 sent R1 to the emergency room for low blood pressure. R1's Emergency Department Note dated 9-27-17 documents, (R1) is complaining of lightheadedness that has been occurring for about a week and is found to have a systolic blood pressure in the 70-80 range. (R1) reports receiving four anti-hypertensive's even though feeling lightheaded and having low blood pressure. Patient was given two liters of normal saline by I.V. (Intravenous) for [MEDICAL CONDITION]. (R1) reports of excruciating pain and was given oral [MEDICATION NAME] for post-operative pain. Blood pressure medications held. On 10-31-17 at 10:50 a.m., E4 (Licensed Practical Nurse/LPN) stated, I was (R1's) nurse on 9-27-17 and had no [MEDICATION NAME] to send with (R1) for the trip to Chicago. (R1) wanted [MEDICATION NAME] for pain. On 11-2-17 at 8:45 a.m., E6 (LPN) stated, I gave (R1) the last Dilauded around midnight the night before (R1's) appointment in Chicago. (R1) was worried that she would not have the Dilauded for the trip to Chicago and would be in pain. (R1) did not have the Dilauded for the appointment. I held (R1's) Carvedilol on 9-22-17, 9-24-17, and 9-26-17 because (R1's) blood pressure was below the parameters. I did not do an assessment of (R1) when (R1's) blood pressure were low or obtain an order from the physician. On 11-2-17 at 11:05 a.m., E9 (Physical Therapist) stated, On 9-26-17 during (R1's) therapy session (R1's) blood pressure dropped to 98/38. I had to stop the therapy session and report it to the nurse. (R1) was dizzy. On 11-2-17 at 9:35 a.m., E7 (Van Driver) stated, I took (R1) to Chicago on 9-27-17. (R1) kept saying she was uncomfortable and asking when we would be getting there (Chicago). (R1) was uncomfortable from sitting too long. (R1) did not have any pain pills with her. Before we got to Chicago, (R1) fell in the van and hit her knee. I got her up and finished taking her to her appointment. When I got to (R1's) appointment I took (R1) inside and I went back out to the van. A nurse called me while I was out in the van and said that (R1) fainted while in the doctor's office and was being sent to the emergency room . On 11-2-17 at 11:15 a.m., E1 (Administrator) stated, (E4/LPN) should have done an assessment of (R1) when (R1's) blood pressure was low on 9-26-17. (R1) should have been sent to Chicago with [MEDICATION NAME] for pain. We (the facility) should have done a lot more for this resident. We messed up. On 10-31-17 at 11:00 a.m. R1 stated, My blood pressure dropped in therapy the day before I went to Chicago (9-26-17). I could not finish therapy. The nurse did nothing for me. Therapy took me back to my room and nothing was done. I kept telling the nurses I did not feel right. I was sent to Chicago with no [MEDICATION NAME]. During the trip to Chicago I was in excruciating pain and I became disorientated and fell in the van. At this time R1 also stated, It was over a three hour trip. When I got to my appointment with the surgeon, the van driver just dropped me off there. The van driver did not stay with me. I lost consciousness while in the bathroom at the surgeon's office and fell again. The surgeon's office sent me to the emergency room and I was admitted to the hospital for treatment for [REDACTED]. (Intravenous Fluids), a blood transfusion, treatment for [REDACTED]. On 11-2-17 at 8:45 a.m., Z2 (Surgeon's Registered Nurse) stated, (R1) arrived to us on 9-27-17 with [MEDICAL CONDITIONS], and pain. (R1) had to be sent to the emergency room immediately for treatment. On 11-2-17 at 12:40 p.m., Z3 (Nurse Practitioner) stated, I have had issues at this facility with neglect. (R1) not receiving treatment for [REDACTED]. (R1) was planning to discharge home that week and I would not have wanted to discharge (R1) in that condition. (R1) not having [MEDICATION NAME] for the trip to Chicago was neglectful because (R1) would have had persistent unrelieved pain. Not having the [MEDICATION NAME] set (R1) up for failure. I am sure (R1's) pain contributed to (R1's) falls and disorientation. I would have stopped (R1's) [MEDICATION NAME]. I would have monitored (R1) for dehydration.

