Every finding on record at Loft Rehab of Peoria, The

Based on observation, interview, and record review, the facility failed to maintain a clean and orderly home-like environment. This failure has the potential to affect all 103 residents residing within the facility.Findings include:The facility's Resident Rights Policy, dated 2/1/25, documents, Resident Rights. 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.The facility's Plant Operations Floor Care Technician Job Description, dated June 2021, documents, Position Purpose: Ensures the provision of a clean environment for our residents and staff, providing high-quality services and high standards of cleanliness, ensuring compliance with infection control practices. Major Duties and Responsibilities: Performs all types of floor care and maintenance throughout the facility, include hard surfaces and carpeting.The facility's Plant Operations Housekeeper Job Description, dated June 2021, documents, Position Purpose: Ensures the provision of a clean environment for our residents and staff, providing high quality services and high standards of cleanliness, ensuring compliance with infection control practices. Major Duties and Responsibilities: Carries out all cleaning duties as directed by the Plant Operations Manager according to required department policies and procedures. Ensures that the daily and deep cleaning schedules are adhered to. Essential Functions: Operates plant operations equipment (Example: vacuums, floor cleaners, buffers, shampooers, etcetera). Wet-mops rooms, halls, and other areas; shampoos rugs and furniture.The facility's Plant Operations Manager Job Description, dated June 2021, documents, Major duties and responsibilities: The Plant Operations Manager is responsible for efficiently managing the facility's housekeeping operations and the Plant Operation staff. The primary function of this position is to ensure nursing home residents enjoy a clean and orderly living environment.The facility's Resident Council Minutes, dated 6/17/26, documents, Housekeeping Issues/Comments: Trash not always being taken out. Rooms are not cleaned regularly. Wet floors sign up when they didn't mop.On 8/5/26 from 8:55 AM through 9:26 AM, a tour was conducted of the facility. Room (#) had widespread floor staining, food debris beneath the bed and across the floor, and heavy grime accumulated under the sink in the corner. Room (#) had scattered floor debris, crumbs beneath the bed, and multiple unexplained stains throughout the living space. Room (#) had food debris on the floor under the furniture, scattered trash, and sticky stains noted both in the main room and the adjoining bathroom. Room (#) had sticky residue under the window-side bed, with heavy black buildup and staining along the base of the bathroom walls. Room (#) had extensive yellow floor staining, thick debris around the baseboard, scattered debris across the floor, and distinct streaking marks across the flooring. Room (#) had food and debris underneath the bed. Room (#) had food crumbs under the bed closest to the door and scattered debris throughout the interior. Room (#) had sticky residue beneath the bed, floor scuffs/marks, and heavy dirt accumulation throughout the room. The area outside of the front lobby double doors located by the employee bathrooms had visible dirt, grime, and discarded food materials located adjacent to the double doors. The hallway connecting to the dining room had dirt/debris outside of each double door along with dirt, dust, and debris surrounding the ice machine.On 8/5/26 at 2:13 PM, a follow-up tour was conducted with V19/Housekeeping Supervisor. V19 verified rooms still lacked proper cleaning, showing lingering food debris, grime, sticky residue, and stains and the front lobby double doors and the dining room hallway ice machine area remained dirty with unaddressed debris and grime. V19 stated housekeepers are assigned to individual hallways daily and are required to perform comprehensive cleaning duties within their designated zones. These mandatory daily tasks include organizing resident rooms, dusting, wiping down all surfaces, and thoroughly sweeping and mopping entire room layouts including behind doors and underneath all furniture. V19 also stated daily housekeeping obligations extend to sweeping, mopping, and maintaining all assigned hallway common areas, breakrooms, nurses' stations, and bathrooms.On 8/5/26 at 2:40 PM, R8 (Resident Council President) stated, Sometimes the housekeepers don't even come into our rooms (especially on the weekends) or they don't clean the rooms all the way. The housekeepers get in a hurry, so not everything is being cleaned good. We have complained about this in resident council.The facility's Resident Roster, dated 8/3/26, documents 103 residents reside within the facility.

Based on interviews and record reviews, the facility failed to implement a comprehensive care plan with interventions for one (R2) resident in five residents reviewed for care plans and failed to prevent abuse for one resident (R1) of four residents reviewed for abuse. This failure resulted in R1 being physically abused with a cane causing a bruise to her neck, nightmares, and exacerbating R1's PTSD (Post Traumatic Stress Disorder) and anxiety. This past noncompliance, which involved R1 and R2, occurred from 5/20/2026 to 5/28/26. Findings include:The facility policy, Comprehensive Care Plans, revised 1/20/26, documents, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The facility policy, Abuse, Neglect, Exploitation, revised 1/23/26, documents, It is the policy of this facility to provide protections for 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. The Final 5 (five) Day Follow-up Abuse Investigation Report sent to (the State Agency), documents R1 a [AGE] year-old female was physically abused by R2. On 5/20/26, Certified Nursing Assistant (CNA) responded to (R1) calling out for help from her room which was occupied by R1 and R2. CNA observed R2 holding a cane to R1's throat and pulling R1's hair. No acute injuries were noted upon assessment of R1. R1's admission record documents R1's date of admission to the facility was 5/8/26 and her diagnoses included but are not limited to: Chronic Obstructive Pulmonary Disease, Unspecified, Post-Traumatic Stress Disorder, Unspecified, Panic Disorder, Anxiety Disorder, Unspecified, Bipolar Disorder, Unspecified, and Sleep Disorder, Unspecified. R1's current care plan documents R1 is cognitively intact. On 6/16/26 at 10:30am, R1 stated on 5/20/26 her old roommate (R2) came up behind her when she was bent over arranging her belongings on her bed, put a whooping stick to my throat and was pulling back on it. She (R2) was stating this is how we do it. I started screaming for help and they came right away and pulled her off me. She left a bruise to my throat and the whole experience (R1 tearing up) has really ramped up my PTSD (Post Traumatic Stress Disorder) and anxiety. I have nightmares, can't sleep, I keep my door closed and I don't go down for meals because I don't know if I will run into her. If I go to activities I always face forward and do not have my back to anyone. The facility has been good in fixing the situation and trying to help me but (R2) should never have had anything like that (cane) in our room in the first place. She would get agitated and belligerent with staff prior to this. 6/17/26 at 1:00pm, V22 (Certified Nursing Assistant) stated she was in the clean utility room on the 300 hall when she heard R1 screaming for help. V22 immediately went to R1's room and saw R2 behind R1 holding a cane to her (R1) neck and pulling it back with both hands as if she was choking (R1). V22 stated she called for help and went over to get the cane from R2 and separate them, as she got the cane R2 grabbed a hold of R1's hair and V22 had to disentangle R2's finger from R1's hair. V22 stated another staff member came in (cannot recall who) and took R2 from the room with her cane. (R2) was yelling at (R1) about taking her glasses. While at the nurse's station (R2) was bragging and laughing about what she did to (R1) to another resident (unsure of resident). On 6/17/26 at 2:30pm, V1 (Administrator) stated she had just got home from work on 5/20/26 when she received a call from V19 (Licensed Practical Nurse) reporting the altercation between R1 and R2 stating R2 was witnessed holding her cane to R1's neck. V1 stated she told V19 to notify police and call medics, then called V2 (Director of Nursing) to notify of allegation. V1 returned to the facility to investigate further and noted police and emergency medical transport were already at the facility. R2 was sitting in her wheelchair up by the nurse's station and R1 was in her room. V1 stated R2 was talking nonsensically about [NAME] and [NAME] were part of something and were going to be murdered by (R1) and (R1) took her glasses to impersonate her (R2) to take all of her money form (local bank). The police decided not to arrest R2, so she was sent to local emergency department for a psychiatric evaluation. R1 was assessed by the emergency medical crew and nursing with no injuries noted. R1 was moved to a different room, referral to psychiatry, and had an emergency telehealth appointment the following morning. V8 (Social Service Director) checks on R1 frequently to see how she is doing. R2 returned from the emergency department after being cleared by psychiatry and was found to have a Urinary Tract Infection and was given orders for antibiotic therapy, placed in room by herself, emergency appointment the following morning with psychiatric services, and is being monitored closely when around other residents. R2's Face Sheet documents R2 admitted to the facility on [DATE] and her diagnoses included but are not limited to: Heart Disease, Unspecified, Heart Failure, Unspecified, Depression, Unspecified, and Anxiety Disorder, Unspecified. R2's Psychotropic Evaluation, dated 2/14/26, documents that R2 has chronic behavior potentially causing harm to self or others. R2's current care plan lacked a behavior focused plan of care until 5/20/26. On 6/17/26 at 2:30pm, V1 verified R2's current care plan did not have documentation or interventions in place for behaviors prior to 5/20/26 and verified R2's admission psychotropic evaluation, dated 2/14/26, documented R2 was chronic harm to herself and others. Prior to the survey date of 6/16/2026, the facility had taken the following actions to correct the non-compliance:1.Immediate actions taken: immediate separation of residents, nursing assessment, notification of law enforcement and emergency medical services, nursing and emergency medical services evaluation, emergency department evaluation of R2, treatment of UTI (Urinary Tract Infection), roommate separation upon return, review and update of care plans, psychiatric follow-up, increased staff monitoring of resident interactions and R1 continued support from facility staff (Social Services and Activities).2. All residents have the potential to be affected; no others were identified at this time. R1 and R2's care plans revised to include psychosocial risks identified.3. Measures put into place/systems changed: Ad hoc QAPI (Quality Assurance and Performance Improvement meeting held to discuss resident-to-resident physical aggression and threatening behavior. Clinical startup tool implemented with audits to be done twice weekly for four (4) weeks to ensure resident care plans identify psychosocial risk.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided and to implement individualized fall prevention interventions for two of three (R1 and R2) reviewed for falls in a sample of three. This failure resulted in R1 sustaining a displaced transcervical left femoral neck fracture, a left iliopsoas hematoma, and a Lumbar 3 vertebral body fracture, and being admitted to the hospital requiring surgical intervention. This failure also resulted in R2 being admitted to the hospital with a subdural hematoma. Findings include: The facility's Accidents and Supervision policy, reviewed 1/25/26, documents 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 form documents all staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. Evaluation and Analysis-the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. This form documents that supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. The facility's Fall Prevention Program, reviewed 2/2/2026, 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. 1.R1's Fall Risk evaluation, dated 8/2/25, documents a score of 18. This form documents a score of 10 or higher indicates the resident is at high risk of falls. R1's electronic care plan documents R1 is at risk for falling related to impaired cognition, moves about the room during the night without a noted purpose, and safety awareness associated with Alzheimer's dementia. R1's Unwitnessed Fall, dated 8/2/25 at 8:00pm, documents R1 was noted lying in the middle of the floor of her bedroom. R1 stated she was trying to go to the toilet but fell in the process of trying. R1's fall intervention was to encourage R1 to remain in a supervised area when up in a wheelchair. This form documents R1 was last assisted with cares 1 1/2 hour prior. R1's Unwitnessed Fall, dated 8/19/25 at 10:45am, documents R1 was observed sitting on the floor on her buttocks, feet flat on the floor, knees bent, between both beds in the room facing the wall with the sink. R1's wheelchair was not within reach, and R1 had socks on. R1 stated, I fell out of bed. R1 stated she did not know why she was attempting to get out of bed. R1's fall intervention put into place was when R1 is noted to be awake in bed, move to a supervised area for observation. This form documents R1 was last provided cares 45 minutes prior. R1's Unwitnessed Fall, dated 10/7/25 at 1:30pm, documents a Dietary Aide stated R1 was on the floor mat beside another resident's bed with feces on her hands. R1 was in a sitting position in front of her wheelchair. R1's fall intervention was to toilet before and after meals. This form documents R1 was last assisted 1 1/2 hours prior to the incident. R1's Unwitnessed Fall, dated 10/16/25 at 9:45pm, documents tV7, Licensed Practical Nurse, heard R1 call for help. Upon approach, observed R1 laying on the floor face up. R1 stated she fell and hit her head. R1's head to toe assessment performed and was within baseline for R1 except for R1 stating she hit her head. R1's fall intervention put into place was to monitor to ensure R1 was in the middle of the bed after cares. This form documents R1 was last assisted 1 hour prior. R1's Unwitnessed Fall, dated 11/21/25 at 6:35pm, documents R1 was observed on the floor in the left lateral position; R1 admitted to hitting her head and stated she was trying to go to the bathroom. Assessment revealed a small, soft, non-tender bump on the top of her scalp. No other injuries were noted. R1 stated she was trying to go to the bathroom. R1's fall intervention put into place was to during times of restlessness, offer toileting. This form documents R1 was last assisted with care 30 minutes prior. R1's Unwitnessed Fall, dated 4/8/26 at 6:50am, documents upon entering R1's room, R1 was laying on her right side facing the door with the wheelchair laying on its back. R1 stated that she was trying to go to the bathroom and fell. While attempting to turn R1, she yelled out in pain, stating her hip hurt. V10, R1's Family, did not want R1 sent to the emergency room at that time; she wanted to wait for Hospice to assess. R1. R1's fall intervention put into place is to toilet before breakfast. R1's Unwitnessed Fall, dated 4/30/26 at 7:10am, upon entering R1's room, R1 was sitting on the floor, giving her back to the toilet, wheelchair was in front of her. R1 had her pants halfway down; R1 was holding them with one hand. R1 was not wearing any shoes at the moment. R1 stated that she just wanted to go to the bathroom. There were no injuries noted except for R1, complaining of lower back pain. R1's fall intervention put into place was to remain in the dining area after breakfast. This form documents R1 was last assisted 1 hour prior. R1's Unwitnessed Fall, dated 5/1/26 at 6:50am, R1 was sitting on the floor in her room, in the seated position with her back against the wall. R1 had her pants pulled down to her knees. R1's wheelchair was next to the door. R1 stated she did not know what happened, just get her up. R1's fall intervention was to offer R1 to get up in the first group in the mornings. R1's Unwitnessed Fall, dated 5/11/26 at 1:55pm, alerted by another resident that a resident needed assistance. Upon arrival to room, R1 was observed on the floor lying on her left side with her head under the bedside table and her feet toward the closet. R1's feet were tangled in her cover. R1's fall intervention was to ensure R1 was in the middle of the bed before exiting the room. R1 was last assisted with cares approximately 1 hour prior to the incident. R1's Unwitnessed Fall, dated 5/16/26 at 6:30pm, R1 was in another residents room on the floor. R1's fall intervention was to monitor for wandering. R1 was last observed approximately 30 minutes prior to the incident. R1's Unwitnessed Fall, dated 5/16/26 at 9:45pm, R1 was observed on the floor mat curled up lying on her right side. R1 was assisted up with three staff members. R1's pants were pulled down halfway and incontinent brief was off and next to her. This form documents R1 was incontinent at the time of the incident. R1's fall interventions were to monitor closely for impulsive behaviors. R1 was last assisted with cares approximately 90 minutes prior. R1's Progress Notes, dated 5/17/26, documents around 7:20am, V4, Licensed Practical Nurse, was called to R1's room by a Certified Nursing Assistant, stating R1 appeared to be in pain, grabbing at her left lower extremity. Upon entering the room, R1 was observed in the fetal position laying on the right side. V4 attempted to do a full body skin assessment; however, R1 started to scream once the writer tried to reposition R1's legs. V4 offered R1 pain medication and she refused. V4 notified V10, R1's Family at 7:20am and she agreed to send R1 to the emergency room for an evaluation. This form documents Hospice was notified, and they state they would send a nurse out, but if R1 needed further evaluation, it was ok to send her to the hospital. Hospice notified the facility that ETA (estimated time of arrival) would be 45 minutes. R1 agreed to take the pain medication and appeared to be resting. V4 and Hospice staff attempted another assessment that was unsuccessful due to leg pain. R1 was transferred to the emergency room at 9:30am. R1's Progress Notes, dated 5/18/26, documents R1 was admitted to hospital on [DATE]. R1's Emergency Department Note, dated 5/17/26 documents a clinical impression of a closed fracture of the left hip. R1's Computed Tomography (CT) Scan, dated 5/17/26, documents an acute displaced transcervical left femoral neck fracture and a left iliopsoas hematoma. This form also documents a possible Lumbar 3 vertebral body fracture, not seen on the prior CT. This form documents R1 had an acute fracture, which was discussed with orthopedics and ultimately admitted to inpatient services. R1's Progress Notes, dated 5/27/26, documents R1 was readmitted to the facility. R1 has a dressing to her left hip, and it is to stay in place for seven days. R1 also has a TLSO (thoracolumbosacral Orthosis) brace to stay in place at all times except for showers. 2. R2's Fall Risk Assessment, dated 7/15/26, documents R2 is at risk for falls. This form documents a score of 10 or higher indicates the resident is at high risk of falls. R2's Unwitnessed Fall Assessment, dated 7/12/25, documents the Laundry Aide informed V3. Licensed Practical Nurse, that R2 was sitting on the floor in front of her wheelchair. R2's fall intervention was to place a non-slip cover on the wheelchair. R2's Unwitnessed Fall Assessment, dated 7/14/25. documents R2 slid out of her wheelchair onto her buttocks in the dining room. R2's fall intervention was to ensure a non-slip cover was in place. R2's Unwitnessed Fall Assessment, dated 7/15/25, documents R2 was observed sitting on the floor in her bedroom. R2's fall intervention was to place a scoop mattress to better enable R2 to define the bed parameters. R2's Unwitnessed Fall Assessment, dated 7/19/25, documents another resident yelled out that a resident was on the floor. R2 was found on her bottom in front of the wheelchair. The peer stated she saw R2 stand and fall. R2's fall intervention was offered to toilet if restless. R2's Unwitnessed Fall Assessment, dated 8/9/25, documents R2 had fallen on her knees in the dining room. Upon entering the dining room, R2 was observed sitting in her wheelchair without her foot pedals in place. R2's Unwitnessed Fall Assessment, dated 8/26/25, documents R2 was observed on the dining room floor in front of her wheelchair in the prone position. R2 was non-responsive. R2 was sent to the emergency room for an evaluation. R2's progress notes document R2 sustained an unwitnessed fall on 12/25/25 and 12/31/25 in the common area, with no injuries. R2's Unwitnessed Fall, dated 1/24/26, documents R2 was observed lying on the dining room floor on her left side, with legs bent bilaterally. R2 had a skin tear on her left kneecap and a nodule appearing on the left side of her forehead. R2 nodded her head yes when asked if she was in pain. R2 was sent to the emergency room for further evaluation. R2's Progress Notes, dated 1/25/26, documents R2 remains in the local hospital, she pulled out her gastrostomy tube, and has a brain bleed. R2's readmission Packet, dated 1/27/26, documents the current problem was a Subarachnoid bleed on 01/24/2026. R2's electronic medical record, dated 2/2/26 through 6/10/26, documents 8 unwitnessed falls, with several emergency room visits, due to being on an anticoagulant medication. On 6/10/26 at 11:45am, there were approximately 20 residents sitting in the dining room, with only one activity person in the area. On 6/11/26 at 10:00am, R2 was observed in her bed with her legs over the side. R2's floor mat was in place and the bed was in the low position. On 6/12/26 at 9:30am, R2 was in her room with the door closed. R2's bed was in the low position. R2 was lying in a prone position, but her tray table with her breakfast was sitting in front of her. R2's floor mat was not in place. On 6/10/26 at 11:00am, V1, Administrator, stated falls are one of the concerns the facility is working on in Quality Assurance. On 6/10/26 at 11:45am, V12, Activity Director, stated one of the activity staff is always in the dining room, but are unable to monitor everyone, especially if they are in the middle of an activity. On 6/12/26 at 11:30am, V11, [NAME] President of Clinical Operations/Registered Nurse, stated residents are going to fall. V11 stated falls are being monitored in Quality Assurance, and all staff have already been in-serviced on fall prevention.