Based on interview and record review the facility failed to provide [MEDICATION NAME] (Opioid Pain Medication) to control pain for one of three residents (R1) reviewed for pain in the sample of three. These failures resulted in R1 experiencing an acute exacerbation of unrelieved chronic pain resulting in R1 becoming disorientated, falling, and requiring hospitalization for severe pain. Findings include: The facility's Pain Practice Guide dated 11/2011 documents, Opiod [MEDICATION NAME] are use to treat moderate to severe pain that does not respond to other [MEDICATION NAME]. Pain that it is not treated effectively at any point in the cycle can lead to chronic pain. R1's Electronic [DIAGNOSES REDACTED]. This same record documents R1 was admitted to the facility for therapy to return to home following a Spinal Fusion. R1's physician's orders [REDACTED]. R1's Pain Care plan dated 9-20-17 documents R1 had pain to the lower back evidenced by verbalization related to recent spinal surgery. This same Care plan documents R1 will have the following goals: Express pain management within acceptable limits. Administer pain analgesea per physician's orders [REDACTED]. R1's Progress Note dated 9-25-17 and signed by Z3 (Nurse Practitioner) documents, (R1's) chief complaint is back pain. Chronic back pain requires muscle relaxer every eight hours and [MEDICATION NAME] as needed. R1's BIMS (Brief Interview for Mental Status) dated 9-27-17 documents R1's BIMS score is a 15 indicating R1 is cognitively intact. R1's Incident Report dated 9-27-17 at 11:00 a.m., documents R1 was found on the floor in the bathroom at the doctor's office (Z1/Surgeon). This same report documents Z1 sent R1 to the emergency room . R1's Emergency Department (ED) Note dated 9-27-17 documents, (R1) states she was out of [MEDICATION NAME] for trip to appointment. (R1) reports of excruciating pain and was given oral [MEDICATION NAME] for post-operative pain (while at ED). Will admit to hospital for pain management. On 11-2-17 at 8:45 a.m., E6 (Licensed Practical Nurse/LPN) stated, I gave (R1) the last [MEDICATION NAME] around midnight the night before (R1's) appointment in Chicago (9-26-17). (R1) was worried that she would not have the [MEDICATION NAME] for the trip to Chicago and would be in pain. (R1) did not have the Dilauded for the appointment. I tried to order the [MEDICATION NAME] from pharmacy but it did not come in. Someone should have tried to re-order the [MEDICATION NAME] before it was completely gone. On 10-31-17 at 10:50 a.m., E4 (Licensed Practical Nurse/LPN) stated, I was (R1's) nurse on 9-27-17 and I had no [MEDICATION NAME] to send with (R1) for the trip to Chicago. (R1) wanted [MEDICATION NAME] for pain. On 11-2-17 at 9:35 a.m., E7 (Van Driver) stated, I took (R1) to Chicago on 9-27-17. (R1) kept saying she was uncomfortable and asking when we would be getting there (Chicago). (R1) was uncomfortable from sitting too long. (R1) did not have any pain pills with her. Before we got to Chicago, (R1) fell in the van and hit her knee. On 10-31-17 at 11:00 a.m. R1 stated, I asked the nurse two days prior to going to my Surgeon appointment if I was going to have my pain pill [MEDICATION NAME] to take with me. On the day I left I asked (E4/Licensed Practical Nurse) if I could have a [MEDICATION NAME] before I left and take two with me. (E4) told me that my [MEDICATION NAME] did not come in so I would not have any to take with me. I was sent to Chicago with no [MEDICATION NAME]. During the trip to Chicago I was in excruciating pain and I became disorientated and fell in the van. At this time R1 also said, It was over a three hour trip. When I got to my appointment with the surgeon, the van driver just dropped me off there. The van driver did not stay with me. I was still in alot of pain and I lost consciousness while in the bathroom at the surgeon's office and fell again. The surgeon's office sent me to the emergency room and I was admitted to the hospital for treatment for [REDACTED]. On 11-2-17 at 8:45 a.m., Z2 (Surgeon's Registered Nurse) stated, (R1) arrived to us on 9-27-17 with pain. (R1) had to be sent to the emergency room immediately for treatment. (R1) should have been sent with [MEDICATION NAME] and should have had [MEDICATION NAME] before being brought to this appointment. On 11-2-17 at 12:40 p.m., Z3 (Nurse Practitioner) stated, (R1) not having [MEDICATION NAME] for the trip to Chicago was neglectful because (R1) would have had persistent unrelieved pain. Not having the [MEDICATION NAME] set (R1) up for failure and contributed to (R1) falling. (R1) should have had a [MEDICATION NAME] before leaving for the trip to Chicago and should have been sent with at least two [MEDICATION NAME] for the trip there and back.

Based on record review and interview the facility failed to immediately notify the physician of multiple changes in conditions related to, low blood pressures, unavailability of pain medication, pain, and abnormal labs (laboratories) for one of three residents (R1) reviewed for physician notification in the sample of three. Failure to notify R1's physician for medical treatment resulted in R1 experiencing excruciating pain, [MEDICAL CONDITION], and lightheadedness, which required hospitalization for treatment of [REDACTED]. Findings include: The facility's Change in Condition policy dated 11/2016 documents, The facility must immediately inform the resident's physician when there is a significant change in the resident's physical, mental, or psychosocial status in clinical complications, and when there is a need to alter treatment significantly due to adverse consequences or to commence a new form of treatment. Immediate notification is recommended for any symptom, sign, or apparent discomfort that is acute or sudden in consent and is a marked change in relation to usual symptoms and signs, or is unrelieved by measures already prescribed. The facility's Laboratory Tracking Guidelines dated 08/2014 document, Lab test results will be communicated with the ordering physician for results evaluation before the end of the shift during which the results were received with the date, time, and name of the nurse communicating the results and the orders given by the physician once the results are received. R1's Electronic [DIAGNOSES REDACTED]. R1's physician's orders [REDACTED]. Carvedilol 3.125 mg one time daily and 6.25 mg at bedtime for Hypertension (Hold if (R1's) B/P (Blood Pressure) is systolic less than 110 or diastolic is less than 50 and call MD). [MEDICATION NAME] ER (Extended Release) 30 mg one time daily for Hypertension (Hold if (R1's) B/P (Blood Pressure) is systolic less than 110 or diastolic is less than 50 and call MD). Losartan Potassium 25 mg daily for Hypertension (Hold if (R1's) B/P (Blood Pressure) is systolic less than 110 or diastolic is less than 50 and call MD). [MEDICATION NAME] (Dilauded) 2 mg every three hours as needed for pain. R1's Blood Pressure Log dated 9-22-17 documents R1's blood pressures dropped below the physician's parameters of 110/50 on 13 different occasions ranging from 9-22-17 to 9-26-17. R1's Electronic Medical Record does not include documentation of R1's physician being notified of any of R1's abnormally low blood pressures. R1's Complete Blood Count (CBC) dated 9-25-17 documents R1 had a low RBC (Red Blood Cell Count) of 2.81 with a normal parameter of 3.90 to 5.40 m (million cells)/cmm (cubic millimeters), low Hemoglobin of a 8.9 with a normal parameter of 12 to 16 g/dL (grams per decilitre), and a low Hematocrit of 26.4 with a normal parameter of 36-48 percent. R1's Electronic Record does not include documentation of R1's physician being notified of R1's abnormal lab results. R1's Medication Administration Records dated 9-20-17 to 9-27-17, document R1's Carvedilol 6.25 mg 8:00 p.m. dose was held on 9-22-17, 9-24-17, and 9-28-17 due to (R1's) blood pressure being below the parameters. R1's Electronic Medical Record