Based on record review and interview, the facility failed to report an allegation of employees to resident verbal abuse to the State Agency for one of three residents (R2) reviewed for abuse in the sample of six.Findings include: The facility's Abuse, Neglect, Exploitation Policy, dated 1/23/26, documents, Policy: 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. Policy Explanation and Compliance Guidelines: 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. VII. Reporting/Response- A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (example: law enforcement when applicable) within specified timeframes: Immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or a result in serious body harm.On 3/20/26 at 11:19 AM, V3/ADON (Assistant Director of Nursing) stated, On 2/11/26 (R2) caught me in the dining room and reported to me that two CNA's (V6 and V7) had used foul language towards (R2) and called (R2) a c**t. I told (R2) I would investigate the situation. I immediately went and reported the allegation to (V2/DON) who told me I had to report it to the corporate staff (V4 and V12). I then immediately reported the alleged allegation to (V4 and V12). After (V4 and V12) spoke to (R2), they instructed (V6 and V7) to be removed from (R2's) hallway and place them on a different hallway at the other side of the building. (V6 and V7) were at the facility working during that time and never was suspended to my knowledge.As of 3/20/26 at 11:05 AM, the facility's reports to the local State Agency did not contain documentation of an alleged verbal abuse altercation from two CNA's (V6 and V7) to R2 on 2/11/26 as being reported.On 3/20/26 at 12:55 PM, the Regional Director (V12) and the President of Operations (V4) mentioned they were covering for the Administrator (V1) during the week of 2/11/26. V12 said on 2/11/26, the DON (V2) told her that apparently, R2 claimed to the ADON (V3) two CNAs (V6 and V7) called her a c**t and were being mean to her. Once they heard this, they (V4 and V12) pulled R2 into an office to talk. R2 then changed her story, saying no one called her names, she just didn't like the care she was getting. V12 didn't think it qualified as an abuse allegation, but they still moved V6 and V7 to a different floor so they wouldn't work with R2 anymore. Both V4 and V12 confirmed they did not send a report to the State Agency (Illinois Department of Public Health) regarding R2's allegation of V6 and V7 calling her a c**t.On 3/20/26 at 1:50 PM, R2 stated she reported to V3/ADON around a month ago that two CNA's (V6 and V7) were saying mean things to her and called her a c**t. R2 stated, After I reported to (V3) what (V6 and V7) did too me, two older ladies (probably in their 60's with gray hair) (identified as V4 and V12) pulled me into the office and asked me directly what happened. I told them both that (V6 and V7) had taken care of me a few nights prior and called me a c**t. I did not tell (V4 and V12) who the two CNAs were because I had already told (V3/ADON) the name of the employees and wasn't going to keep repeating it. (V4 and V12) told me they were going to move (V6 and V7) to a different hallway, so they would no longer be working with me.

Based on record review and interview, the facility failed to complete a thorough investigation and remove the perpetrator from resident cares while the investigation was underway for one of three residents reviewed for abuse in the sample of six.Findings include: The facility's Abuse, Neglect, Exploitation Policy, dated 1/23/26 documents, Policy: 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. Definitions: Verbal Abuse- means the use of oral, written or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Investigation of Alleged Abuse, Neglect and Exploitation- A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or report of abuse, neglect or exploitation occurs. B. Written procedures for investigation include: 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations: 6. Providing complete and thorough documentation of the investigation. V1. Protection of the Resident- The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.R2's admission Record documents R2 is a [AGE] year-old female who admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Bipolar Disorder, Age- Related Osteoporosis, and Generalized Muscle Weakness.R2's MDS (Minimum Data Set) Assessment, dated 2/25/26, documents R2 is moderately cognitively impaired.On 3/20/26 at 10:24 AM, V2/DON (Director of Nursing), stated V3/Assistant DON reported an allegation to her on 2/11/26. According to the report, a resident (R2) claimed two CNAs/Certified Nursing Assistant (V6 and V7) called her a c**t. V2 then instructed V3 to notify corporate staff V4/Vice President of Operations and V12/Regional Director of Operations, as they were covering for the Administrator (V1) that week.On 3/20/26 at 11:19 AM, V3/ADON stated, On 2/11/26 (R2) caught me in the dining room and reported to me that two CNA's (V6 and V7) had used foul language towards (R2) and called (R2) a c**t. I told (R2) I would investigate the situation. I immediately went and reported the allegation to (V2/DON) who told me I had to report it to the corporate staff (V4 and V12). I then immediately reported the alleged allegation to (V4 and V12). After (V4 and V12) spoke to (R2), they instructed (V6 and V7) to be removed from (R2's) hallway and place them on a different hallway at the other side of the building. (V6 and V7) were at the facility working during that time and were never suspended to my knowledge.On 3/20/26 at 12:55 PM, the Regional Director (V12) and the President of Operations (V4) mentioned they were covering for the Administrator (V1) during the week of 2/11/26. V12 said on 2/11/26, the DON (V2) told her that apparently, R2 claimed to the ADON (V3) two CNAs (V6 and V7) called her a c**t and were being mean to her. Once they heard this, they pulled R2 into an office to talk. R2 then changed her story, saying no one called her names, she just didn't like the care she was getting. V12 didn't think it qualified as an abuse allegation, but they still moved V6 and V7 to a different floor so they wouldn't work with R2 anymore. Both V4 and V12 confirmed that V6 and V7 weren't suspended pending an investigation, and they didn't document the incident, interview other staff or residents, or write up an official investigation.On 3/20/26 at 1:50 PM, R2 stated she reported to V3/ADON around a month ago, that two CNA's (V6 and V7) were saying mean things to her and called her a c**t. R2 stated, After I reported to (V3) what (V6 and V7) did too me, two older ladies (probably in their 60's with gray hair) (identified as V4 and V12) pulled me into the office and asked me directly what happened. I told them both that (V6 and V7) had taken care of me a few nights prior and called me a c**t. I did not tell (V4 and V12) who the two CNAs were because I had already told (V3/ADON) the name of the employees and wasn't going to keep repeating it. (V4 and V12) told me they were going to move (V6 and V7) to a different hallway, so they would no longer be working with me.On 3/20/26 at 2:07 PM, V6/CNA stated she was called to the office by V4/President of Operations and V12/Regional Director of Operations on 2/11/26. When V6 arrived at the office, V4 and V12 kept saying, You tell her what (R2) said, then the other corporate lady would say no you tell her. V6 stated finally one of the corporate ladies spelled out R2 reported V6 called her a c**t. V12 reported to V6 they didn't believe it because R2's story kept changing, so they switched V6 to another hall and instructed her to not work on that side where R2 resides any longer.On 3/21/26 at 1:09 PM, V7/CNA stated, On 2/11/26 I was calling the office by (V4/President of Operations) and (V12/Regional Director of Operations) and was told (R2) reported I called (R2) a c**t. Both (V4 and V12) stated since (R2) is targeting (V6) and myself that we had to be assigned to a different hallway. They didn't send me home.

Based on observation, record review, and interview, the facility failed to protect one resident(R2) from abuse of 5 residents reviewed for abuse, in a total sample of five residents. This failure resulted in R1 pulling out his penis and placing his penis on R2's lips. A reasonable person would feel intimidated, stressed, and humiliated.FINDINGS INCLUDE:The facility policy, entitled Abuse, Neglect, and Exploitation, date reviewed/revised 2/11/2025, documents, Sexual Abuse is non-consensual sexual contact of any type with a resident; and B. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. 1. An assessment of the individual's functional and mood/behavioral status, medical acuity, and special needs will be reviewed prior to admission. 2. The facility will make individual determinations in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment, and equipment.R1's Electronic Medical Record/EMR documents R1 was admitted to the facility from a local hospital on [DATE], with the diagnoses of Cerebral Infarction, Vascular Dementia, Centrilobular Emphysema, Other Sexual Dysfunction, Aphasia, Tobacco Use, Hyperlipidemia, Nicotine Dependance, Diabetes Mellitus Type II, Dehydration, and Hypertension. R1's Brief Interview for Mental Status (BIMS) is zero-indicating R1 is not cognitively intact.R1's local hospital documentation prior to admission documents: Interval HPI [History/Physical Information]: 11/27: Persistent receptive aphasia. Patient reportedly inappropriate towards female staff. Assigned all male nurses moving forward. Video sitter in place for consistent failure to abide by safety measures. Minimal ability to follow commands due to receptive aphasia. 11/28/2025: No change in neuro status. Still has inability to answer questions but has been seeing some inappropriate words to bedside nursing. Patient refused labs this a.m. 12/1/2025: No change in neuro status. Spoke with daughter and she reported that the patient has been sexually inappropriate for 3 to 4 days prior to his stroke. The patient most likely started having his stroke when he started being sexually inappropriate because his stroke is located in the left posterior frontal temporal parietal lobes 12/2/2025: No change in neuro status. Still aphasic. Per bedside staff the patient is no longer verbally sexually inappropriate but still has inappropriate behavior; DOS [date of service] 12/2/25 Subjective: Patient alert and sitting upright in bed. Patient participatory with ST [skilled therapy] services. Patient made lewd comments to clinician and attempted to touch his genitals x2 but redirectable with verbal cues to stop; DOS 12/3/25 Started carbamazepine 200 mg [milligrams] twice daily for hypersexuality after a stroke.The facility's Final Report to the State Agency documents: Allegation Date: 12/13/2025; Brief Description of Allegation: Allegation of resident to resident incident (R1) with his flaccid penis exposed and placing on (R2's) face/lip area; SUMMARY OF THE INVESTIGATION: Staff was walking down the hallway when she observed (R1) with his penis exposed and trying to place it on the face of (R2). (R2) was seated in a wheelchair and (R1) was attempting to stand. Staff immediately separated.R1's psychiatric note, dated 12/15/25, documents: Prior to admission, the patient was started on carbamazepine specifically to address hypersexual behaviors; however, staff report that it is ineffective. The patient currently requires one-on-one supervision due to his history of inappropriate sexual behaviors.R2's EMR documents: Diagnoses- Metabolic Encephalopathy, Obstructive Reflux Uropathy, Adult Failure to Thrive, Anxiety Disorder, Unspecified Dementia, GOUT, Dysphagia, Atrial Fibrillation, Peripheral Vascular Disease, Hypertension, Hyperlipidemia. Atherosclerotic Heart Disease, and Osteoporosis. R2's Minimum Data Set/MDS documents R2's cognitive status as not able to be interviewed- resident is rarely/never understood. On 12/23/25, at 11:00 a.m., R2 was observed sitting in her wheelchair. R2 was not able to communicate and sat with her mouth open.On 12/23/25, at 12:40 p.m., R1 was observed in his room with a sitter. R1 does not have to cognitive ability to understand or to be interviewed.On 12/24/25, at 9:40 a.m., V3/Certified Nursing Assistant, confirmed: On 12/13/25, she went to the 200 Hall and when she turned the corner, she saw R1's penis out of his pants and touching in between [R2's] lips; [R2's] mouth is always open; the situation occurred at the entrance of the 100/200 dining room; [R1] sat right down and buttoned his pants when he saw me.On 12/24/25, at 12:12 p.m., V8/Vice President of Business Development confirmed [regarding R1's admission screening]: I was not on the front end [of the screening process]; looped in after the fact; there were gaps in the front end and screening was worked through the case manager and not at bedside; We talked at the corporate level, education with the team; and starting 1/5/26, we will have a dedicated [city] person [for admission screening].On 12/30/25, at 11:05 a.m., V1/Administrator confirmed: Had the facility known about R1's behaviors/hypersexual in the hospital, V1 would have requested a deeper dive; and would probably not accepted him [R1] for admission, but if the needed to, they would have admitted him to a private room and assigned a 1:1 staff member to see what his behaviors are.On 12/30/25, at 2:00 p.m., V10/Facility Doctor confirmed due to R2's dementia, she is vulnerable and cannot defend herself.

Based on observation, interview, and record review, the facility failed to assess, monitor, and apply a physician ordered hand protector for contracture prevention, and ensure Range of Motion Services were provided for one (R39) of three residents reviewed for splints and contractures in the sample list of 53. Findings include: The facility's ADLs (Activities of Daily Living) Policy, dated 2/10/25, documents, Policy: 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. Policy Explanation and Compliance Guidelines: 2. The facility will provide a maintenance and restorative program if indicated to assist the resident in achieving and maintaining the highest practical outcome based on the comprehensive assessment. The facility's Facility Assessment, dated 9/5/2024, documents, Services and Care We Offer Based on Our Resident's Needs: General Care- Mobility and fall/fall with injury prevention. Specific Care or Practices: Transfers, Ambulation, Restorative Nursing, Contracture Prevention/Care. R39's Physician Order Sheet, dated 7/27/23, documents a Physician Order for a right-hand protector to prevent contracture twice a day. This order did not include parameters for how long splint should be on and when to remove the splint. R39's current Medical Diagnosis list documents Cerebral Infarction affecting right dominant side, Contracture of Right Hand, and Abnormalities of Gait and Mobility. R39's MDS (Minimum Data Set) Assessment, dated 5/17/2025, documents R39 is cognitively impaired, requires assistance with all ADLs, has an impairment on one side of R39's upper extremities, and an impairment on both sides of R39's lower extremities. R39's current Care Plan documents, (R39) has an ADL self-care performance deficit related to Activity Intolerance, Fatigue, Impaired balance, right hand contracture, memory loss, post laminectomy syndrome with pain, obesity. This same care plan does not document any active or passive range of motion exercises to R39's right hand. R39's electronic medical record does not contain any evidence of Range of Motion exercises being performed to R39's right hand. On 6/30/25 at 1:30 PM, R39 was observed lying in bed. A right-hand splint labeled with R39's name was on the bedside table. R39's right arm was drawn up toward R39's chest, with the right hand curled into a fist, indicating a contracted posture. The hand protector was not in use, and there was no staff present to explain the absence. On 6/30/25 at 2:15 PM, V21 (Physical Therapist) stated therapy gave the order on 7/27/23 for R39's right hand protector. V21 further stated R39's hand was becoming contracted, and the protector was to keep R39's fingernails from digging into R39's hand. V21 stated R39's order should have had more clear instructions for right placement and removal of right-hand protector. On 6/30/25 at 2:25 PM, V7 (MDS Nurse) stated she does not do quarterly assessments for residents with a brace/splint. V7 stated the facility does not have a nursing assessment to address splints and braces for contractures. V7 confirmed the facility does not have a restorative program, and there is no documentation to show R39 has received Range of Motion to R39's right hand. On 6/30/25 at 2:20 PM, V13 (Assistant Director of Nursing) stated V13 was not aware R39 had a right-hand protector. V13 further stated she is not aware of a nursing assessment being completed for R39's right hand protector, and V13 stated she is not aware who would complete the assessment.

Based on interview and record review, the facility failed to promptly notify the resident's physician of a change in condition for one of three residents reviewed for significant change in a sample of four. Findings include: The facility's Notification of Change Policy, dated 2/10/225, documents, Policy: 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. Circumstances requiring notification included: Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental, or psychosocial status. R1's Face Sheet documents R1 admitted to the facility on [DATE] ,with the following diagnoses: Metabolic Encephalopathy, Cerebral Atherosclerosis, Type Two Diabetes Mellitus, Chronic Kidney Disease, and Alzheimer's Disease. R1's MDS (Minimum Data Set) Assessment, dated 4/11/25, documents R1 is severely cognitively impaired. R1's Progress Note, dated 4/3/25 and signed by V8/RN (Registered Nurse), documents, (R1) exhibited significant agitation and was highly resistant to care. (R1) was observed attempting to ambulate and transfer independently, demonstrating increased difficulty and decline in gait balance, compared to her baseline. Despite staff efforts to approach and assist, (R1) remained uncooperative and did not allow physical contact. Notably, (R1's) gait has deteriorated, placing her at an increased risk for falls. R1's Progress Note, dated 4/4/25 and signed by V8/RN, documents, (R1) continues to demonstrate a noticeable decline in gait and balance. Overnight, (R1) made multiple attempts to stand from her wheelchair but was unable to do so as (R1's) legs repeatedly gave out. (R1) is also exhibiting increased confusion and difficulty following simple instructions. While seated in her wheelchair, (R1) was observed sliding down and had to be boosted back up several times. While being transferred to bed, two staff members had to assist, which represents a notable decline from (R1's) baseline. (R1) did not bear weight during transfer, and her legs buckled during the stand-pivot maneuver. R1's Emergency Department to Hospital Admission Note, dated 4/4/25, documents, Disposition: Admit. Clinical Impression- 1. Urinary Tract Infection. 2. Altered Mental Status. On 5/23/25 at 12:04 PM, V8/RN, stated, I just remember the night before (R1) was not acting herself. (R1) was agitated and her gait had slightly declined. I didn't feel like (R1) was so off that (V9/R1's Physician) needed notified. The next day, early in the morning, I noticed (R1) had more of a significant decline. (R1) was unable to stand on her own and had increased confusion. I passed on in report (R1's) declining in condition. I should have notified (V9/R1's Physician) before waiting to pass it on in report. I don't know why I didn't. On 5/23/25 at 9:24 AM, V7/LPN (Licensed Practical Nurse) stated, While I was passing medication to (R1) the morning she was sent to the local hospital, I noticed (R1) was weak, confused, and not acting like herself. (R1) ended up getting sent to the (local hospital) and admitted with a urinary tract infection. On 5/23/25 at 1:15 PM, V9/R1's Physician stated the facility should have notified him when R1 experienced a change in her condition. On 5/24/25 at 9:12 AM, V1/Administrator stated, I would expect the physician to be notified when a resident is experiencing any change in condition per regulation and per our policy. (V8) should have notified (R1's) Physician when she identified (R1) was experiencing a change in condition.