does not include documentation of R1's physician being notified of the low blood pressures. R1's Physical Therapy Encounter Note dated 9-26-17 at 1:30 p.m., documents R1 felt dizzy, was having difficulty talking, unable to tolerate therapy, and had a blood pressure of 98/38. R1's Electronic Medical Record does not include documentation of R1's physician being notified of R1's change in condition and low blood pressure while in therapy. R1's Incident Report dated 9-27-17 at 11:00 a.m., documents R1 was found on the floor in the bathroom at the doctor's office (Z1/Surgeon). This same report documents Z1 sent R1 to the emergency room for low blood pressure. R1's Emergency Department Note dated 9-27-17 documents, (R1) is being admitted to the hospital for treatment of [REDACTED]. (R1) states she was out of [MEDICATION NAME] for trip to appointment. On 11-2-17 at 8:45 a.m., E6 (Licensed Practical Nurse/LPN) stated, I held (R1's) Carvedilol on 9-22-17, 9-24-17, and 9-26-17 due to (R1's) blood pressure being low. I did not know I was supposed to notify (R1's) physician, so I did not. Z3 (R1's Nurse Practitioner) was not notified of (R1's) CBC. (R1) was out of [MEDICATION NAME] on 9-26-17, but I did not notify (R1's) physician when (R1) was out of the [MEDICATION NAME]. On 11-2-17 at 11:15 a.m., E1 (Administrator) verified that R1's Physician should have been notified of the abnormal CBC on 9-25-17, blood pressures below R1's normal range, R1's blood pressure drop with therapy on 9-26-17, R1's medication being held due to low blood pressure, and R1 being out of [MEDICATION NAME]. E1 confirmed that according to R1's Electronic Record R1's physician was not notified of any of these circumstances. On 11-2-17 at 12:40 p.m. Z3 (R1's Nurse Practitioner) stated, I work side by side with (Z4/R1's Physician). I reviewed my notes and (Z4's) notes. We (Z3 and Z4) did not receive notification of (R1's) abnormal CBC results from 9-25-17. We have not been notified of (R1's) abnormally low blood pressures, or of (R1's) blood pressure dropping while in therapy on 9-26-17. We have not been notified of (R1's) Carvedilol being held due to low blood pressures. We were not notified that (R1) ran out of [MEDICATION NAME] and did not have [MEDICATION NAME] for the trip to Chicago. (R1) was planning to discharge home that week and I would not have wanted to discharge (R1) in that condition. (R1) not having [MEDICATION NAME] for the trip to Chicago would have caused (R1) persistent unrelieved pain. I should have been notified in advance of (R1) needing the [MEDICATION NAME] re-filled prior to (R1) running out. Not having the [MEDICATION NAME] set (R1) up for failure. I would have stopped (R1's) [MEDICATION NAME] had I known (R1's) blood pressures were dropping. I would have changed several of (R1's) blood pressure medications and ordered orthostatic blood pressures to be monitored. I would have monitored (R1) for dehydration. I should have been notified immediately of (R1's) abnormal CBC. I should have been notified of all of (R1's) changes in condition so (R1) could have got treatment. (R1) was discharging home that week and I would not have wanted to send her home in that condition.

Based on interview and record review, the facility failed to offer or administer oral liquid [MEDICATION NAME] pain medication as ordered for one of 16 residents (R4) reviewed for medication administration in the sample of 22. This failure resulted in continued mouth pain, inhibiting R4 from eating adequate amounts of food which contributed to an 11.6 pound weight loss in 14 days. Findings include: R4's Order Summary Report dated August 2017 documents R4's [DIAGNOSES REDACTED]. This report documents orders including [MEDICATION NAME] mouthwash, 15ml (milliliters) every four hours as needed for pain/discomfort. R4's Patient Admission/Readmission Screen dated 8/29/17 documents R4 has pain in all aspects of the mouth. This screen documents the pain as aching, throbbing and sore. This screen also documents eating exacerbates the mouth pain and the pain affects R4's appetite. R4's Medication Administration Records dated August and September 2017 do not document that the [MEDICATION NAME] mouthwash was administered. R4's Electronic Medication Administration Record [REDACTED] 9/6/17 2:15pm, 5 out of 10 pain level 9/7/17 2:15pm, 5 out of 10 pain level 9/8/17 6:15am, 6 out of 10 pain level 9/11/17 10:15pm, 1 out of 10 pain level 9/14/17 2:15pm, 5 out of 10 pain level, 6:00pm, 5 out of 10 pain level. R4's Electronic Weight Records document R4's weights as follows: 8/30/17- 142.6 pounds 9/2/17- 133 pounds 9/4/17 131.6 pounds 9/10/17 131 pounds. (11.6 pound loss in 12 days). R4's Progress Notes for nutrition/weight dated 9/7/17 at 2:13pm document R4's diet was changed to mechanical soft texture secondary to mouth pain. There is no documentation related to the [MEDICATION NAME] mouthwash. R4's Progress Notes for nutrition/weight dated 9/11/17 at 12:54pm document R4's weight loss is related [MEDICAL CONDITION] with [MEDICAL CONDITION] and [MEDICAL CONDITION] treatment and R4 has had decrease appetite/po (by mouth) intakes s/t (secondary to) mouth pain. There is no documentation related to the [MEDICATION NAME] mouthwash. R4's Progress Notes dated 9/14/17 at 12:49pm document new orders from {Z4, R4's Oncologist}. Per MD (medical doctor) R4 has had further weight loss of 7.6 pounds in 7 days and that R4 is to be assessed for pain every four hours and as needed due to oral cavity pain inhibiting pt (patient, R4) from eating. On 10/11/17 at 1:30pm, R4 stated R4's mouth felt like it was on fire. R4 stated the facility had handed R4 a sealed bottle of liquid mouthwash at discharge that Z4, R4's Oncologist had ordered for R4's mouth pain. R4 stated R4 was unaware that was available for R4 to use for the mouth pain until staff handed R4 the sealed bottle of Magic Mouthwash to take home upon discharge. R4 stated R4 told multiple unidentified staff members about the mouth pain. R4 stated unidentified staff would give R4 a pain pill if R4 asked but it was not effective for R4's mouth pain. R4 stated the mouthwash [MEDICATION NAME] for the mouth pain was never offered to R4. R4 stated it was hard to eat and that R4 was not eating much because of the mouth pain which was worse with eating. R4 stated the mouthwash helped R4's pain and R4 was able to eat when R4 started taking the mouthwash [MEDICATION NAME] upon discharge from the facility at home. On 10/11/17 at 3:20pm, E6, Certified Occupational Therapy Assistant (COTA) stated R4 would complain of mouth pain to E6. E6 stated she thought it was affecting his eating. E6 stated R4 told her that the unidentified staff knew about the mouth pain so E6 did not notify the nurse of R4's complaints. On 10/12/17 at 7:55am, Z4, R4's Oncologist stated R4 was prescribed the [MEDICATION NAME] mouthwash because R4 had been receiving [MEDICAL CONDITION] treatments to the throat for [MEDICAL CONDITION]. Z4 stated the [MEDICATION NAME] mouthwash numbs the throat and helps with pain control and the ability to eat foods easier. Z4 stated if the facility would have administered the [MEDICATION NAME] mouthwash, R4's mouth pain would have been lessened. Z4 also stated R4 would have been able to eat more food and R4 would not have lost so much weight.