Based on record review and interview, the facility failed to prevent a significant medication error for one (R4) of four residents reviewed for medication administration in a sample of seven. This resulted in R4 being administered a medication with a documented drug allergy and developing a rash, and experiencing a sore throat and difficulty swallowing. Findings include: The Facility Medication Administration Policy, revised 1/4/24, documents: medications are administered by licensed nurses/staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice; review Medication Administration Record to identify medication to be administered; refer to drug reference material if unfamiliar with the medication, including mechanism of action or common side effects; and correct any discrepancies and report to the nurse manger. R4's current Care Plan documents an antibiotic drug allergy (Sulfasalazine/sulfa drug). The Care Plan also documents: risk for complication related to an antibiotic allergy (Sulfasalazine) and to check new medication orders against allergies prior to administration; and to report discrepancies to the physician and pharmacy. R4's Hospital Consultation Note, dated 1/13/25, documents diagnoses including recurrent Methicillin Resistant Staphylococcus Aureus/MRSA of Urinary Tract Infection/UTI, Bacteriuria and Kidney Stones. The Consultation Note also documents to start prophylactic oral antibiotic (Bactrim/Sulfamethoxazole-Trimethoprim 400-80 milligram/mg/sulfa drug) one tablet daily for 30 days and an allergy to an antibiotic (Sulfasalazine) with a reaction of headaches. R4's Nursing Note, dated 1/17/25, documents R4's diagnoses including Adult Failure to Thrive, Methicillin Resistant Staphylococcus Aureus/MRSA of Urinary Tract Infection/UTI, History of Falls, Zoster without complications, Abnormal Gait, Rheumatoid Arthritis, Calculus of the Kidney, Disorders of the Peripheral Nervous System, Scoliosis, Diabetes Mellitus, Osteoporosis, Overactive Bladder, Hypokalemia, Pneumonia and Urinary Tract Infection. R4's Medication Administration Record/MAR, dated 1/1/25 through 1/31/25, documents an antibiotic drug allergy (Sulfasalazine). The MAR also documents a Physician's Order for an oral antibiotic (Sulfamethoxazole-Trimethoprim 400-80 milligram/mg) to start on 1/17/25 through 1/27/25, but to be held on 1/22/25. The MAR documents administration of the antibiotic on 1/17/25 through 1/24/25, and 1/26/25. The MAR does not document the antibiotic was held on 1/22/25. The MAR also documents an additional one-time dose of the oral antibiotic (Sulfamethoxazole-Trimethoprim 400-80 milligram/mg) was administered on 1/17/25. R4's Nursing Note, dated 1/17/25 at 7:47 pm, documents V12 (R4's Nurse Practitioner) ordered the antibiotic medication (Bactrim/Sulfamethoxazole-Trimethoprim 400-80 milligram/mg) be finished as ordered. R4's Nursing Note, dated 1/17/25 at 10:36 pm, documents a possible drug allergy to antibiotic (Sulfamethoxazole-Trimethoprim 400-80 milligram/mg). R4's Nursing Note, dated 1/18/25 at 6:01 pm, documents V13 (R4's Physician) was notified of the drug allergy and was awaiting a reply. R4's Nursing Note, dated 1/22/25 at 12:36 am, document R4 had an extreme dry mouth resulting from the sulfur antibiotic and R4 states R4 has a history of allergies due to sulfur medications. V13 (R4's Physician) was notified and the medication was placed on hold until the Physician gives orders. R4's Nursing Note, dated 1/22/25 at 2:00 pm, documents R4 had some difficulty swallowing medications and water and the potential side effects of antibiotic medication listed as an allergy. The Nursing Note documents awaiting response from Primary Care Physician/PCP and will have a speech screening if difficulty continues. R4's Nursing Notes, dated 2/14/25 at 6:55 pm and 6:57 pm, document a possible drug allergy to antibiotic (Sulfamethoxazole-Trimethoprim 400-80 milligram/mg). R4's Nursing Note, dated 2/19/2025 at 8:04 am, documents R4 states she is having reaction to medication and the Doctor was notified. R4's Nursing Noted, dated 2/19/2025 at 1:35 pm, documents an order from V12 (Nurse Practitioner) ordered sulfa antibiotic to be d/c (discontinued). (V12/APN) ordered medication (prednisone every day for three days) for prevention of hives or further allergic reactions to medications. Orders processed. On 4/11/25 at 11:16 am, V13 (Pharmacist) stated, It looks like (R4) admitted on [DATE] with the antibiotic order. (R4's) Sulfasalazine allergy was flagged, which means that (R4) was allergic to the Sulfamethoxazole-Trimethoprim 400-80 milligram/mg, also known as Bactrim. On 1/17/25, our pharmacy flagged the allergy and spoke to (V14/Registered Nurse/Director of Nursing) and (V15/Registered Nurse) to verify sending the antibiotic medication. (V15) said it was okay to send the medication. It looks like the medication (Sulfasalazine) was also pulled from the contingency box on 1/18/25. Then in February 2025, the Facility sent additional Physician Orders for refills on the same medication. On 2/18/25, a four-day antibiotic supply was sent and on 2/19/25, an order for a prophylactic three day supply of medication (Prednisone) was sent for R4's complaints of sore throat and rash. We did notify the Facility and communicated with them regarding (R4's) drug allergy. I am not sure, but given what I am looking at, there may have been some miscommunication on clarifying the drug allergy, because I see it started and stopped multiple times. On 4/11/25 at 11:37 am, V12 (R4's Nurse Practitioner) stated, I carried over the antibiotic (Sulfasalazine/Sulfamethoxazole-Trimethoprim 400-80 milligram/mg) orders from (R4's) Urologist recommendation and also from the Hospital Consultation. I did not think that the allergies were a big deal. (R4) was not allergic, (R4) was bat*hit crazy. (R4) said that (R4) was having trouble swallowing and that (R4's) throat hurt, but (R4) did not have any trouble swallowing, it was complete nonsense. Ultimately, I was just following the Urologist orders, but I cannot confirm that the Urologist verified (R4's) allergies. On 4/11/25 at 10:02 am, V11 (R4's Physician) stated, Giving (R4) this sulfa (Bactrim/Sulfamethoxazole-Trimethoprim 400-80 milligram/mg) medication is technically a mistake. Treating some of the bacteria requires sulfa medications, this was just an oversite.

Based on interview and record review, the facility failed to report alleged physical abuse to the State Agency for one of six residents (R1) reviewed for abuse in the sample of six. Findings include: The Facility's Abuse, Neglect and Exploitation Policy, dated 12/5/2023, documents, When abuse, neglect or exploitation is suspected, the Administrator/Abuse Coordinator Designee should contact the State Agency to report the alleged abuse. The facility must annually notify covered individuals' obligation to comply with the following reporting requirements each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility. Each covered, individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. On 1/21/2025 at 2:25 P.M, V7 (Activities Aide) stated on 1/6/2025, R1 was in the dining room area and reported to V7, My aide hit me. V7 stated V7 reported what R1 had said to V1 (Administrator). On 1/22/2025 at 2:15 P.M, V1 (Administrator) confirmed V7 reported to V1 that R1 alleged a Certified Nursing Assistant/CNA had hit her. V1 verified an investigation into the allegation was started. V1 stated, I did not report this (alleged abuse) to the (local state agency). As of 1/22/25, the past six months of reports to the State Agency did not contain R1's abuse allegation made on 1/6/25.

Based on observation, interview, and record review, the facility failed to ensure drug diversion of a narcotic did not occur for one (R1) of three residents reviewed for narcotic medications in the sample of eight. Findings include: The facility's undated Controlled Drug Policy and Procedure documents: To provide physical facilities and method of operation for the administration and control of narcotics, depressants, and stimulant drugs, which will meet the requirement of State and Federal narcotic enforcement agencies. Controlled drugs, as determined by the facility, are counted every shift by the nurse reporting on duty with the nurse reporting off-duty. The inventory of the controlled drugs must be recorded on the narcotic records and signed for accuracy of count. The controlled drug checklist must be signed by the nurse coming on duty and going off duty to verify that the count of all controlled drugs is correct, if used at facility discretion. The facility's Medication Storage policy and procedure, revised 12/20/23, documents: Narcotics and Controlled Substances: Schedule II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key. Schedule II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area, such as in a refrigerator. Any discrepancies which cannot be resolved must be reported immediately as follows: Notify the DON, charge nurse, or designee and the pharmacy; Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted; The DON, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities such as the local law enforcement, Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy, and possibly the State Licensure Board for Nursing Home Administrators. Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies. The facility's Pharmacy Services policy and procedure, revised 12/21/22, documents: 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 in coordination with the licensed pharmacist, will provide for: A system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications; Prompt identification of loss of or potential diversion of controlled medications; and Determination of the extent of loss or potential diversion of controlled medications. The pharmacist, in collaboration with the facility and medical director, should include within its services to: Determine (in accordance with or as permitted by state law) the contents of the emergency supply of medications and monitor the use, replacement, and disposition of the supply; and Provide feedback about performance and practices related to medication administration and medication errors. The facility's Abuse, Neglect, and Exploitation policy and procedure, revised 12/5/23, documents: Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a residents' belongings or money without the resident's consent. The Face Sheet for R1 includes the following diagnoses: Quadriplegia C1-C4 complete, Chronic Obstructive Pyelonephritis, Stage 2 Pressure Ulcer of Sacral Region, Low Back Pain, and Traumatic Left Hip Fracture. The current Physician Orders for R1 documents a physician order for Oxycodone 5 mg; give one tablet by mouth every six hours as needed for severe pain was ordered on 6/27/24. The current Care Plan for R1 documents R1 receives opiate medications related to Quadriplegia, has potential for pain related to Neuropathic pain with history of left hip fracture and stage II coccyx pressure ulcer. On 9/26/24 at 12:00 pm, R1 was sitting in a wheelchair in the dining room being assisted with meal. At 1:20 pm, R1 was being mechanically lifted from her wheelchair into bed and cares were provided. At 3:00 pm, R1 was lying in bed on her right side. R1 stated she doesn't take pain medications very often, but has them if she needs them. R1 stated she has pain off and on, and at the first of August she needed the Oxycodone for abdominal pain, but was told she didn't have any. R1 stated she asked to go to the hospital to get checked out. The MAR (Medication Administration Record) for R1, dated 7/1/24 through 7/31/24, documents R1 received three tablets of Oxycodone 5 mg during the month of July 2024; One tablet on 7/19/24, 7/25/24, and 7/26/24. The MAR for R1, dated 8/1/24 through 8/31/24, documents R1 did not receive any Oxycodone until 8/8/24. On 9/27/24 at 9:20 am, V2, DON (Director of Nursing), stated V11, Licensed Practical Nurse/LPN, informed her there was no Oxycodone for R1 in the medication cart. V2, DON, stated she called the Pharmacy and was told the medication had been delivered on the morning of 7/30/24. V2 was unable to locate the Packing Slip, Disposition Form, or the Oxycodone. V2 reported this to V1, Administrator, and an investigation was started. V2, DON, stated if the disposition sheet and the medication were missing, no one would have been able to count it, or know it was gone. On 9/27/24 at 9:25 am, V1, Administrator, stated she was notified by V2, DON, that a card of Oxycodone for R1 had been delivered on 7/30/24, and the staff could not find it. V1 stated she immediately started an investigation and was able to determine the medication was missing. V1 stated the facility video cameras were watched, medication carts and medication rooms were checked, and the locked document shred container was drilled open and searched. V1 stated inside the shred container there were the two packing slips for R1's Oxycodone proving the order date, when it was delivered, and an empty card of Hydrocodone. V1, Administrator, stated Nurses surrounding the time frame were interviewed, pharmacy was notified, and documents received regarding when medication was given, who gave the medication, and who ordered the medication. The Pharmacy was able to tell us that the Oxycodone was ordered three times, but the facility was unable to identify who ordered the medication due to the signatures being unidentifiable and not matching any of the Nurses working at the facility. On 9/27/24 at 12:15 pm, V11, LPN, stated she worked Friday 7/26/24 and gave (R1) Oxycodone on that Friday and she still had some, like half a card left. V11, LPN, stated she did not work again until the next Thursday, 8/1/24, and R1 complained of pain, and there wasn't any Oxycodone to give her. That is crazy she didn't have any pain medication. V11, LPN, stated she reported to V2, DON, who was going to call the pharmacy. V11, LPN, stated on Friday, 8/2/24, she was called to the office and V1, Administrator, and V2, DON, began asking (V11 LPN) about R1's pain medication. V11, LPN, stated she told V1 and V2 that (R1) doesn't ask for pain meds very often and (R1) had some the last day (V11) worked and when (V11) came back (R1) didn't have any. A Medication Error Report, #285 dated 8/2/24, documents: (Don/Director of Nursing) notified of issues with pain medication, Oxycodone. Through the course of initial investigation, it was identified that there was a full card of Oxycodone that had been delivered on 7/30/24 that was not present in the narcotic drawer. Resident went to the ER (emergency room ) for c/o (complaints of) pain and reported to the ER that there was no pain medication available at (the facility). Immediate Action Taken: Investigation in progress. Final Five Day to Follow to (State Agency) 8/2/24. Has a UTI (urinary tract infection) per (local hospital) ER. DON on site to verify medication discrepancy. The facility replaced the missing medication for the resident, 8/2/24. The Daily Assignment Sheet for the 400 hall, dated 7/29/24 documents V20, LPN, worked the third shift from 6:00 pm to 6:00 am on 7/30/24. V19, Former LPN, worked on the 400 hall on 7/30/24 from 6:00 am to 6:00 pm. The Narcotic Shift Count form for the 400 hall medication cart, dated 7/4/24 through 7/30/24, documents the 400 hall narcotic medications were not consistently counted, by two Nurses, at shift changes on: 7/5/24, 7/6/24, 7/9/24, and 7/10/24 through 7/30/24. The 400 hall narcotic medications were not counted at all on: 7/7/24, 7/11/24, 7/12/24, 7/16/24, 7/19/24, 7/20/24, 7/21/24, 7/25/24, 7/26/24, and 7/27/24. The facility was unable to provide a Disposition form for R1's Oxycodone. The Daily Assignment Sheets document V19, Former LPN, worked the following days on the 400 hall: 7/15/24, 7/17/24, 7/18/24, 7/23/24,7/24/24, 7/27/24, 7/29/24, 7/30/24, and 7/31/24. The pharmacy Packing Slip and Packing Slip Proof of Deliver forms, dated 7/1/24, documents 30 tablets of Oxycodone 5 mg were ordered and delivered for R1. The facility provided a Phone Reorder Form, dated 7/18/24 at 5:01 pm, documenting V19, Former LPN, attempted to reorder Oxycodone 5 mg for R1, which was not sent by the Pharmacy due to being too early and was previously delivered on 7/1/24. The facility provided two Medication Re-order Forms documenting that Oxycodone 5 mg was again re-ordered for R1 two times on 7/29/24 via fax (facsimile) machine, with unidentifiable signatures consisting of one straight line and one scribbled marking. The Daily Assignment Sheet, dated 7/29/24, documents V19, Former LPN, worked from 6:00 am to 6:00 pm. The pharmacy Packing Slip, dated 7/29/24, documents Oxycodone was ordered for R1 and the Packing Slip Proof of Delivery, dated 7/30/24, documents a card containing 30 Oxycodone 5 mg were delivered and signed for by V20, LPN, the third shift Nurse at 5:23 am. The facility's initial report to the State Agency, dated 8/2/24, documents the facility verified misappropriation of R1's narcotic Oxycodone on 8/2/24. DON notified of issues with pain medication, Oxycodone. The facility replaced the missing medication for the resident on 8/1/24. Through the course of the initial investigation, it was identified that there was a full card of Oxycodone that had been delivered on 7/30/24 that was not present in the narcotic drawer. The local Police were notified, and case (number) filed. Final to follow. The Facility investigation documents interviews were obtained on 8/2/24 from the Residents from the 400 hall and with V11, LPN/Licensed Practical Nurse, V19, Former LPN, V20, LPN, and V21, LPN. V11, LPN's, interview documents V11, LPN, dispensed one Oxycodone to R1 on 7/26/24 and recalls there being approximately a half of card (15) of Oxycodone remaining, and when she returned to work on 8/1/24 there was no Oxycodone available for R1. V19, Former LPN's, interview documents numerous attempts were made to contact V19 without success, and when V19 arrived at the facility for her 6:00 pm shift (V19) was immediately escorted to the conference room and advised she was being suspended for not following facility policy for narcotic count; reasonable suspicion of missing narcotics-Oxycodone. V19, Former LPN, denied knowing of anyone taking R1's medications from the facility. V19, Former LPN, stated, You all want to do a drug test, do it: when they low I re-order; resident (R1) asked for a pain med, look at the sheet; I be on my meds as (V2, DON) be on me to reorder; may have been a few on the card prompted me to reorder; don't remember calling in a refill; sometimes I count cards sometimes I don't; maybe I did fax. V20, LPN's, interview documents V21 stated she put away the narcotics when they came from pharmacy the morning of 7/30/24, did not leave anything unattended on the medication cart. V20, LPN, stated when she handed off the keys on 7/30/24 to V19, Former LPN, there were two cards of Norco (Hydrocodone) in the medication cart and no Oxycodone. V20, LPN, stated right after shift change, V19, Former LPN, left the facility to go get gas and left report on the medication cart. V21, LPN, denied seeing narcotics being taken out of the facility. This Report documents video surveillance verified: V20, LPN, placed narcotic medications into the 400 hall narcotic medication lock box on 7/30/24 prior to shift change; V19, Former LPN, with bizarre behaviors of shuffling through papers in a bin at the Nurses Station; V19 putting something under her jacket, between her lab coat and jacket; V19 going into the medication room at 5:18 am and coming out of medication room at 5:18 am, then going back into the medication room at 5:19 am and coming back out at 5:21 am, without taking anything in or out of the room; and V19, Former LPN, leaving the facility . The facility's investigation summary documents: The facility notified the provider of the issue and orders received to replace the missing medication/Oxycodone for (R1) on 8/1/24. (The facility) pharmacy notified and the facility assumed the charges for the missing medication so (R1) not responsible for the cost of replacement. (Local City) Police notified of incident report #24-16252. Nursing staff assigned to the cart interviewed. Schedule and delivery times verified, and nurse assigned during the time frame in question immediately suspended. Reeducation of narcotic policy /process started with licensed nursing staff. VP (Vice President) of Clinical Services assisted with the investigation. Recycle bins emptied; cart thoroughly checked and reconciled. R1 interviewed and denied current pain and stated she has received her pain meds when requested. Thirty resident interview and all state their medication needs have been met; they are receiving their pain meds to address pain, and all feel safe at the facility. The facility's Disposition documents: Through the course of the investigation the facility has substantiated missing medication/Oxycodone. The facility replaced the medication at no charge to the resident. The (City) Police Department notified and formal report made #24-16252; The officer stated there was not enough evidence to charge the suspended nurse member criminally. The suspended nurse was not reinstated; terminated for not following process and reasonable suspicion based on observations through the course of the investigation. The facility used this incident as an opportunity to improve its processes and provide additional reeducation on medication management/inventory control. The employee file for V19, Former LPN, includes a Disciplinary Action Form that was completed for V19, Former LPN, on 8/9/24. This form documents V19, Former LPN, was terminated on 8/9/24 for reasonable suspicion and not following facility policy and procedure for missing medications, medication administration, and narcotic counts.

Based on observation, record review, and interview, the facility failed to provide readily available grievance forms, and failed to post grievance/complaint procedures in a prominent location throughout the facility. This has the potential to affect all 89 residents residing in the facility. Findings include: The facilities CMS (Centers for Medicare and Medicaid services) Long Term Care Facility Application for Medicare and Medicaid Form 671, dated 8/20/24 and signed by V1/Administrator, documents 89 residents currently reside within the facility. The facility's Resident/Family Grievance Policy and Procedure, dated 5/6/24, documents, Policy Explanation and Compliance Guidelines: 1. Social Services Director has been designated as the Grievance Official. 3. Notices of resident's rights regarding grievances will be posted in prominent locations throughout the facility. 7. Information on how to file a grievance or complaint will be available to the resident. Information may include, but is not limited to: a. The contact information of the grievance official with whom a grievance can be filed, including his or her name, business address (mailing and email) and business phone number. C. The time frame that a resident may reasonably expect completion of the review of the grievance and a written decision regarding his or her grievance. On 8/21/24 at 10:20 am during resident council meeting, R19, R34, R45, R55, and R77 all stated they do not know where or how to file a grievance. On 8/22/2024 at 2:45 pm, a tour was conducted with V1/Administrator, asking V1 to show where the grievance forms are located for the residents and where prominent location(s) are for the grievance procedure in the building. V1 verified there was not a posted grievance procedure in any prominent locations around the building, and no grievance forms readily available for the residents that she is aware of.

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) worked at least eight hours daily. This failure has the potential to affect all 89 residents residing within the facility. Findings include: The facilities CMS (Centers for Medicare and Medicaid services) Long Term Care Facility Application for Medicare and Medicaid Form 671, dated 8/20/24 and signed by V1/Administrator, documents 89 residents currently reside within the facility. The facility's Nurse Schedule dated August 4 to August 31, 2024, documents the facility did not have the services of an RN at least eight hours a day on 8/4/24, 8/11/24, 8/17/24, and 8/18/24. On 8/23/24 at 12:00 pm, V1/Administrator verified they are required to have at least 8 hours of RN coverage daily, based on the staffing calculator the facility utilizes and the number of skilled residents. On 8/23/24 at 12:15 pm, V3/Director of Nursing stated, I am responsible for scheduling the nurses. V3 verified the nursing schedules were accurate and (the facility) did not have an RN for at least eight hours on 8/4/24, 8/11/24, 8/17/24, and 8/18/24.

Based on observation, interview, and record review, the facility failed to clip nails for one resident (R66), shave three residents (R40, R62, and R137), and shower one resident (R137) for four of four residents reviewed for ADLs (Activities of Daily Living) in the sample of 33. Findings include: The Certified Nursing Assistant/CNA Job Description, dated June 2021, documents the CNAs are to Assist residents with bath functions (i.e. (example) bed bath, tub or shower bath, etc.) as directed. Assist residents with nail care (i.e. clipping, trimming, and cleaning the finger/toenails). (Note: Does not include diabetic residents.) Shave male residents. Keep hair on female residents clean shaven (i.e. facial hair, under arms, on legs) as instructed. The Activities of Daily Living (ADLs) policy, dated 12/5/22, documents, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's ability in ADL's 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. 1. On 8/20/24 at 11:08 am, R62 was lying in bed. R62 complained he has not been getting his showers or being shaved. R62 had a long grey/white straggly beard and mustache. On 8/21/24 at 12:15 pm, R62 was lying in his bed. R62 still had not been shaved. R62 stated he has not been shaved in over three weeks, and likes to be shaved at least once a week. R62 stated, I have also not been getting my showers twice a week for the last month, nor given a bed bath on the days I don't get a shower. This has been going on for around a month. The staff say they don't have time or have enough staff to get to everyone. I do refuse my showers every once in a while, but not very often, and the staff does not offer me a bed bath instead. On 8/21/24 at 12:20 pm, V7/Licensed Practical Nurse verified R62's beard and mustache were long and straggly. V7 stated, (R62's) beard and mustache is never long like it is now. (R62) likes to be shaved frequently. I don't know why he hasn't been shaved. R62's Skin Monitoring/Shower Review Sheets documents the last shower R62 had was on 8/6/24. R62's electronic Bathing Report, dated 7/31/24 to 8/22/24, documents R62 prefers bathing on Tuesday and Friday Evenings. The report documents R62 was bathed on Friday 8/2, Tuesday 8/6, Tuesday 8/13, and Friday 8/16/24. 2. On 8/20/24 10:32 am , R137 was lying in bed with V9/R137's Family Member by the bedside. V9 asked if the facility was supposed to shave R137 because R137 had not been shaved since he admitted to the facility last week. R137 had a goatee and a mustache, but also had long white whiskers on the sides of his face that were not a part of the mustache or goatee. R137 looked like he had not been shaved in several days. R137 was asked if he wanted to be shaved, R137 stated, Yes, I asked. On 8/22/24 at 11:54 am, V3/Director of Nursing stated showers should be given twice a week, and the resident should be shaved on shower days and when requested. V3 also stated even if a resident has COVID-19 and is in isolation, they should still get a bed bath. On 8/22/24 at 12:06 am, V1/Administrator stated the showers should be documented in the chart, and a Skin Monitoring/Shower Review Sheet should be filled out each time to document skin issues. The Skin Monitoring/Shower Review Sheet should also be filled out if a bed bath if given. V1 verified 8/20/24 was the only Skin Monitoring/Shower Review Sheet for R137. 33973 3. On 8/20/24, at 10:10 am, R40 sat in a wheelchair outside of her room with long white chin whiskers. On 8/21/24, at 11:13 am, R40 sat in a wheelchair in the main Dining Room with long white chin whiskers. At this time, R40 stated, I usually pluck them out myself. It bothers me if someone notices them. R40 stated she would like for someone to pluck them out. On 8/22/24, at 1:00 pm, R40 sat in her room with long white chin whiskers. R40's current Care Plan documents: (R40) has an ADL (Activities of Daily Living) self-care performance deficit needs and participation may vary related to recurrent falls secondary to physical deconditioning. This focus has interventions including but not limited to: Resident currently requires assistance with ADLs: .Personal Hygiene: set up help. R40's Minimum Data Set/MDS assessment, dated 8/3/24, documents R40 is moderately cognitively impaired and requires set up or clean up assistance for Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). On 8/22/24, at 1:03 pm, V13, Certified Nursing Assistant/CNA, confirmed R40 needed to be shaved. V13 stated the CNAs usually shave residents on their shower days. At this time, V13 checked the shower schedule and stated R40 gets her showers on Wednesday second shift and Saturdays on day shift. V13 stated, (R40) should have been shaved last night. 4. On 8/20/24, at 10:59 am, R66 was in his room with very long fingernails. R66 stated, I don't like them this long. R66's nails are past the pad of his fingers, jagged and sharp. On 8/22/24, at 9:20 am, R66 was in bed with long jagged fingernails. R66's current Care Plan includes, (R66) has an ADL (Activities of Daily Living) self-care performance deficit .Resident presents with residual LUE (Left Upper Extremity) impairments for mobility, gross and fine motor control which limit functional use with interventions including but not limited to Resident currently requires assistance with ADLs - Personal hygiene - supervision. R66's Minimum Data Set/MDS Assessment, dated 6/1/24, documents R66 is cognitively intact and requires supervision or touching assistance for Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). On 8/22/24 at 9:26 am, V11, Licensed Practical Nurse/LPN, confirmed R66's nails are very long and they should have been clipped. V11 stated the CNAs (Certified Nursing Assistants) are supposed to clip them.

Based on observation, interview, and record review, the facility failed to place an oxygen sign outside resident bedrooms for two residents (R8 and R14), have a physician order for the cares and administration of oxygen for one resident (R8), and failed to change oxygen tubing/humidifier bottles per facility policy for one resident (R18) of three residents reviewed for oxygen therapy in the sample of 33. Findings Include: The Oxygen Policy, dated 5/10/21, documents, Oxygen is administered to residents who need it. Consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use. 8. Storage of oxygen shall be in accordance with the facility's Oxygen Safety Policy. 1. R14's Physician Order, dated 3/12/24, documents oxygen at 2 (two) liters per minute by nasal cannula every shift. R14's Care Plan documents R14 has altered respiratory status/difficulty breathing related to Sleep Apnea, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure. R14's oxygen setting is to be at 2 (two) liters per minute by nasal cannula. On 8/20/24 at 10:46 am, R14 was lying in bed wearing oxygen. There was no sign on R14's door to indicate oxygen was in use. On 8/21/24 at 2:45 pm, V3/Director of Nursing confirmed R14 did not have an oxygen sign located on his door or doorway. V3 also stated there should be an oxygen sign on all residents' rooms that have oxygen. 33973 2. On 8/20/24 at 10:22 am, R8 was resting in bed with oxygen infusing via nasal cannula. There was no signage for oxygen on R8's bedroom door. On 8/21/24, at 2:34 pm, R8 was in bed with oxygen infusing via nasal cannula. There is no signage on the door for oxygen in use. R8's current Physician Order Sheet/POS does not include any oxygen orders for use or cares of oxygen supplies. R8's August 2024 Medication Administration Record/MAR does not include any documentation of oxygen supplies/cares of. On 8/21/24, at 2:35 pm, V10, Licensed Practical Nurse/LPN, verified there is no oxygen in use signage on R8's door and there should be. On 8/23/24, at 1:12 pm, V3, Director of Nursing/DON, confirmed a physician order must be obtained for the usage and cares of oxygen. 49187 3. R18's current POS (Physician Order Sheet) documents a Physician order for Ipratropium-Albuterol Solution 0.5mg (milligrams)/2.5mg/3 milliliters one vial inhalation orally four times a day. On 8/21/24 at 11:34 am, R18's nebulizer tubing and nebulizer mask was lying on R18's nightstand, un-bagged and dated 8/13/24. V14/Licensed Practical Nurse confirmed R18's nebulizer tubing and mask were dated 8/13/24 and not bagged. V14 stated, Nebulizer tubing and mask should be changed at least once weekly (on Sunday evenings) and be bagged when not in use.

Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter bag and tubing were not touching the floor and the urinary bag was covered for one (R2) resident of two residents reviewed for urinary catheters in a sample of 33. Findings include: The facility's Catheter Care policy, revised 1/24/23, documents, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. R2's current Physician Order Sheet/POS documents R2 has a urinary catheter. On 8/20/24, at 10:24 am, R2 is in bed with an uncovered indwelling urinary catheter bag draining yellow urine. R2's catheter bag and tubing are touching the floor. On 8/20/24, at 12:44 pm, R2 was in bed with an indwelling urinary catheter bag and tubing touching the floor. On 8/20/24, at12:50 pm, V8, Certified Nursing Assistant/CNA, verified R2's catheter bag and tubing are on floor and the bag is without a privacy bag. V8 stated, It should have a privacy bag and be tied up so it's not touching the floor. On 8/23/24, at 1:03 pm, V3, Director of Nursing/DON, confirmed indwelling urinary catheter bags should be covered and off the floor, as well as the tubing.

Based on interview and record review, the facility failed to provide written notification of transfer to the hospital to a resident's representative (R8) and failed to notify the facility Ombudsman of resident Discharges/Transfers monthly for three residents (R8, R65, R84) of four reviewed for discharges in the sample of 33. Findings include: 1. R65's Social Service Note, dated 8/6/24 at 3:07 pm, documents R65 was accepted to a new facility. R65 will be picked up on 8/10/24 at 8:00 am. Please have R65 ready. R65's Face Sheet, printed 8/22/24, documents R65 was discharged on [DATE] to another facility. The Admission/Discharge Log, dated 7/10/24 to 8/10/24, does not document R65 was discharged to another facility. 2. R84's Nursing Note written by V12/Licensed Practical Nurse, dated 8/3/24 at 11:36 pm, documents R84 called V12 to his room, and R84 complained of shortness of breath and chest pains. R84's oxygen level was at 88 percent. R84 stated he wanted to go back to the hospital. R84 had just come back from the hospital at 10:30 am. R84 stated he would feel better if he went to the hospital. V12 called for transportation to take R84 to the hospital. R84's Nursing Note, dated 8/4/24 at 8:42 am, documents R84 is in the hospital. R84's Face Sheet, printed 8/22/24, documents R84 was discharged on [DATE] to the hospital. The Admission/Discharge Log for 7/10/24 to 8/10/24 does not document R84 was sent to the hospital. On 8/22/24 at 12:55 pm, V2/Administrator in Training stated, (V17/Social Services) was doing the Discharge Report incorrectly. The Ombudsman should have been notified of all residents that were discharged and why they discharged . (V17) will be trained so she knows how to do the report correctly. 33973 3. R8's Progress note, dated 7/18/24, documents R8 was transferred out to the hospital. The facility has no evidence of written notification of transfer to R8's Representative or notification to the Ombudsman. On 8/22/24, at 12:04pm, V2, Administrator in Training/AIT, produced the facility's Admission/Discharge To/From Report, dated 7/1/24 to 8/10/24, that is submitted to the Ombudsman monthly. V2 confirmed this report only documents the residents who went home and does not include R8 or any of the residents who went out to the hospital. On 8/23/24, at 11:30am, V2, AIT, confirmed there is no evidence of written notification of transfer on 7/18/24 for R8's hospitalization .

Based on observation, interview, and record review, the facility failed to ensure a resident on a mechanically altered diet was provided supervision at meals as ordered for one (R2) of 18 residents reviewed for meal supervision in a sample of 33. Findings include: The facility's Certified Nursing Assistant Job Description, dated June 2021, documents, Food Service Functions: Serve food trays. Assist with feeding as indicated (i.e. cutting foods, feeding, assist in dining room supervision, etc.). The facility's Comprehensive Care Plans policy, revised 1/25/23, documents, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .Policy Explanation and Compliance Guidelines: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. R2's current Physician Order Sheet/POS documents R2 is on a Regular diet, dysphagia puree texture, honey consistency, and has diagnoses including but not limited to Dementia, Dysphagia, Oropharyngeal Phase, Schizophrenia, and Bipolar Disorder. R2's Minimum Data Set/MDS Assessment, dated 7/24/24, documents R2 is severely cognitively impaired and on a mechanically altered diet. R2's current Care Plan documents Current diet: Regular diet, Regular texture, Nectar Thick Liquids. NO Straws with interventions including but not limited to: Feed self, needs food set up and Supervision with meals. R2's Speech Therapy SLP (Speech Language Pathology) Evaluation and Plan of Treatment, Certification period 7/29/24 - 9/7/24 and start of care date 7/29/24, documents, Current Referral: Reason for Referral/Current Illness: Patient is a [AGE] year old male presenting to speech therapy for an evaluation in swallow function due to recent hospitalization for aspiration pneumonia. Patient received speech therapy services during hospitalization and was recommended a pureed solid/honey thick liquids .Swallow Strategies: Compensatory Strategies/Positions: Upright position for all PO (by mouth) intake, aspiration precautions, supervision with all meals. On 8/20/24, at 12:44 pm, R2 was lying in bed with his head of bed elevated. V8, Certified Nursing Assistant/CNA, placed R2's meal tray in front of him on the bedside table. V8 stated, He had a recent change and is on puree now. I kind of just watch him because of his change. At 12:47 pm, V8 left R2 to eat alone in his room. On 8/22/24, at 3:10 pm, V3, Director of Nursing/ DON, stated, (R2) is always at risk for choking because he's on a modified diet and has trouble ridding of his own secretions. If his care plan and speech therapy say he requires meal supervision, then yes he should be supervised. On 8/23/24, at 9:50 am, V1, Administrator, stated, We recognize the importance of residents on modified diets or at risk for choking and expect for them to be supervised in their room or come out to the assisted dining room.

Based on interview and record review, the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital for one of three residents (R8) reviewed for bed holds in the sample of 33. Findings Include: R8's clinical record documents R8 was hospitalized on [DATE]. R8's clinical record does not contain documentation of written notice of the facility bed hold policy. On 8/22/24, at 3:15pm, V1, Administrator, was unable to produce any documentation the facility's bed hold policy was provided to R8 or R8's representative.

Based on observation, interview, and record review, the facility failed to ensure a resident call device was within reach for one resident (R66) of 18 residents reviewed for call devices in a sample of 33. Findings include: The facility's Call Lights: Accessibility and Timely Response policy, revised 12/6/23, documents, Policy: 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: 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. On 8/20/24, at 10:59am, R66 sat in a wheelchair in his room beside his bed. R66's padded round call device was on the floor near the head of R66's bed and out of his reach. R66 tried to lift up the call device cord with his cane and bring it closer, but R66 couldn't lift it up. On 8/20/24, at 11:00am, V8, Certified Nursing Assistant/CNA, came into R66's room and verified R66's call device is on the floor and out of R66's reach. V8 verified it should be in his reach while sitting in his room.