Based on observation, interview, and record review the facility failed to timely assess R8 for pain, failed administer pain medication prior to treatment, and failed to identify pain on the care plan for one (R8) of four residents reviewed for pain on the sample of 17. This failure resulted in R8 moaning and crying out expressing pain for 2 consecutive days during positioning and treatment of [REDACTED]. Findings include: R8's Minimum Data Set ((MDS) dated [DATE] documents that R8 requires extensive assistance with bed mobility, transfers, and toileting. R8's Physician order [REDACTED]. R8's physician's orders [REDACTED]. R8's POS documents an order dated 4/24/15 for Tylenol Extra Strength Tablet 500 milligrams (mg), give one tablet by mouth every four hours as needed for pain. The Focused Wound Exam by Z1 (Wound Physician) dated 8/12/15 documents wound measurements to coccyx of 5.8 cm by 2.3 cm by 0.5 cm (centimeters) with 0.3cm of undermining. On 8/17/15 at 12:00 pm R8 moaned and cried out as E19 Licensed Practical Nurse (LPN) and E20 Certified Nursing Assistant (CNA) repositioned R8 to the right side for R8's pressure ulcer treatment. R8 cried out and jerked each time E19 cleansed and applied treatment to R8's pressure ulcer. E19 stated that R8 did not receive pain medication prior to the treatment. E19 also stated that R8 jerked with the pressure ulcer treatment on this day at 10:00 am. E19 stated that R8 did not receive pain medication prior to the treatment at 10:00 am. R8's Pain assessment dated [DATE] documents facial grimacing and Unable to console, distract or reassure. R8's Medication Treatment Record documents that R8 last received Tylenol for pain on 8/1515. R8's Progress Note dated 8/18/15 at 5:46 am documents res (R8) unable to sleep during shift, let out loud screaming noises throughout the shift. On 8/18/15 at 9:45 am E26 CNA stated (R8) has been yelling out-moaning and reported to E19. On 8/18/15 at 9:50 am E19 LPN stated that R8 had been calling out. E19 stated E19 gave R8's 8:00 am dose of [MEDICATION NAME] (antibiotic) capsule 300 mg. E19 stated that E19 did not administer R8's pain medication. E19 stated that R8 has Tylenol ordered for pain. E19 stated that the last time R8 received Tylenol for pain was on 8/15/15. On 8/18/15 at 10:00 am E32 (CNA) stated that when E32 came in on shift at 6:00 am (R8) was crying out. E32 stated that E19 LPN asked E32 who was crying out and I stated it was (R8). E32 stated that E32 provided incontinence care and repositioned R8 about 6:30 am on 8/18/15 and R8 was moaning and crying out. E32 stated (R8) said 'it hurts' throughout incontinence care, turning, repositioning . E32 stated that R8 cried out during incontinence care and repositioning again at 9:00 am. On 8/18/15 from 9:00 am to 11:00, R8 remained positioned on R8's right side without repositioning based on 15 minutes or less observational intervals. R8 cried out at 9:00 am, 9:45 am, 10:00 am, and 11:00 am. R8 remained positioned on the right side from 11:00 am to 11:30 am based on continuous observation and continued to cry out at 11:10 am, 11:13 am, 11:14 am. On 8/18/15 at 10:30 am E19 stated I have not done a pain assessment yet on R8. On 8/18/15 at 10:45 am E31 CNA stated I just went into check on (R8) because she was calling out. I repositioned the nasal canula but R8 continues to cry out. (E19) is aware. On 8/18/15 at 11:01 E19 stated that she had not treated R8 with pain medication yet. On 8/18/15 at 10:20 am E2 Director of Nursing stated that if R8 verbalized pain then R8 should have received pharmacological or non pharmacological interventions for pain. E2 stated Moaning or crying out is a sign of distress and should be addressed in a timely manner. On 8/20/15 at 10:30 am Z4 Nurse Practitioner, stated that R8 has [DIAGNOSES REDACTED] of Sacrum and has had Stage IV Pressure Ulcer since admission (3/7/15). Z4 stated that Z4 examined R8 on 8/17/15 and R8 was in Multi System Organ Failure based on R8's laboratory tests and current mental status decline. Z4 stated that Z4 ordered R8 to be NPO (nothing by mouth) and