Based on interview and record review, the facility failed to provide adequate supervision, failed to develop a care plan and implement interventions for residents at risk for wandering/elopement, and failed to ensure the front door was alarmed for one of three residents (R1) reviewed for elopement risk in the sample of 17. These failures resulted in a cognitively impaired resident (R1) with a known history of wandering, exiting the facility without staff knowledge for 40 minutes until the resident tried to reenter the facility, falling in the mud, and complaining of head and back pain. The facility is located close to a four-lane road that has high activity of traffic. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 5-7-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and quality assurance program. Findings include: The Elopements and Wandering Residents policy, dated 3/1/2020, documents, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and received care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner.3. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and managing residents at risk for elopement or unsafe wandering a. residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person centered care plan. c. Interventions to increase staff awareness of the residence risk, modify their residence behavior, or to minimize risks associated with hazards will be added to the residence care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. R1's Face Sheet documents R1 was admitted to the facility on [DATE], with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Chronic Respiratory Failure with Hypoxia, Other Sequel of Cerebral Infarction, Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage One Through Stage Four Chronic Kidney Disease, or Unspecified Chronic Kidney Disease, Localization- Related (Focal) (Partial) Symptomatic Epilepsy and Epileptic Syndrome with Complex Partial Seizures, not Intractable, With Status Epileptics, Vascular Dementia, Mild, with Agitation, and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. R1's MDS (Minimum Data Set), dated 2/15/24, documents a BIMS (Brief Interview for Mental Status) Score of 7/15, indicating (severe cognitive impairment). R1 uses a wheelchair. R1 does not wear an alarm to prevent elopement. R1's Care Plan, dated 10/11/23, documents, (R1) is an elopement risk/wanderer. Disoriented to place. R1's Care Plan, dated 10/11/23, documents R1 has a behavior problem related to disrobing in public places around others, combative with cares, yelling profanities and additional co-morbidities. The intervention dated 10/12/23 documents R1 was placed on 1:1 observation for safety and exit seeking behaviors. Please monitor at a safe distance. If R1 pushes past staff and out a door, stay with R1 and call for help. R1's Care Plan, dated 10/16/23, documents, (R1) is an elopement risk/wanderer. Disoriented to place. R1's Care Plan, dated 3/26/24, documents, (R1) is an elopement risk and a wanderer. (R1) has impaired cognition and requires assistance with decision making. (R1) is frequently noted to make statements wanting to go home and is not always easily redirected. The facility is working on safer placement in a different facility to reduce risk of elopement. The Final Incident Report for R1 sent to the State Agency (not dated) documents nursing staff last saw R1 a little before 8:00 PM,on 3/16/24. During the investigation, it was determined R1 went out the facility front door at approximately 7:50 PM. R1 was assisted back into the facility at approximately 8:39 PM. R1 expressed he fell while he was outside, R1 was sent to the emergency room for evaluation and treatment. Due to R1's impaired cognition, R1 was not able to express why he decided to go outside. However, when R1 was assisted back into the facility, it was noted his jeans were undone and had fallen around R1's ankles. It is plausible R1 was outside looking for a restroom due to his cognitive needs. R1's emergency room Notes, dated 3/16/24 at 10:11 PM, documents, (R1) presents from (the facility) where he had an unwitnessed fall outside. EMS (Emergency Medical Staff) states (R1) was complaining of some back pain but otherwise no other concerns or further information. (R1) states he had some chest pain and shortness of breath as well as lightheadedness prior to falling. Unsure if (R1) lost consciousness but thinks he may have hit his head. Denies any neck pain, vomiting, abdominal pain. Does have some pain in his bilateral knees. Skin assessment, Abrasions, swelling, and mild TTP (thrombotic thrombocytopenic purpura) bilateral knees. The facility is located with a busy road in front of the facility and within a quarter mile of a high traffic four-lane intersection. R1's Nursing Note, dated 3/12/24 at 5:57 AM, documents R1 appears to be confused throughout the night. Appears to be aggressive and very restless throughout the night. Stayed up all night asking staff about keys to his car and wanting to go home. Continued to call family throughout the night attempting to see if anyone can pick him up. Assisted resident to his room to rest at this time. R1's Nursing Note written by V15, Licensed Practical Nurse/LPN, dated 3/15/24 at 1:30 AM, documents V15 observed R1 exiting out of 100 hall doors at this time. R1 stated he was trying to go home and was going outside to find his car. 15 min checks were initiated at this time. V15 attempted to call R1's Power of Attorney and no response. R1 was redirected into bed and R1 is resting at this time. R1's Nursing Note, dated 3/15/24 at 5:41 AM, documents R1 is resting in bed at this time. Displaying behaviors throughout the entire night. R1 continued to come up with reasons to leave the facility so he can go outside. Redirected R1 back to his bedroom to get some rest. 15 min checks continue at this time. R1's Nursing Note written by V1, Administrator in Training/AIT, as a Late Entry, dated 3/16/24 at 9:00 PM,documents R1 went out the facility front door at approximately 8:00 PM, and walked to the left of the facility, staying on facility grounds. Resident was assisted back into the facility at approximately 8:39 PM. Resident was dressed appropriately for the weather, and was wearing shoes, socks, jeans, sweatshirt, jacket, and a hat. Resident was unable to express why he went outside. Upon assessment, R1 complained of head and back pain, R1 was able to move all extremities per usual, however, R1 was sent to the emergency room /ER for evaluation based on head and back pain. R1's Nursing Note written by V1, AIT, as a Late Entry, dated 3/16/24 at 9:05 PM, documents, Upon assessment, it is plausible that the patient went outside to use the restroom evidenced by his pants down at his ankles. R1's Nursing Note written by V15, LPN, dated 3/16/24 at 9:00 PM, documents, It was reported to this nurse that (R1) was outside of the facility knocking on 400 hall door. This nurse observed (R1) in a wheelchair coming up the hallway with a staff member. Upon assessment, (R1) appeared to be covered with mud to the front and back of his clothing and shoes. Last seen (R1) around 8:00 PM when his medications were administered to him. Resident stated he was trying to go home, so he left the facility and he fell so he came back. Also, (R1) stated he hit his head and hurt his back. R1's Wandering/Elopement Risk Assessment, dated 3/15/24 at 1:39 AM, documents R1 is a High Risk for Wandering. R1 is disoriented, has had recent medication changes, has dementia with psychosis, positions self at exit doors, and states I want to go home. R1 last elopement attempt was 3/15/24. R1's Fall Assessment, dated 4/5/24 at 3:00 PM, documents R1 is a high risk for fall scoring a 50 on the assessment. R1 has an impaired gait and overestimates or forgets limits. On 5/2/24 at 10:00 AM, V18, Certified Nursing Assistant/CNA, was sitting in R1's room providing 1:1 supervision. V18 stated she was not here the day that R1 fell but she heard he had come back from a home visit. I know he does get more worked up when he's been out with family. He doesn't remember how he fell when he was out there. V19 stated she knows he went to the ER, but he does not have any fractures. The resident is receiving 1:1 supervision 24/7 and that it has been that way for a while. He had a 1:1 before, but he started doing a lot better and was ambulating and conversating with staff. I was off a few days and then when I came back, he was a 1:1. I work the 6-2:30 PM shift and I work all over the facility. V18 stated he does not have an ankle band/electronic monitoring device, and thinks they don't use those here. V18 stated she tries to keep an eye on him even when he is sleeping. I may go out and help answer a light or go to the bathroom real quick, but I head back. He is mostly using a 1:1 for falls, elopement, and aggression. He would say he wants to go where he used to live or wants to go to his car and exit-seek. On 5/2/24 at 10:25 AM, V15/ Licensed Practical Nurse/LPN, stated, I was there the day that (R1) eloped. My nurses note on that day are correct. My main goal once I saw (R1) was to be sure he was ok and get (R1) sent out to the hospital. I then notified (V1/AIT). I don't remember (V1) coming in; I didn't see (V1) that night. (R1) is confused and (R1) does this a lot. It's normal for (R1) to be so confused and want to leave the building all the time. The nurse on the other side was the one who was pushing (R1) up the hallway. That might've been (V16, LPN) but I can't remember. I initiated the 15-minute checks and I think that stays in place for 72 hours. I am not sure what exact facility policy is, but I initiated them the day before the elopement happened. When I have (R1) and am his nurse, then I am the one who is responsible for (R1's) 15-minute checks. I was (R1's) nurse that night (3/16/24 elopement), but I was the only nurse on 100 and 200 hall due to a call off, so I would've required a CNA to be completing those checks, and I am not sure who I was working with. I know I was very busy with all the residents I had that night. I think that night it would have been a CNA doing the 15-minute checks. Those would be charted on a paper form. On 5/2/24 at 1:00 PM, V17/Regional Nurse Consultant, stated, (R1) was on one-on-one monitoring, but after a while that starts to make him more agitated, so we have to try other things. I know after this last incident of elopement, they decided that the 15-minute checks would not be enough, and he needed one on one supervision at all times. That's what he has now. On 5/2/24 at 1:05 PM, V1/Administrator in Training/AIT, stated I will look to see if we have any 15-minute checks documented on (R1). They should be documented. The front doors are supposed to lock at night. I am not sure how (R1) actually got out of the building. Interviews were conducted with the nurse working. (No other documentation was provided to show other staff were interviewed or the origin of exiting was ever discovered by V1) On 5/2/24 at 1:50 PM, V1/AIT, stated, Prior to (3/16/24), we were all (all staff) completing close observations of (R1) and making sure he was safe. There was no formal sheet or area that they had to document these checks. We know based on the video surveillance that he exited the front doors at 7:50 PM. Normally, we should have a receptionist at the front door until 8:00 PM and the doors lock/alarm after 8:00 PM. I don't know if the receptionist was not there/ left early, or why there wasn't anyone at the front to keep him from going out. On 5/3/24 at 11:46 AM, V20/Nurse Practitioner, stated R1 was being treated by Psychiatry for his behaviors. V20 was notified when R1 eloped from the facility, and R1 was sent to the emergency room due to complaints of head and back pain. On 5/3/24 at 2:55 PM, V1/AIT, stated the day R1 left the building (3/16/24) he went out the front door at 7:50 PM. V1 knows this from watching the video of R1 leaving. There is usually staff at the front desk until 8:00 PM, but that day (V26/Receptionist) left at 7:00 PM. V26 should have locked the door when she left the building. If the door is locked and opened it will set off an alarm. R1 did not have an alarm on his ankle. The facility does not put alarms on residents. On 5/4/24 at 9:39 PM, V22, LPN, stated she knows of one resident being an elopement risk and that is R1. V22 is not aware of there being a list of residents that are an elopement risk. V22 was asked how she knows if a resident is an elopement risk, and V22 stated the information is relayed in shift report. On 5/4/24 at 7:20 PM, V26, Receptionist, stated when she leaves in the evening, she is supposed to lock both of the front doors and set the alarm. V26 doesn't know where to find the policy about locking and alarming the doors. When V26 was trained for her job, she was just told to do it. V26 also stated she heard from staff that R1 eloped, but was not at the facility when it happened. V26 is not aware of any other residents that are elopement risks, and does not know where to find that information. On 5/5/24 at 11:58 AM, V1/AIT, stated, (V26) left at 7:00 PM on 3/16/24, and did not lock or alarm the front doors. Had (V26) locked the door, (R1) would not have got out. V1 does not know if there is a policy about locking the door or if it is in the job description. V1 did not ask V26 why the door was not locked when V26 left on 3/16/24. The Immediate Jeopardy began on 3/16/24 at 7:50 PM, when the facility failed to prevent R1 from leaving the facility unattended and being gone for 40 minutes. V1 (Administrator in Training) was notified of the Immediate Jeopardy on 5/6/24 at 1:27 PM. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Reassessment of all residents for wander risk assessment. Completed 5/7/24 by V27, Assistant Director of Nursing 2. At risk residents for wandering/elopement had care plans reviewed and updated with safety measures and interventions. Completed 5/7/24 by V28, Care Plan Coordinator 3. Updated safety measures and interventions were added to Kardex . Completed 5/7/24 by V28, Care Plan Coordinator 4. Re-education on elopement policy and procedure as well as Identifying the signs and symptoms of wandering. Completed 5/7/24 by V2, Director of Nursing 5. Re-educate on the facility policy and procedure regarding elopement. Completed 5/7/24 by V2, Director of Nursing 6. Document Performance Improvement Plan/PIP implementation, PIP progress, and Quality Assurance Agency/QAA Committee Meeting Minutes where PIP is discussed. Completed 5/7/24 by V2, Director of Nursing

Based on interview and record review, the facility failed to obtain scheduled medications from the pharmacy for two of three residents (R2 and R9) reviewed for pharmacy services in the sample of 17. This failure resulted in R9 abruptly stopping and missing his scheduled seizure medication for a minimum of two days resulting in R9 experiencing weakness, seizure, and a fall breaking three ribs. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 5-7-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and quality assurance program. Findings include: The facility's Medication Errors policy, dated 9/28/23, documents, It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Significant Medication Error means one which causes the resident discomfort or jeopardizes his/her health and safety. The facility shall ensure medications will be administered according to the physician's orders. The facility's Medication Reordering policy, dated 12/21/22, documents, It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 1. R9's MDS (Minimum Data Set), dated 4/11/24, documents a BIMS (Brief Interview for Mental Status) Score of 8/15, indicating (moderate cognitive impairment). R9's Care Plan, dated 3/20/22, documents R9 is at risk for seizure activity and/or injury related to seizures as well as for complications associated with psychotropic medication used for treatment management of seizure disorder. Care Plan update documents R9 has a risk for limited mobility related to a recent fall on 4/10/24, with three left posterior rib fractures. The Final Report for R9 sent to the State Agency (not dated) documents, (R9) informed staff that he fell multiple times in his room on 4/10/24. (R9) sent to hospital due to complaints of pain related to self-reported fall. (R9) returned from hospital ED (Emergency Department) on 4/10/24 with unremarkable X-ray. Informed 4/19/24 that (R9) had minimal displaced fracture of 8th, 9th, 10th posterior left ribs. R9 is a [AGE] year-old who admitted on [DATE] with diagnosis of Generalized Idiopathic Epilepsy, Disorders of Psychological Development, Frontal Lobe and Executive Function Deficit, Muscle Weakness/Abnormalities of Gait and Mobility. Bims (Brief Interview for Mental Status)-8. R9 self-reported multiple falls in his room due to seizure activity. R9 is ambulatory without assistive devices and can get self-up off the floor. On 4/10/24 (R9) notified staff that he wanted to go to the hospital. R9 stated, I fell five times and I need to go to ED (Emergency Department). R9's Medication Administration Record, dated 4/1/24 - 4/30/24, documents R9 has an order for Keppra (Seizure medication) 1000 milligrams, two tablets to be given at 8:00 AM and 8:00 PM daily for seizures. This same record does not document R9 was given any Keppra on 4/9/24 or 4/10/24. Those dates are coded to see the Progress Notes for why Keppra 1000 mg (give 2 tablets twice a day) was not given to R9 on 4/9/24 at 8:00 AM, 8:00 PM, and 4/10/24 at 8:00 AM. On 4/10/24 at 8:00 PM, it is documented R9 was in the hospital. R9's Progress Note written by V21/LPN, dated 4/9/24 at 7:10 AM, documents to give Keppra 1000 mg/milligram tablet. Give 2 (two) tablet by mouth two times a day related to Epilepsy, Unspecified Intractable, Without Status Epilepticus. The medication is on order. R9's Progress Note written by V22/LPN, dated 4/9/24 at 9:29 PM, documents to give Keppra 1000 mg/milligram tablet. Give 2 (two) tablet by mouth two times a day related to Epilepsy, Unspecified Intractable, Without Status Epilepticus. The medication is on order. R9's Progress Note written by V12/LPN, dated 4/10/24 at 3:16 PM, documents to give Keppra 1000 mg/milligram tablet. Give 2 (two) tablet by mouth two times a day related to Epilepsy, Unspecified Intractable, Without Status Epilepticus. The medication is not available. R9's Nursing Note, dated 4/10/24 at 5:46 PM, documents R9 put on his call light and stated, I keep falling and I need to go to the emergency room . The Certified Nursing Assistant/CNA notified V12/Licensed Practical Nurse. V12 asked R9 what he needed. R9 stated, I need to go to the emergency room . I have fallen multiple times. All falls were unwitnessed by staff. R9 insisted on going to the ER. R9 denies hitting his head and no pain reported. R9's Emergency Department/ED note, dated 4/10/24 at 6:33 PM, documents, (R9) came from the facility for evaluation of right wrist and left hip pain status post two unwitnessed ground level falls. Emergency Medical Staff/EMS reports (R9) has not had Keppra in four to five days. EMS reports (R9) reported believing he had seizures with each fall. EMS reports a 30 second tonic-clonic seizure in route to the ED. (R9) reports back pain currently. (R9) is alert to place and situation, disoriented to time and self. EMS reports (R9) is disoriented to self at baseline. R9's Emergency Department Note, dated 4/10/24 at 7:23 PM, documents, (R9) presents with Seizure and a Fall. The history is provided by the patient. The patient is a [AGE] year-old male with a past medical history of seizures on Keppra, moderate developmental delay, presenting with a chief complaint of seizure and fall. (R9) reports he was living at the facility, and he has not received his anti-epileptic medication for an unknown amount of time. He states they have not been able to fill it due to issues with the pharmacy. (R9) states he did receive his medication today. States he had two seizure episodes without bowel or bladder incontinence or tongue biting. He does not remember the episodes. He knows he did fall but is unsure if he hit his head. Currently his only pain is in his right wrist, left hip, and left ribs. Otherwise, he has no complaints chest pain, shortness of breath, numbness, weakness, tingling, headaches, vision changes and no recent illnesses. R9's Emergency Department/ED Report, dated 4/10/24, documents R9's Keppra level as expected was low. R9's Keppra level was less than 2.0 per lab report. R9 was given a loading dose of 2 Grams intravenous Keppra. R9's Emergency Department/ED Report, dated 4/10/24, documents R9 arrived by ambulance to the ED on 4/10/24 at 6:20 PM. Labs were done at 7:01 PM. Keppra 1000 milligrams was given at 8:27 PM. At 8:28 PM an X-ray of R9's left hip, left ribs, and right wrist were done. At 8:37 PM R9 received 1000 milligrams of Keppra. R9 was discharged at 11:30 PM back to the facility. R9's Nursing Note, dated 4/10/24 at 11:50 PM, documents R9 is back to the facility from ER visit. R9 is alert and oriented with complaint of left lower back pain. R9's X-ray Impression, dated 4/11/24 at 1:20 PM, documents, Acute Left Rib Fractures. R9's Left Rib X-ray Report, dated 4/11/24, documents, Left Ribs: Acute, mildly displaced fractures of the 8th, 9th, and 10th posterior left ribs. R9's Fall Interdisciplinary Team Note, dated 4/11/24 at 8:31 AM, documents R9 self-reported that he fell multiple times on 4/10/24. R9 was ambulating without assistance and fell hitting a garbage can. R9 stated, I fell multiple times in my room because I can't concentrate. R9 was sent to the Emergency Department. R9's Nursing Note, dated 4/19/23 at 3:37 AM, documents R9 has been restless and in pain. R9 stated he has two cracked ribs keeping him from sleeping and causing him pain. R9's Nursing Note, dated 4/19/24 at 2:13 PM, documents V20, Nurse Practitioner, was notified of R9's rib fractures. The Pharmacy Records, dated 5/4/24 at 12:19 PM, documents Keppra was removed from the E-box for R9 by V5/LPN on 4/6/24 at 8:15 AM, and V22/LPN on 4/8/24 at 10:49 PM. The E-box did not have any more Keppra available. According to the Epilepsy Foundation typically anti-epileptic drugs take up to a couple of days to be completely out of your body. Drugs.com says the half-life for Keppra is 44 hours. On 5/2/24 at 10:14 AM, R9 confirmed he had a recent fall and broke ribs. R9 states before the fall, he was not getting his Keppra because they (the facility) were out for 5 days and I kept telling them this was going to happen. I fell forward in my room and got myself up and then I went over by my bed and fell backwards. That was a fall over my trash can, and I broke two ribs. I was alert but I know I had a seizure. That's what happens when I don't get my medicine. On 5/2/24 at 10:20 AM, R10 (R9's roommate) stated he witnessed R9's fall in their room. R9 fell and then got up and went over by his bed then fell again backwards. On 5/3/24 at 11:52 AM, V20/Nurse Practitioner, stated, I think (R9) did have a seizure that caused him to fall ,or (R9) was weak from withdrawals of not getting the Keppra. I believe the labs done at the hospital (R9's) level was close to zero in his system when (R9) fell . V20 also stated from the x-ray, it was determined R9 had a minimal fracture of the 8th, 9th, and 10th rib. On 5/3/24 at 3:30 PM, V1, Administrator in Training/AIT, stated, We (the facility) get notified when medications are delivered. There were problems with the change over from one pharmacy to the other delaying some of the medication. On 5/3/24 at 3:15 PM, V2, Director of Nursing/DON, stated 4/8/24 was her first day working at the facility. The facility had changed pharmacy's on 4/1/24 and there were issues. V2 stated, (R9) told me on the 9th (4/9/24) that he was not getting his Keppra. (R9) was upset and I told (R9) to calm down, and I would take care of it. I did the best I could. V2 called the pharmacy about R9's Keppra, and was told the refill was too soon. V2 requested the medication be sent, but the pharmacy did not send it. On 4/9/24, V2 talked to V11, Pharmacy Customer Service, explaining the facility needed medication for R9. V2 was asked if the doctor could have been contacted to write a script to get the medication at the local pharmacy. V2 stated, I suppose I could have. Who would think the pharmacy would not send the medication. I don't know if they did not believe me or what. (V17/Regional Nurse Consultant) called the pharmacy, and it (Keppra) was finally sent to the facility on [DATE]. V2 confirmed R9 missed at least three doses of his seizure medication on 4/9 and 4/10//24. On 5/3/24 at 6:43 PM, V11, Pharmacy Customer Service, stated R9 had an order for Keppra 1000 mg tablets. On 3/19/24, the order was filled by another pharmacy for a 30-day supply. On 4/1/24, a new pharmacy was the supplier. On 4/5 and 4/7/24, there was a request from the facility to refill R9's Keppra. The facility was told it was too soon to refill. The facility should have had plenty of medication on hand. On 4/8/24, the pharmacy got a call for the Keppra and sent a notice by Electronic mail/Email that it was too soon to refill the order. The pharmacy did not get a response to the Email. On 4/10/24, V2/DON called that they (the facility) needed the medication STAT (immediately). The Keppra was delivered to the facility at 3:52 PM on 4/10/24. V11 also stated the E-box had eight 250 mg tabs of Keppra. There were four tabs removed on 4/6 for R9 and four tabs removed on 4/8/24 for R9. On 5/4/24 at 6:52 AM, V21, Licensed Practical Nurse/LPN stated there was a day (4/9/24) R9 did not have Keppra available, and there was none in the E-box. V21 reordered the medication through the computer. On 5/4/24 at 9:39 PM, V22, LPN, stated she remembers running out of Keppra for R9 and needing to take it from the E-box, but there was none in the E-box. 2. R2's current computerized medical record, documents R2 was admitted to the facility on [DATE] with a diagnosis of Opioid Dependency, Essential (Primary) Hypertension, Suicidal Ideation's, Major Depressive Disorder, Cerebral Infarction due to Embolism of Right Middle Cerebral Artery, Other Specified Disorders of Brain, Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms, and Vascular Dementia with Other Behavioral Disturbance. R2's MDS (Minimum Data Set), dated 3/12/24, documents a BIMS (Brief Interview for Mental Status) Score of 12/15, indicating (mild cognitive impairment). R2's Medication Administration Record, dated 4/1/24-4/30/24, documents R2 was to get Norco 5-325 mg tablet, give 1 tablet by mouth three times a day for pain. R2 did not get the Norco as scheduled on 4/1 and 4/2/24. R2's Orders Administration Note, dated 4/1/24 at 8:58 AM, documents an order for Norco 5-325 mg tablet, give 1 tablet by mouth three times a day for pain. Awaiting signed script. R2's Orders Administration Note, dated 4/1/24 at 12:09 PM, documents an order for Norco 5-325 mg tablet, give 1 tablet by mouth three times a day for pain. Need signed script. R2's Orders Administration Note, dated 4/1/24 at 8:52 PM, documents an order for Norco 5-325 mg tablet, give 1 tablet by mouth three times a day for pain. Not available on order. R2's Orders Administration Note, dated 4/2/24 at 7:29 AM, documents an order for Norco 5-325 mg tablet, give 1 tablet by mouth three times a day for pain. Awaiting signed script. R2's Orders Administration Note, dated 4/2/24 at 12:39 AM, documents an order for Norco 5-325 mg tablet, give 1 tablet by mouth three times a day for pain. New pharmacy new script needed. R2's Orders Administration Note, dated 4/2/24 at 8:21 PM, documents an order for Norco 5-325 mg tablet, give 1 tablet by mouth three times a day for pain. Not available on order. On 5/3/24 at 11:38 AM, V20, Nurse Practitioner, stated, I would believe that (R2) did not get her pain medication for a couple of days. There has been a terrible problem with the new pharmacy not getting the medications filled like they should. The facility does have a backup box that the medication should have been pulled from. The Immediate Jeopardy began on 4/10/24 at 5:46 PM, when R9 fell breaking three ribs from the facility failing to give R9 his seizure medication for at least two days. V1 (Administrator in Training) was notified of the Immediate Jeopardy on 5/6/24 at 1:35 PM. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Audit of all resident's receiving seizure medications. Completed 5/7/24 by Pharmacy. 2. Resident's receiving seizure medications the medication is in house and being administered per the physician order. Completed 5/7/24 by V2, Director of Nursing 3. All nursing staff have access to the backup medication machine. Completed 5/7/24 by V2, Director of Nursing 4. Re-education on medication administration and contacting physician and pharmacy if medication is not available. Completed 5/7/24 by V2, Director of Nursing 5. Document Performance Improvement Plan/PIP implementation, PIP progress, and Quality Assurance Agency/QAA Committee Meeting Minutes where PIP is discussed. Completed 5/7/24 by V1, Administrator in Training