ordered all oral medications to be held. Z4 stated, I was not told R8 had pain during repositioning or dressing changes on 8/17/15. Z4 stated that on 8/18/15 at 12:06 pm Z4 received a fax (facsimile), which asked if R8's oral Tylenol order could be changed to suppository form due to R8's decline in mental status and due to R8's Nothing by Mouth (NPO) status. Z4 stated that the fax did not mention that R8 was having pain. Z4 stated that on 8/19/15 at 12:15 pm E23 Licensed Practical Nurse and E9 Registered Nurse stated to Z4 (R8) was crying out in pain all through the night, every time (R8) was turned or moved or touched. Z4 stated I have never been told (R8) was having pain until 8/19/15 when I walked into the facility. If I would have known about (R8) having pain on 8/17/15 with the dressing change I would have considered a higher dose of the Tylenol. (R8) should have been given Tylenol one hour prior to the treatment (pressure ulcer dressing change). I should have been notified. R8's Care Plan dated 3/9/15 does not document pain interventions. On 8/18/15 at 2:00 pm E2 confirmed that pain is not addressed on R8's Care Plan dated 3/9/15. E2 stated R8 should have had pain addressed on the Care Plan on admission. The facility Pain Practice Guide dated 2011 includes the following: If a patient has evidence of pain, the physician is notified to obtain orders for pain medication. An effective pain management intervention plan addresses.[MEDICATION NAME].Some conditions that may be associated with pain include.pressure ulcers and skin conditions. Create a comprehensive interdisciplinary care plan. The interdisciplinary team designs the patient's care plan to focus on all of the patient's issues including those associated with pain symptoms.

Based on observation, record review, and interview, the facility failed to ensure a safe transfer to prevent injury for one of 7 residents reviewed for falls (R3), out of a sample of 18, by failing to transfer R3 with two staff persons as required. This failure resulted in a patellar fracture requiring orthopedic treatment for [REDACTED]. The facility staff failed to apply protective arm sleeves, to prevent skin tears for one resident (R12) in the sample of 18. Findings include: 1. According to the current physician's orders [REDACTED]. The Minimum Data Sets (MDS) for 6/7/12 and 11/6/12 assess R3 with minimal cognitive impairment, and extensive assistance of two staff for bed mobility, transfers and toileting. The current Task list on the electronic medical record shows R3 to be a fall risk. Nursing progress notes dated 8/13/12 at 9:29am and 9:34am state that the CNA (Certified Nurse Aide) reported that R3 was on the commode and R3 heard her knee "pop" and "crack." R3 complained of pain but would not allow the nurse to examine R3. A portable x-ray was done later on 8/13/12. On 8/14/12 Z1 (attending physician) examined R3 at the facility and wrote, "sprain {right} knee, possible patellar fracture." Z1 ordered non-weightbearing status and referred R3 to Z2 (Orthopedist) On 8/16/12, Z2's examination noted a twisting type injury and stated "{R3} was being transferred to the commode and pivoted with her foot planted and felt and heard a pop." Z2 noted a right knee nondisplaced patella fracture, and ordered a long leg splint. The Statement by Witness by E4 (CNA) in the facility's incident investigation dated 8/13/12 states that R3 wanted to use the commode. There were no other CNAs available at that time so E4 offered R3 the bedpan. R3 refused the bedpan and stated she was strong enough to assist with a pivot transfer. E4 stated they stood up together with R3 standing on her left leg. When E4 started to lower R3 to the commode, R3 "began moving her legs, making the lowering difficult for me. She was no longer bearing her own weight. I had to catch her and move commode closer to keep her from falling on the commode. Once seated on the commode, I heard a POP. . . . .