Based on observation, interview, and record review, the facility failed to assess a heel wound, failed to provide treatment orders, and failed to develop a wound care plan for one resident (R5) with a pressure-related heel wound of three residents reviewed for wounds in the sample of seven residents. This failure resulted in an unstageable left heel wound identified on 2/3/24 and without physician treatment orders until 2/14/24. Findings include: Facility Policy/Wound Treatment Management, dated 9/19/23, documents: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. Dressings/treatments will be monitored daily to ensure they remain clean, dry and intact with documentation in place to ensure compliance. Treatments will be documented on the TAR (Treatment Administration Record). 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. Current Physician's Order Summary Report indicates R5 was readmitted to the facility on [DATE] and has diagnoses that include Diabetes Mellitus, Morbid Severe Obesity, Paraplegia, Neuromuscular Dysfunction of Bladder with Indwelling Urinary Catheter. On 2/13/24 at 1:15pm, R5 stated he has a wound on his heel from not being repositioned by staff. R5 stated he is unable to move his legs and needs to be positioned by staff. R5 stated his heel wound is due to unrelieved pressure. Progress Note, dated 2/3/24 at 4:19pm, indicates R5 was found to have a new area on left heel. Note indicates, Contacted wound nurse and new treatment and preventative measures added for new area. (Nursing Order) to apply (iodine) and cover with bandage. Progress Note, dated 2/3/24 at 8:40pm, indicates R5 was sent to the hospital for change in condition. Progress Note, dated 2/8/24 at 1:45pm, indicates R5 returned from the hospital at that time. Wound Log indicates R5's left heel wound was documented on the log on 2/7/24 as an Acquired Diabetic wound measuring 3.0cm (centimeter) x 4.0cm with depth Unable To Determine. Admit/Readmit Screener, dated 2/8/24 at 10:06pm, indicates R5's skin was assessed on readmit and the following areas were identified: Abdominal wound, Right lower abdomen and Left medial leg. Readmit Screening did not identify or document R5's left heel wound. On 2/14/24 at 10:45am, V3, ADON (Assistant Director of Nursing)/Wound Nurse, provided dressing changes to R5's wounds. Dressings removed from R5's abdominal wounds and left heel wounds were all dated 2/12/24. V3 confirmed the dressings were not changed on 2/13/24 as ordered. R5's left heel was noted to have an inner, posterior wound covering 75% of R5's entire heel. Wound bed was mostly dry and dark brown/black in color. Wound Physician Note, dated 2/14/23 at 3:56pm, indicates R5 has a full thickness diabetic wound of the left posterior heel measuring 2.2cm (centimeter) x 1.5cm, depth not measurable due to presence of non-viable tissue and necrosis. Wound note indicates R5's heel wound is 100% covered with thick adherent black necrotic tissue (eschar). Note indicates Recommendations are to apply (iodine) once daily for 30 days; float heels in bed, offload wound, reposition per facility protocol and apply a (pressure relieving boot). Current Physician Orders, skin assessments and current TAR do not include any treatment orders, interventions, or assessments for R5's left heel wound until 2/14/24. R5's Care Plan was not revised to include left heel wound or interventions. On 2/14/24 at 2:pm, V3, Wound/Treatment Nurse, confirmed there was no assessment of R5's heel wound until 2/14/24, and stated the nurse who found R5's heel wound on 2/3/24 should have assessed the wound, notified the physician, and received treatment orders. V3 also stated R5's heel wound should have been included in the readmission skin assessment on 2/8/24.

Based on interview and record review, the facility failed to administer pain medication for one resident (R88) of three reviewed for closed records in a sample of 37. This failure resulted in resident suffering severe pain and transferring to the hospital for pain control. Findings include: The facility's Pain Screening and Management policy, revised 3-26-21, documents, Standard: It will be the standard of this facility to screen residents and attempt to provide effective pain and comfort management .4. Administer pain medications according to physician's orders and resident request for 'PRN' (as needed) medications. R88's current Physician Order Sheet/POS documents R88 was admitted on [DATE], with diagnoses including Orthopedic Aftercare, Osteoarthritis left knee, Fibromyalgia, and Morbid Obesity. This same POS includes orders for Acetaminophen 500mg (milligrams) two tabs every eight hours as needed for mild pain (dated 3-20-23), Fentanyl patch 72 hour 100 mcg/hr (micrograms per hour) apply one patch transdermally every 72 hours for pain and remove per schedule (dated 3-16-23), and Morphine Sulfate ER (Extended Release) oral tablet one by mouth every eight hours as needed for pain total left knee replacement (dated 3-16-23), and Tramadol HCL (Hydrochloride) 50mg tablet one by mouth every six hours as needed for pain left total knee replacement (dated 3-16-23). R88's current Care Plan documents R88 receives opiate medications related to: Pain not managed by alternate interventions, recent left total knee arthroplasty, bilateral knee and foot pain. Interventions include to administer medication as prescribed by the physician. R88's March 2023 Medication Administration Record/MAR documents the following: R88 had a Fentanyl 72 hour patch placed on 3-16-23 at 9:05pm. R88 received Tramadol 50mg on 3-19-23 at 4:02pm for pain level of 10/10 and again on 3-20-23 at 1:53am for a pain level of 10/10; both doses were documented as ineffective. On 3-20-23, at 5:28am, Acetaminophen 1000mg was given for 6/10 pain and documented as ineffective. This MAR documents that R88's Fentanyl patch was not replaced at the 72 hour mark on 3-19-23, and no Morphine was given. R88's Progress note, dated 3-20-23 at 12:35am, documents, This resident is upset and agitated about not receiving fentanyl patch yet. This nurse and nurse from day shift phoned pharmacy in regards to not receiving order yet. Per pharmacy it needed a new script .resident states 'she will go through withdrawal without it.' R88's Progress note, dated 3-20-23 at 8:45am, documents, Resident c/o (complained of) pain 10/10, PRN Tramadol given, resident requesting to be sent to ER (emergency room ) for uncontrolled pain, EMS (Emergency Medical System) called and resident sent to (named local hospital) via EMS ambulance. On 6-2-23, at 9:10am, V2, Director of Nursing/DON, stated, They are supposed to come with a script from pharmacy for narcotics such as (R88's) Fentanyl, and it didn't come. (R88) was admitted on a Friday night. This same date, at 1:20pm, V2, DON, stated R88's Morphine and Fentanyl patches were never delivered. We do not have Morphine or Fentanyl patches in our back up. (R88) was on a high dose of Fentanyl; (R88) had to have been miserable.

Based on observation, interview, and record review, the facility failed to implement fall interventions of low bed position and floor mats to prevent a fall with injury for one (R2) of three residents reviewed for falls in a sample of three. This failure resulted in acute fractures to R2's knee and femur. Findings include: R2's Minimum Data Set assessment, dated 12-28-22, documents R2 is moderately cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 9, is able to understand and be understood, and requires limited assist with one person for bed mobility and transfers. R2's Fall Risk Screens, dated 10-12-22 and 11-9-22, document R2 is at high risk for falls with a score of 45. R2's Fall Risk Screen, dated 12-3-22, documents R2 is at high risk for falls with a score of 75. R2's current Care plan documents R2 is at risk for falls and includes a fall intervention, date initiated 11-12-22, of Place floor mats/landing strips on the floor beside the bed while resident is in bed. Place mats on (both sides). A second intervention, date initiated 5-12-21, states Keep bed in lowest position acceptable by the resident when the resident is in bed. R2's Fall Incident Report, dated 1-5-23 and signed by V10, Licensed Practical Nursing/LPN, documents, Nursing Description: On 1-5-23 at 6:15am (R2) was found laying on the floor face down next to his bed. R2 was sent to the hospital. R1's CT (Computerized Tomography) scan of the left knee without contrast , dated 1-5-23, documents, Findings: 1. Large lipohemarthrosis indicating acute fracture. 2. Two possible areas of acute nondisplaced fracture through the inferomedial patella and through the medial proximal aspect of the medial femoral condyle. On 1-5-23, at 11:30am, R2 lay supine in R2's bed which is positioned at regular height. R2 stated R2 broke his knee cap yesterday by falling out of bed. Leg brace noted to R2's left leg. On 1-5-23, at 12:40pm, R2 is laying in bed. A floor mat is on the floor to right side of bed only. There is no floor mat on the left side of R2's bed. R2's bed is at regular height. At this time, R2 stated he fell out of bed and broke his knee cap. R2 stated he fell to the right while sleeping and there was no mat down. R2 stated, If it had been there I'd be okay. On 1-5-23, at 2:50pm, R2 is laying in bed with one floor mat to the right side of his bed only; R2's bed is at regular height. R2 stated, I need the floor mat and it is usually down but it wasn't last night. It was against the wall. On 1-5-23, at 2:51pm, V13, LPN, verified at this time, R2 does not have a floor mat down on the left side, and R2's bed is at regular height. V13 stated R2 is supposed to have floor mats on each side of his bed. A second floor mat could not be located in R2's room. V13 stated R2's bed is supposed to be in the lowest position. On 1-10-23 at 12:27pm, V10, LPN, stated the following regarding R2's fall on 1-5-23: The bed was low but not in the lowest position. I wondered if they were ready to get (R2) up or something. (R2's) bed should have been the the lowest position. His bed was up about 1/12 to 2 feet high. On 1-10-23 at 12:40pm and 1:48pm, V11, LPN, stated the following regarding R2's fall on 1-5-23: (R2's) bed was at the position of regular height for getting in and out of bed and not in the lowest position. (R2) rolled and his incontinence pad and bed linens went with him. V11 did not see a floor mat. On 1-10-23 at 2:00pm, R2 was in bed with only a floor mat to the right side of R2's bed only. On 1-10-23, at 2:04pm, V12 LPN verified at this time, R2 does not have a floor mat along the left side of his bed. V12 stated according to R2's care plan, R2 is supposed to have a floor mat on both sides. On 1-10-23, between 2:30pm and 3:05pm, V2, Director of Nursing, stated the following: (R2) should have bilateral floor mats at all times and (R2's) bed should always be in the lowest position when (R2) is in it. The facility's Standards of Clinical Care - Fall Prevention policy, revised 3-27-21, documents, Standard: It will be the standard of this facility to complete an initial assessment, on-going monitoring/evaluation of resident condition and subsequent intervention development in an attempt to prevent falls and injuries related to falls. The facility's Standards and Guidelines for Comprehensive Assessments and Care Plans, revised 4-5-21, documents Guidelines: 11. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will be provided by qualified persons in accordance with each resident's written plan of care and will also be culturally-competent and trauma-informed.

A. Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent falls, investigate falls, determine a root cause analysis, implement new fall prevention interventions after a fall, and obtain neurological checks after unwitnessed falls and falls with a resident striking her head/face for three of four residents (R5, R6, R41) reviewed for falls in the sample of 43. These failures resulted in R41 having repeated falls and sustaining multiple head injuries. B. Based on interview and record review, the facility failed to transfer one of three residents (R1) reviewed for transfers with a mechanical lift in the method ordered by his physician and deemed safe for him in the sample of 43. This failure resulted in R1 sustaining skin tears and bruising and a large chest wall hematoma. Findings include: A. The facility's Standards and Guidelines: Falls policy, revised 3/27/21, states, It will be the standard of this facility to complete an initial assessment, on-going monitoring/evaluation of resident condition and subsequent development in an attempt to prevent falls and injuries related to falls. Guidelines: 4. The staff will evaluate, and document falls that occur while the resident is active in the facility census. Fall investigations should include time of day, any known activity occurring when the fall transpires, witnesses to the fall (if any) rolls out of bed, injuries (type, location, etc.) and new interventions as needed and appropriate. Following a fall, post event monitoring should occur to monitor vital signs, change in function, change in cognition, increased pain or changes in skin condition, etc. 5. If a resident sustains a fall while a resident, staff should attempt to identify possible causes of the fall. Causes refer to factors that are associated with or that directly result in a fall; for example, a balance problem caused by an old stroke or recent (stroke). After a fall, the Interdisciplinary Team (IDT) should review circumstances surrounding the fall and develop an appropriate intervention(s) and plan of care. If the cause of the fall is unclear, the IDT will attempt to establish reasonable interventions related to the current condition of the resident to attempt to prevent recurrence. 6. Based on evaluation of an existing fall(s) pertinent interventions will be implemented by staff such as, but not limited to: resident education if appropriate, staff re-education regarding transfer techniques and safety during ADL (Activities of Daily Living) care, resident footwear, appropriate lighting, maintaining close proximity of frequently used items, medication reviews, toileting programs, use of hip protectors, referral to therapy for strengthening/coordination of balance, addressing medical issues such as [CONDITION(S)] and dizziness, and tapering, discontinuing, or changing problematic medications, use of fall prevention programs that provide more frequent supervision and restraints, if warranted. Findings include: 1. R41's Physician Order's dated 5/2022 document R41 was admitted on [DATE] with diagnoses of [CONDITION(S)] and Multi-System Degeneration of the Autonomic Nervous System. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R41 is severely cognitively impaired, requires extensive assist with transfers and toileting, is unable to stabilize without staff assistance, and has limitations of her lower extremities. R41's fall investigations and progress notes document R41 had falls on 3/17/22, 3/23/22 (hit her head), 3/30/22 (hit her head), 4/9/22, two falls on 4/10/22 (both unwitnessed), 4/18/22, 4/20/22 (hit her head), two falls on 4/22/22 (fell on her face), 4/24/22, 5/2/22 (hit her head), 5/4/22 (hit her head), 5/11/22 (hit her head), 5/15/22 (unwitnessed/hit head), and 5/26/22 (hit her face). R41's Fall Investigations and Progress Notes document the following: R41's root cause analysis for her falls on 4/20/22, 4/22/22, 4/24/22, 5/2/22, and 5/4/22 determined that she stood up from her wheelchair by herself and fell , hitting her head. R41's two falls on 4/22/22 and fall on 4/24/22 had no new interventions to prevent falls, and on 5/2/22 R41 again stood up from her wheelchair and fell , sustaining another head injury. R41's new intervention for her fall on 5/4/22, when she again stood up from her wheelchair and fell backwards hitting her head, was visual observation when out of bed. On 5/11/22 R41 fell striking her head on the floor after she was seen ambulating in the hallway alone, and on 5/15/22 R41 was found on the floor after she had fallen out of her wheelchair and sustained a right temporal hematoma and a bruise on her right forehead. R41's care plan does not document any fall interventions initiated after either fall on 4/22/22 or after the fall on 4/24/22. R41's Medical Record and Progress Notes document neurological checks (assessments) following falls were completed on 3/30/22 at 8:00am, and 4/10/22 from 9:45am-2:00pm. R41's medical record documents no other neurological checks for R41's falls that were unwitnessed or involved hitting her head/face on 3/23/22, 3/30/22, 4/10/22, 4/20/22, 4/22/22, 5/2/22, 5/4/22, 5/2/22, 5/4/22, 5/11/22, and 5/15/22. On 5/26/22 at 2:00pm, V1, Administrator, stated and confirmed that no other neurological checks were documented for R41's falls, and no new fall interventions were put into place following both falls on 4/22/22 or the fall on 4/24/22. R41's Emergency Department (ED) notes document the following: 3/23/22 Clinical Impression: 1. Fall, 2. [MEDICATION(S)] head trauma 3. Traumatic hematoma of head. History of present illness (HPI): fell out of her wheelchair hitting her head on the floor. R41's head CT dated 3/23/22 documents Small left frontal scalp hematoma. 4/20/22 Admission diagnoses: Fall, Subarachnoid hemorrhage, Right orbital fracture, Right maxillary fracture. HPI: Slid out of wheelchair and hit her head. R41's CT of her facial bones dated 4/21/22 documents 1. Acute post traumatic displaced fractures of the right anterior and lateral maxillary sinus walls with hemorrhage into the maxillary sinus. 2. Acute post traumatic mildly displaced fracture of the right lateral orbital wall and orbital floor. 3. Acute post traumatic mildly depressed fracture of the right zygomatic arch. 4. Acute post traumatic right preseptal periorbital soft tissue contusion. R41's head CT dated 4/21/22 documents Acute post traumatic subarachnoid blood laying of left greater than right prefrontal sulci. 4/22/22 Clinical Impression: 1. Fall, 2. History of falls, 3. Contusion of face, 4. contusion of knee, right. 5. Contusion of knee, left. 5/2/22 Chief Complaint: Fall, unwitnessed. Clinical Impression: 1. Head injury. 2. Contusion of scalp. R41's physical exam documents Head: Swelling with tenderness to hematoma of right forehead. R41's head CT dated 5/2/22 documents Acute post traumatic right frontal scalp with right preseptal periorbital post traumatic hematoma. 5/4/22 Clinical Impression: 1. Fall, 2. Head Injury. R41's head CT dated 5/4/22 documents Small right frontal scalp, periorbital, and premalar soft tissue contusions. 5/11/22 Chief complaint: Fall. HPI: Stood up from her wheelchair, walked a few steps, fell , hit the back of her head on the right side. R41's head CT dated 5/11/22 documents no acute changes. Clinical Impression: Fall. 5/15/22 Clinical Impression: 1. Fall, 2. Head contusion. Was found at her nursing home with a bump on her head after falling out of her wheelchair. R41's head CT dated 5/15/22 documents Small post traumatic right frontal-temporal scalp contusion. On 5/26/22 at 12:00pm, V35, Advance Practice Registered Nurse/Certified Nurse Practitioner/ Neurology Practitioner, stated (R41) is not being properly supervised by staff at the facility. (R41) has had too many falls and hit her head many times. A lot of the falls are unwitnessed falls. (R41) sits at the facility with nothing to do. (Staff) will leave (R41) sitting somewhere, and when a dietary person or housekeeping staff comes by, (Nursing staff) will tell them to keep an eye on her. Just random people who don't know how to take care of (R41). I just now received this message- (R41) is in the ED again with an unwitnessed fall and having head and neck pain. R41's Hospital Neurology Follow up with V35 dated 5/23/22 documents (R41) needs closer monitoring due to continued falls, she has had too many falls in the past three months. R41's Progress Notes dated 5/4/22 at 1:11pm, document R41 had an unwitnessed fall and hit the back of her head, and (R41) is a high fall risk and would benefit from a one on one; due to only having one CNA (Certified Nursing Assistant) per hall to cover multiple people, and (the CNA) cannot focus on the high fall risk residents. On 5/25/22 at 12:32pm, V28, Licensed Practical Nurse (LPN) who wrote R41's Progress Note on 5/4/22 at 1:11pm, stated We do the best we can, but it's hard for staff to always keep an eye on (R41). They (Administration) will have staff from the offices up front come and sit with (R41) as they can. At this time R41 sat unaccompanied behind the nurse's station and was bent over in her wheelchair rubbing the floor with her fingers. V28 was passing medications at this time, left her cart, and went to the nurse's station to redirect R41. On 5/18/22 from 9:25am-9:37am, R41 sat behind the nurse's station, unattended, and able to propel her wheelchair forward and backward. 2. R5's Incident Report on 4/6/22 documents that R5 was last seen in bed and then the nurse was summoned to R5's room by R5's roommate because R5 was on the floor. This same report states, (R5) did hit her head but refused to go to the hospital. Staff used the (Mechanical Lift) to safely pick (R5) up off the floor. This same report documents no witnesses were found. As of 5/18/22, R5's medical record did not contain documentation that 72-hour neurological checks were completed after R5's unwitnessed fall in which R5 hit R5's head. As of 5/18/22, R5's current Care Plan did not contain a newly implemented fall intervention after R5's 4/6/22 fall. 3. R6's Incident Report on 2/5/22 documents R6 had a fall in the dining room and R6 was found lying prone on the floor. This same report documents R6 was sent to the local area hospital for evaluation. R6's medical record does not contain documentation that R6's 2/5/22 was investigated determining a root cause and adding new fall prevention interventions. R6's current Care Plan does not document any fall prevention interventions after R6's 2/6/22 fall. On 5/18/22 at 2:43 P.M. V1 (Administrator) stated that after a resident has an unwitnessed fall, 72-hour neurological checks should be completed. V1 stated the neurological charting is completed in the resident's electronic medical record. V1 stated V1 could not provide any information showing that R5's neurological checks were completed and stated they should be since R5 hit R5's head during the fall. V1 stated no fall investigation with root cause analysis and newly implemented fall interventions could be provided for R5's fall on 4/6/22 or R6's fall on 2/6/22. V1 verified newly implemented fall interventions after a resident fall should be placed on the resident's care plan. V1 verified R5's care plan for falls had not been updated after R5's 4/6/22 fall and verified R6's care plan for falls had not been updated after R6's 2/5/22 fall and should have been. B. The facility's Standards and Guidelines: SG Mechanical Lifts (revised 3/27/21) policy documents, The Nursing and Therapy department will coordinate the screening of residents to determine the appropriateness of mechanical lift transfers and/or repositioning, and 5. When using the mechanical lift staff will adhere to manufacturer guidelines, physician's orders and/or the plan of care. R1's medical record and physician orders document R1 was admitted to the facility on [DATE] with diagnoses of Radiculopathy, Lumbar Region, Abnormalities of gait and mobility, and Muscle weakness (generalized). R1's physician orders document R1 is to be transferred using (Full mechanical) lift unless changed by therapy. R1's Hospital Discharge Orders dated 4/21/21 document diagnosis of Lumbar Laminectomy and an order to transfer using a full mechanical lift. R1's baseline and current care plan dated 4/21/22 and revised on 5/12/22 documents Transfer: the resident is not able to help with a transfer at all and will need the assistance of two staff and a (full mechanical lift) to move from bed to chair and back. R1's Incident investigation dated 5/10/22 at 10:46am documents R1 was being transferred from his bed to a chair with a sit-to-stand lift when he began to have a bowel movement, started coughing phlegm up, his knees buckled, and he could not hold himself up. The investigation documents R1 was lowered into a chair, and sustained skin tears/shearing to his chest from the buckle on the sling, and that (V8, family member) (was) educated (R1) not strong enough for sit-to-stand but (V8) refuses to allow (full mechanical lift). R1's Incident investigation documents R1 was sent to the Emergency Department (ED) on 5/11/22. R1's Hospital Discharge Notes dated 5/16/22 document Primary Discharge Diagnosis as Chest wall Hematoma and large upper extremity hematomas due to coagulopathy and sit to stand lift straps. R1's chest CT report dated 5/12/22 documents: IMPRESSION: 1. Large left chest wall hematoma involving the pectoralis major muscle measuring up to 16.2 cm (centimeters) in greatest dimension. R1's ED notes dated 5/12/22 document extensive bruising/bleeding from skin tears (chest). On 5/17/22 at 2:05pm, V6, Licensed Practical Nurse (LPN), stated on 5/10/22 she had cleaned up and dressed R1, then had V29, Certified Nursing Assistant (CNA) assist her in using the sit-to-stand lift to stand R1 to pull up his pants and transfer to a chair. V6 stated the sling was positioned correctly, snug, and fastened securely, and R1 was holding on to the lift handles. V6 stated when the lift began to raise R1 from the bed, he began coughing and having a bowel movement, could not hold on to the lift handles, and his knees buckled, so they sat him quickly in the chair. V6 stated the movement of the sling caused an abrasion/skin tear to R1's chest. On 5/17/22 at 2:40pm, V7, Therapy Director, stated the sit-to-stand lift was not an appropriate transfer method for R1 due to his Covid 19 infection, fatigue, weakness, and inconsistency in his daily abilities to perform therapy tasks. V7 stated on some days R1 could shave himself and on other days he could not shave himself. V7 stated they did work with R1 on sit-to-stand lift transfers in therapy, R1's ability to safely transfer with the sit-to-stand lift was inconsistent, and it was not safe to be used on the general floor by staff. V7 stated she has had multiple conversations with V8, family member, explaining that the sit-to-stand lift was not safe and that only a full mechanical lift should be used for R1's transfers. V7 stated We (therapy staff) documented the sit-to-stand lift wasn't safe and was only to be used in therapy, and we gave the staff the same instructions. (V8) flat out demanded the sit-to-stand lift was to only be used, and he was loud and aggressive with staff, demanding they use only the sit-to-stand lift. R1's Physical Therapy treatment notes document the following: 4/26/22 Multiple attempts at sit to stand, unable to complete even with max (maximum) assist and bed raised. 5/4/22 Work on sit to stand transfers and standing balance/tolerance, able to stand on two of four attempts. 5/11/22 Has order for (full mechanical lift). On 5/18/22 at 11:00am, V5, Physician's Assistant (PA), stated that she was notified of R1's bruising and skin tears from the sit-to-stand lift transfer on 5/10/22, and that she came to the facility on [DATE] to examine R1. V5 stated that due to R1's diagnoses and [MEDICATION(S)] and steroid use, his skin was fragile and at high risk for injury/bruising. V5 stated she discussed with V8 and staff that the use of the sit-to-stand lift was not safe for R1 and only the (full mechanical) lift is to be used.

Based on observation, record review, and interview, the facility failed to assess for pressure ulcer risk, and failed to implement pressure relieving interventions for one of five residents (R10) reviewed for pressure ulcers in the sample of 30. These failures resulted in R10 developing three stage four pressure ulcers to the sacrum, left heel, and right heel. Findings include: The facility's Repositioning and Support Structures policy, dated 3-27-21, documents, Repositioning is a common, effective interventions for preventing skin breakdown, promoting circulation, and providing pressure relief. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. Repositioning by facility staff should be congruent with the needs and level of function of the resident to maintain the highest practicable level of function while promoting preservation of skin integrity. Positioning the resident on an existing pressure injury should be avoided, when possible, since it puts additional pressure on tissue that already compromised and may impede healing. The Electronic Medical Record documents R10 was admitted to the facility on [DATE] with no pressure ulcers or skin breakdown. A Wound Assessment Details Report, dated 12/21/20, documents R10 developed a facility-acquired pressure ulceration to the right heel, measuring 2.5 cm (centimeters) x 2.5 cm x Unknown. A Wound Assessment Details Report, dated 12/22/20, documents R10 developed a facility-acquired pressure ulceration to the left heel, measuring 3.0 cm x 0.90 cm x Unknown. R10's Minimum Data Set (MDS), dated [DATE], documents, Always incontinent of bowel and bladder. Bed mobility (extensive assistance, two+ person physical assist). Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin Conditions - Resident has a pressure ulcer/injury. Resident is at risk of developing pressure ulcers/injuries. The resident has one or more unhealed pressure ulcers/injuries. One Stage three pressure ulcer (not present on admission). Two unstageable pressure ulcers (not present on admission) due to coverage of wound bed by slough and/or eschar. One unstageable pressure injury (not present on admission) presenting as deep tissue injury. On this same MDS, R10 is not marked for a turning/repositioning program. R10's Care Plan, dated 2/10/21, documents, Skin Integrity: (R10) has a potential for skin integrity changes including the development of new or worsening pressure ulcers. Interventions include Minimize pressure over boney prominence w/ repositioning when in bed. Extensive assist with two staff for turning/repositioning at routine intervals every shift when in bed. Self-Care &Mobility Deficits: R10 has had a Significant Change in Status (SCS) following [CONDITION(S)] (TIA) w/ongoing residual effects. She now requires an increased amount of assistance for completion of all Activities of Daily Living (ADL) and mobility tasks. Worsening deficits are secondary to a recent TIA. New Risk Factors Include: Left Sided Flaccid [CONDITION(S)], decreased trunk strengths. Other Identified Risks Include: Limited Mobility, Limited Range of Motion (ROM) and Weakness. V18's (Wound Physician) Wound Evaluation &Management Summary, dated 5/3/21, documents Stage four Pressure Wound of the left, lateral heel (over 123 days in duration) that measures 4 x 2.5 x 0.3 cm (centimeters). Stage four Pressure Wound of the right, lateral heel (over 123 days in duration) that measures 1.2 x 0.5 x not measurable cm. Full Thickness (stage four) Wound of the left, medial sacrum (at least 13 days in duration) that measures 2.7x1.5x0.3cm. The facility's Wound Quality System Review Tool, dated 5-4-21, and signed by V13 (Corporate Educational Nurse), documents R10 has not had a Braden assessment completed, and has not had weekly Registered Nurse assessment completed. On 5/04/21 at 1:00 PM, R10's left heel pressure ulcer was 4.0 x 2.5 x 0.3 cm (centimeters) with 75 percent of the wound covered in necrotic tissue (black dead tissue). R10's right heel pressure ulcer was 1.2 cm x 0.5 cm and covered in yellow slough (dead tissue). R10's sacral pressure ulcer was not due for a dressing change and was not observed. On 5/05/21 from 9:36 AM to 12:53 PM, R10 was laying on her back with direct pressure on the sacrum, in the middle of her bed. R10's left and right heels had padded boots and were lying directly on the bed without off-loading of pressure. V10, Licensed Practical Nurse (LPN), went into the resident's room at 11:31 AM, exited the room at 11:31 AM, and did not reposition the resident. At 11:57 AM, V7, Certified Nursing Assistant (CNA), entered the resident's room and exited at 11:58 AM, without repositioning the resident. At 12:18 PM, V7 (CNA) took a tray of food into the resident's room. At 12:24 PM, V10 (LPN) took a tray of food into the resident. At 12:53 PM, the resident was still on her back in the middle of the bed. R10 was observed continually from 9:36 AM, to 12:53 PM, and the resident was not turned or repositioned during this time and remained lying on her back. On 5/05/21 at 11:55 AM, V7 (CNA) stated, I have not provided care for (R10) today. (R10) cannot reposition herself and should be repositioned every two hours. On 5/05/21 at 12:16 PM, V10 (LPN) stated, (V8/CNA) and (V9/CNA) are the staff assigned to care for (R10) today. (R10) cannot reposition herself and should be repositioned every two hours. On 5/05/21 at 1:07 PM, V8 (CNA) stated, (R10) needs assistance with moving in bed. I have not re-positioned (R10), so I am not sure when it was done. It should have been done every two hours. On 5/05/21 at 1:14 PM, V9 (CNA) stated, I don't know when (R10) was re-positioned. I have not done it since 6:00 AM. It should have been done before lunch. V9 was asked what time her shift started. We (V8 and V9) started working at 6:00 AM this morning. On 5/06/21 at12:05 PM, V2 (Director of Nursing) and V13 (Corporate Educational Nurse) both stated routine intervals q shift means turn every two hours and as needed. On 5/06/21 at 1:30 PM, V13 stated, We (the facility) do not have a policy on wound prevention. (R10) should have been re-positioned at least every two hours, or more. We (the facility) do not have current medical records to determine whether a wound risk assessment has been done. The pressure ulcers to the right and left heel were caused by pressure and were facility acquired.