{R3}didn't know which leg it was. . . ." The facility's investigation concluded on 8/24/12 that E4 did an improper transfer of R3 and received education and discipline. On 11/27/12 at 12:00pm E4 confirmed information in the written statement. E4 stated that when she was starting to ease R3 down to the commode, R3 started to "move away from me, and I had to reach to get the commode under her." When E4 eased her down onto the commode, that's when E4 heard the pop. R3 yelled in pain, but could not tell which knee it was at first. E4 stated that R3 did require two people for transfers, but that sometimes some people did transfer R3 with just one person. E4 also stated that they used the stand-lift with R3, but that R3 did not like to use it. On 11/27/12 at 11:20am, E3 (Assistant Director of Nursing) stated that R3 had been a sit-to-stand lift but the right leg was getting progressively weaker. E3 stated that "on a good day" R3 was a two-person lift, and that at the very least, R3 should have had two staff to transfer. 2. R12 has [DIAGNOSES REDACTED]. R12's annual Minimum (MDS) data set [DATE] identified R12 with severe cognitive impairment, requires extensive assist of two staff for transfers, is lifted via mechanical lift, and had sustained skin tears within the assessment period. R12 has a physician's orders [REDACTED]. Nurse's notes document R12 had sustained recent skin tears to the right forearm on 10/07/12 . The 11/06/12 skin notes documented the skin tear was resolved on 11/06/12 resident to wear geriatric sleeves to both upper extremities. On 11/27/12 at 1:10 pm R12 was seated in her wheelchair in the corridor on the Rehab wing. R12 had a blood stain on the sleeve of her long sleeved shirt over her left forearm. R12 was wearing a geriatric sleeve on the right forearm under her shirt but no protective sleeve on the left arm.The bloodstain was shown to Certified Nurse Aide (CNA) E17. When E17 pulled up R12's shirt sleeve a fresh U shaped skin tear was on R12's forearm. E17 stated that R12 is supposed to have a geri sleeve on both arms. E17 did not know why she was not wearing one. E17 then notified a Nurse of the new skin tear. On 11/28/12 at 10:55 am E17 stated she had not noticed that R12 wasn't wearing a geri sleeve on her left arm on 11/27/12 when she transferred R12 from the bed to her wheelchair with the lift in the morning. E17 stated that she had not gotten R12 dressed, the night shift had dressed R12. E17 stated she knows R12 needs both arms covered but she did not think it was on the careplan. On 11/28/12 at 11:00 am E17 pulled up R12's Kardex on the hall monitor screen. The skin care plan for R12 included "bilateral upper extremity geriatric sleeves." The 11/27/12 nurse's note documented a Skin Assessment was done related to a newly acquired Skin Tear to Left Forearm. The area measured 1.8 x .1 cm. The note stated Steristrips were used and Geriatric sleeves were applied to both upper extremities. 3. R9 was admitted to the facility on [DATE]. The physician's orders [REDACTED]. The Resident Assessment Instrument (RAI) of 11/18/12 indicates R9 is cognitively impaired and requires extensive assistance of one for transfers, ambulation, and activities of daily living. The RAI indicates R9 is "not steady and only able to stabilize with staff." The Fall Assessment Reports dated 9/26/12, 10/2/12 and 10/22/12 state R9 had falls on those dates. The Care Plan dated 9/18/12 states R9 is "at risk for falls due to unsteady gait." Fall Assessment of 10/22/12 documents R9's Physical Performance Limitations as "difficulty maintaining standing position, impaired balance during transitions" and that R9 "has a history of being impulsive with poor safety awareness." On 11/26/12 at 11:55 am CNA, E10 and R9 were walking out of the residents bathroom. R9 was using her walker with E10 walking behind. No gait belt was on R9. On 11/26/12 at 11:57am E10 stated, "I did not use a gait belt assisting resident to the bathroom." On 11/26/12 at 1:05 pm Physical Therapist, E12, stated "a gait belt should be used at all times for (R9)." E12 stated that R9 is currently receiving physical therapy five times a week for strength building and safety with transfers so she can walk with walker on her own.