Based on observation, record review and interview, the facility failed to notify the physician of significant weight loss, implement interventions to prevent further weight loss, monitor resident weight and implement nutritional supplements as instructed by the Registered Dietitian, for one of five residents (R17) reviewed for nutrition, in a sample of 30. These failures resulted in R17 experiencing a significant weight loss of 8.56% in one month on 11/13/21, and an additional significant weight loss of 15.23% in three months on 4/21/21. Findings include: The facility policy, titled Weighing/Weight Loss Protocol (revised 3/05/21), documents, It will be the practice of this facility to implement the following systems regarding weight documentation. Guidelines: New admits and readmissions will be weight upon admission, monthly and/or as ordered by the physician. 1. Staff will be responsible for obtaining weights for these admits and will have this information available for morning stand-up meeting. 2. Off-hour admissions will need to be weighed by a member of the nursing staff on the off-hour shift to obtain initial weight if possible; obtaining weight the following day for late night admissions may be acceptable for resident comfort. 3. The (Registered Dietitian) is to review all admission weight for possible interventions. 4. Consistent weight loss noted during the admission weight process will be brought to the attention of the (Medical Doctor) & responsible party. 5. Weight refusals, not consistent with the resident's known preferences or expressed desires, should be documented by the attending nurse in the resident/patient's chart with notification to (Medical Doctor) and responsible party. 6. Monthly weights will be completed by the nursing department. 7. Weekly and daily weights may be obtained per Registered Dietitian or Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/04/21 at 12:30 PM, R17 was sitting in a high back reclining chair, being fed lunch by staff. R17 was eating a pureed diet and was totally dependent on staff for eating. The Electronic Medical Record documents R17 was admitted on [DATE], and has the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R17's Plan of Care, dated 11/27/20, documents R17 as at risk for altered nutritional status due to cognitive/psychiatric changes, requires feeding and hydration assistance, mechanically altered diet, and instructs staff to report any unplanned/unexpected weight loss to the physician. R17's electronic medical record documents R17's weight on 11/03/20 as 132 pounds. R17's weight on 11/13/20 was documented to be 120.7 pounds, which is a significant decrease of 8.56%. There is no documented evidence that the Physician or Registered Dietitian was notified at that time of R17's significant weight loss, and no diet changes were implemented. According to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The electronic medical record documents on 12/14/20, R17's weight as 119.0 pounds. Nursing Progress notes document R17 was hospitalized from 1/09/21 to 1/14/21, and R17's weight upon return to the facility was 125.4 pounds. Nutritional Progress Notes, dated 2/2/21, document (R17) is alert and orientated, she feeds self with tray set up and encouragement to eat, she make her needs known, expresses her likes and dislikes of food, she does have chewing difficulty, not in any need of adaptive equipment, she eats in her room due to COVID guidelines, she has no skin issues, her (oral) intake is fair 25-50% of most meals, weight is 125 pounds, height 60 inches, BMI 24 will continue monitor. A consultation by V6 (Registered Dietitian) on 2/21/21 for R17, documents Interventions: 1.) Recommend continuing a Mechanical Soft Diet with Thin Liquids (texture per Speech Language Pathologist; diet appropriate with chewing difficulties and to encourage (oral) intake. Resident may benefit from a (no added salt/low concentrated sweets diet if (oral) intake improves). Recommend fluids per Medical Doctor (Congestive Heart Failure with Diuretics) 2.) Recommend 120 cc Med Pass (three times per day) to replace house nutritional supplement/high calorie. Recommend a daily MVI to assist with nutrient intakes (poor oral intake) 3.) Recommend daily weights to monitor for weight loss/gain (Congestive Heart Failure). This is the only Consultation from the Registered Dietitian that could be located in the Electronic Medical Records during the last nine months of R17's admission. There is no documented evidence at that time, by review of all weight monitoring records and Medication/Treatment Administration records for February, March and April of 2021, that the facility implemented daily weight monitoring or changed R17's nutritional supplement to Med Pass 120 cc three times per day, as recommended by V6. Nursing Progress Notes document R17 was hospitalized from 2/27/21 to 3/01/21. There is no documented weight recorded upon R17's return to the facility. On 3/02/21, R17's Plan of Care was changed to the following: R17 has specific nutritional needs. Resident has DIFFICULTY CHEWING - Mechanically altered diet in place. WEIGHT FLUCTUATIONS are expected related to (Congestive Heart Failure) with Diuretics. Goal: Resident will not experience an UNPLANNED WEIGHT LOSS of 5% or more in a month or a loss of 10% in 180 days. Interventions: Provide diet and serve as ordered; monitor meal intake; Provide supplements as ordered; monitor intake; REPORT unplanned/unexpected weight loss to physician; Resident receives a SPECIALIZED DIET - Mechanical Soft Diet. The TYPE or the CONSISTENCY of the food is ordered to be modified (check with nurse or check orders prior to offering additional foods). On 3/23/21, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's next documented weight was not recorded until 4/21/21, in which R17 weighed 107.4 pounds. Documentation indicates staff re-weighed R17 later in the day on 4/21/21 to verify her weight, and she was 106.3 pounds, which is a calculated decrease of 15.23%, from R17's previous weight of 125.4 on 1/23/21. As of 5/06/21, there is no documented evidence that the facility notified the physician or Registered Dietitian of R17's weight on 4/21/21 or that any dietary interventions have been implemented. On 5/05/21, R17's weight was documented as 105.8 pounds. On 5/06/21 at 11:05 AM, V4 (Dietary Manager) stated the Registered Dietitian comes to the facility on a weekly basis and is to be reviewing resident weights. The Registered Dietitian will notify V4 of any significant weight changes a resident might have and all dietary recommendations. According to V4, all ordered weights are to be documented in the Vital Sign section of the Electronic Medical Record and orders for Nutritional Supplements are entered in by nursing staff to be documented in the Medication/Treatment Administration Record. 05/06/21 at 9:52 AM, V2 (Director of Nursing) stated the Registered Dietitian is to be conducting quarterly nutritional assessments, at a minimum, and with a significant change in resident weight. V2 stated R17's Plan of Care should have been updated with each significant weight change and new interventions implemented to prevent further weight loss. On 5/06/21 at 9:58 AM, V13 (Corporate Educational Nurse) stated the Registered Dietitian comes to the facility on a weekly basis, and it is unknown as to why both of R17's significant changes in weight were not addressed by the Registered Dietitian at the time it occurred. V13 concluded the documented evidence reviewed was all the facility had available, and there were no indication daily weights were ever obtained, as ordered by V6 on 2/21/21.

Based on observation, interview, and record review, the facility failed to implement fall interventions, provide adequate supervision, and provide assistance of two for Activities of Daily Living (ADL's) for one of three residents (R2) reviewed for falls with injury in the sample of three. These failures resulted in R2 being left unattended during ADL's, falling out of bed, sustaining a right [MEDICAL CONDITION] and experiencing excruciating pain. Findings include: The facility's Fall policy, dated 6-4-18, documents, It will be the standard of this facility to complete an initial assessment, on-going monitoring/evaluation of resident conditions and subsequent interventions development in an attempt to prevent falls and injuries related to falls. Based on evaluation of falls, pertinent interventions will be implemented by staff such as, but not limited to: resident education if appropriate, staff re-educating regarding transfer techniques and safety during ADL (Activities of Daily Living) care, and maintaining close proximity of frequently used times. R2's Minimum Data Set (MDS) Assessment, dated 11-10-20, documents R2 has [DIAGNOSES REDACTED]. This same MDS documents R2 is severely cognitively impaired and requires extensive assistance of two staff physical assistance for bed mobility, transfers, dressing, and toilet use. R2's Fall Risk Care Plan, dated 10-9-20, documents, Goal: I will not sustain a fall related injury by utilizing fall precautions through the review date 2-10-21. Interventions: 5-21-20 Keep (R2's) bed in low position at all times while in bed. 5-21-20 Floor mats/landing strips at bedside per medical doctor orders. 11-4-20 Prior to assisting (R2) to bed verify that both floor mats are present on each side of (R2's) bed every shift. R2's Progress Notes, dated 12/31/2020 at 12:26 PM, and signed by V5 (Registered Nurse/RN), document, (R2's) bed was in low position and (V3/Certified Nursing Assistant/CNA) had moved the fall mat to perform cares on (R2). (R2) was having cares performed on her when (V3) walked away from (R2's) bed to grab a bed pad and (R2) rolled out of bed onto the floor. Staff assisted (R2) back to bed after this nurse evaluated (R2). (V6/Licensed Practical Nurse) then asked (V5) to assess (R2's) right hip area due to seeing that the right hip was protruding and (R2) was crying out in pain and grabbing at the right hip area. (V5) noted that the area looked abnormal. 911 was then called to have (R2) transported to the hospital for an evaluation. R2's Right Femur X-Ray, dated 12-31-20, documents, Impression: Right intertrochanteric femur fracture (right [MEDICAL CONDITION]). R2's Hospital Admission History and Physical, dated 12-31-20, documents, Closed right femoral intertrochanteric fracture: fell from bed at the nursing home. Orthopedics consulted. V3's typed statement, dated 12-31-20, documents, I was assigned to (R2) on 12-31-20. I was providing cares to (R2) and moved (R2's) floor mat out of the way to provide cares and get (R2) dressed. I realized that I needed a bed pad, so I went to the utility room to retrieve one. Upon arriving back to (R2's) room, (R2) had rolled out of bed onto the floor. R2's Surgical Report, dated 1-2-21, documents, Procedure: Open reduction internal fixation right femur with c-arm. V3's Employee Counseling Form, dated 1-4-21, documents, Reason for counseling: Violation of safety rules. (V3) was getting (R2) dressed for the day (12-31-20) and had to leave (R2's) room to go get a fresh bed pad. Floor mats were not properly in place which resulted in a fall to (R2). On 1-11-21 from 11:10 AM to 12:30 PM, R2 was lying in bed facing the left side of the bed. R2 had an eight-inch floor mat on the floor next to the left side of the bed. During this time there was no floor mat next to the right side of R2's bed. On 1-11-21 at 12:10 PM, V2 (Director of Nursing) stated, On 12-31-20 (V3) removed (R2's) floor mat and left (R2's) room to go and get a bed pan. When (V3) left (R2) unattended, (R2) rolled out of bed on the left side of the bed. (R2) sustained a right [MEDICAL CONDITION]. Whenever (R2) is left in bed unassisted, (R2) is to have floor mats on both sides of the bed. (V3) should have made sure he had all supplies at the bedside before caring for (R2) and should have made sure that the floor mats were put back beside (R2's) bed before leaving (R2) unattended. (V3) did not make sure (R2's) bed was in the lowest position when leaving (R2) unattended. According to (R2's) MDS, (R2) should have had two staff assisting (R2) with dressing and toileting. On 1-11-21 at 12:30 PM, V2 (Director of Nursing/DON) stated R2's right side floor mat was missing and was in another resident's room. V2 stated R2 is to have bilateral floor mats at all times when R2 is in bed. On 1-11-21 at 12:40 PM, V7 (CNA) stated she did not know that R2 was supposed to have bilateral floor mats at all times while in bed. On 1-12-21 at 8:30 AM, V5 (RN) stated, On 12-31-20 (V6/LPN) called me to assess (R2). (V3) had moved (R2's) floor mat and had left the room to get a bed pad. (R2) fell out of bed when (V3) left (R2) unattended, and (R2) sustained a right [MEDICAL CONDITION]. (R2) was in excruciating pain. I sent (R2) to the emergency department. On 1-12-21 at 9:40 AM, V3 stated, On 12-31-20 I was getting (R2) ready to get up. I moved (R2's) floor mat to provide cares to (R2). I was dressing (R2) and needed a clean bed pad. I had to leave (R2's) room to get a bed pad and forgot to put the floor mat back next to (R2's) bed. I had left (R2's) bed raised and not in the lowest position when I left (R2's) room. When I returned to (R2's) room, (R2) had fell out of the bed and was lying on her right side in pain. (R2) was whimpering and crying. I immediately got the nurse (V6/Licensed Practical Nurse). I know (R2) needs two staff to provide cares, but I did not have time to ask any other staff to help with (R2's) cares.

Based on interview and record review, the facility failed to follow physician orders [REDACTED]. This failure resulted in R14 being hospitalized and receiving emergency [MEDICAL TREATMENT] treatments. FINDINGS INCLUDE: The facility policy, [MEDICAL TREATMENT], dated (revised) 12/2017 directs staff, It will be the standard of this facility to provide the necessary care and services to those residents receiving [MEDICAL TREATMENT] while a resident at the facility. Once admitted , the facility will verify orders for [MEDICAL TREATMENT], location and times per week in order to secure transportation to the [MEDICAL TREATMENT] center to avoid disruption in service. Once the hospital transfer discharge paperwork/orders has been received the nurse will verify all orders with the physician for accuracy of medications, diet, treatments and any fluid restrictions. If the resident has orders for fluid restriction, they should be clarified as to which shift provides which amount of fluid per shift between nursing and dietary services. Resident's intake and output will be required to be recorded only with a physician's orders [REDACTED]. (R14's) Facility Inquiry Quick Admit Worksheet, dated 11/18/19, documents,[MEDICAL TREATMENT]: T/T/Sa (Tuesday, Thursday and Saturday) at 1:00 P.M., Downtown. Signed up for (local bus service) for [MEDICAL TREATMENT]. R14's (facility) Face Sheet documents that R14 was admitted to the facility on [DATE]. R14's Physician order [REDACTED]. This same document includes the following physician orders: [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday at 1:00 P.M.; Access site left arm, observe access site for bleeding or S/SX (signs/symptoms) of infection every shift.; Check Bruit every shift, if applicable; Regular Renal Diet and [MEDICATION NAME]/[MEDICATION NAME] 2.5% Cream, apply 1 unit to [MEDICAL TREATMENT] site 1 hour prior on Tues, Thurs, Sat. R14's Dietary Progress Note, dated 11/21/19, documents, [MEDICAL TREATMENT]/Nutrition status: (R14's) weights will fluctuate related to fluid shifts with [MEDICAL TREATMENT]. Diet order: CCD (Carbohydrate controlled), Renal, limit milk to 1/2 cup daily with 2000 ML (milliliters) fluid restriction. R14's Progress Note, dated 11/23/19 at 3:00 PM documents, (R14) unable to go to [MEDICAL TREATMENT] due to lack of transportation. Spoke with (local bus service), they stated (R14) wasn't scheduled for transportation today. (R14) aware of issue. Spoke with ([MEDICAL TREATMENT] center), made aware of situation. R14's Progress Note, dated 11/23/19 at 3:30 PM documents, (R14) called this nurse to room, stating (R14) didn't feel well. Went on to say that (R14) felt fatigue and nausea. Requested to go to ER (emergency room ) to get emergency [MEDICAL TREATMENT]. Per (R14's) request, transported via AMT to (local hospital). R14's Nursing Home to Hospital Transfer Form, dated 11/23/19, documents, Missed [MEDICAL TREATMENT] Thursday (11/21/19) and today (11/23/19). R14's Hospital Progress Note, dated 11/23/2020, documents, (R14) with a past medical history of [REDACTED]. (R14) was discharged about 4 days ago and since that time, (R14) reports that he has missed 2 [MEDICAL TREATMENT] sessions. He had been discharged to (nursing facility) and reports he was told he would not be able to get transportation to his [MEDICAL TREATMENT] session today. (R14) reports that while he was in his room today, he started having nausea without vomiting and also noted weakness. (R14) notes that due to missed [MEDICAL TREATMENT] (R14) decided to call (local ambulance) for presentation to the ED. admitted for uremic symptoms and volume overload. R14's (facility) 24 Hour I and O (Intake and Output) Report, dated 11/19/19 to 12/22/19, fail to accurately document physician ordered intake and output levels on 23 out of 28 days. R14's Treatment Administration Record, dated March 2020, documents that facility staff failed to document, Observation of access site for bleeding or signs/symptoms of infection every shift and Check bruit every shift for 9 out of 14 opportunities. On 3/9/2020 at 9:30 AM, R14 stated, My brother and I were homeless. I came to the facility in November because my Case Manager wanted me to be here so I had transportation to my [MEDICAL TREATMENT] appointments. Just before I came here, I had missed a couple of [MEDICAL TREATMENT] appointments and I got very sick. My heart had stopped beating and I ended up in the ICU (Intensive Care Unit) for a few days. I go to [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday at 1:00. I missed two treatments after I first came here because for some reason the City bus didn't come and pick me up and the facility didn't take me to my appointments. Finally after I missed the second appointment, I was feeling so sick I told the nurse I was going to call the ambulance and go to the ER (emergency room ). She didn't want to call for me, but she finally did. They did emergency [MEDICAL TREATMENT] on me for a couple of days and then sent me back here. On 3/10/20 at 1:30 PM, V16/Admissions stated, (R14) was admitted to our facility in November (2019). We knew prior to admission (R14) received [MEDICAL TREATMENT] three times a week. We do have a facility van which is available to transport residents to [MEDICAL TREATMENT] or doctor's appointments, with no charge. I don't know why (R14) was not provided transportation to [MEDICAL TREATMENT] (on 11/21/19 and 11/23/19). On 3/10/20 at 1:46 PM., V15/Advanced Practice Nurse (APN) for (local) [MEDICAL TREATMENT] Clinic stated, (R14) was admitted to the (facility) in November (19,2019) after (R14) had been hospitalized with heart failure secondary to being homeless and missing [MEDICAL TREATMENT] appointments due to transportation problems. The facility assured us they would be able to provide transportation or arrange transportation for (R14) so (R14) could receive (R14's) scheduled [MEDICAL TREATMENT] appointments. After (R14) missed two [MEDICAL TREATMENT] appointments (11/21/19 and 11/23/19), (R14) needed to be hospitalized again to receive emergency [MEDICAL TREATMENT] for two days. When a resident does not receive scheduled [MEDICAL TREATMENT], toxins build up in the body, which the body can not get rid of, which will lead to [MEDICAL CONDITION] and death. On 3/11/2020 at 9:30 AM, V1/Administrator stated, Our facility has a facility van that we use to transport residents to doctor's appointments. Last fall our van was broken and we didn't have a van driver. I don't know why (R14) wasn't provided transportation in November to (R14's) [MEDICAL TREATMENT] appointments. We could have called a non-emergency transport to take (R14). On 3/11/2020 at 11:00 AM, V2/Director of Nurses (DON) verified the facility did not transport R14 or assist in obtaining transportation for R14 for [MEDICAL TREATMENT] appointments in November. On 3/11/2020 at 11:05 AM, V14/Corporate Nurse verified facility staff did not complete physician ordered Intake and Outputs or physician-ordered [MEDICAL TREATMENT] site observations or bruit checks for R14, as ordered.

Based on observation, interview, and record review, the facility failed to implement a ROM (Range of Motion)/Restorative program to prevent a decline in ROM for two of five residents (R42, R49) reviewed for ROM limitations in the sample of 30. This failure resulted in R42 and R49 experiencing a a decrease in Functional Range of Motion. Findings include: The facility's Restorative Nursing Programs policy, dated 12/1/16, documents, It will be the standard of this facility to provide restorative nursing services to residents that require them to attempt to maintain or improve function or as ordered by the physician. The therapy/rehab department will conduct routine screens on residents to ensure there has not been a decline in function. In the event that a change is present, it is appropriate for the resident to receive therapy or restorative programs to attempt to maintain or improve highest practicable level of care. 1. On 3/08/20 at 10:18 AM, R49 had ROM limitations of her bilateral shoulders; unable to reach up to her head, left leg unable to bend at the knee, and right leg stiff with movement. R49 denied doing exercises with staff on a regular basis. On 3/10/20 at 2:21 PM, V18 and V19 (Both Certified Nursing Assistants-CNA) transferred R49 from her high back reclining wheel chair to her bed using a mechanical lift and total assist of both staff members. V18 stated that R49 is not on a restorative program for her ROM deficits. V18 also stated that R49 broke her left leg during a one person assist transfer with a CNA and now she's a total mechanical lift assist because of it. On 3/10/20 at 3:00 PM, R49 stated, I do not get exercises on a daily basis, and I really wish I could. My joints are tight and I can't even bend my left knee. After my knee fracture healed up all the facility did was take the brace off. I haven't even been able to attempt to stand up. I always have to use the mechanical lift. R49's X-ray report, dated 8/12/19, documents that R49 has an acute tibial tubercle avulsion fracture. R49's Fall care plan, dated 10/28/19, documents an intervention on 8/9/19 following her fall for a transfer program to be implemented once R49's left tibia fracture is healed. R49's MDS, dated [DATE], documents that R49 has functional ROM limitations to R49's bilateral upper and lower extremities and in Section O Special Treatments, Procedures, and Programs that R49 is not on a restorative and/or ROM program. R49's Contracture Assessment, dated 2/4/20, documents that R49 has ROM functional limitations with pain to her bilateral shoulders and hips. R49's physician's orders [REDACTED]. On 3/11/20 at 8:44 AM, V1 (Administrator) stated that R49 was not on any ROM/restorative programs. On 3/11/20 at 9:47 AM, V7 (Care plan coordinator) stated, R49's weak hip flexors, right and left leg contractures, and bilateral shoulders are tight and unable to reach completely above her head is the reason why she is coded as bilateral upper and lower ROM limitations. When R49 fell and broke her left tibia/fibia she was a one assist turn and pivot transfer. With the fracture she was switched to a mechanical lift, and the plan was to initiate a transfer restorative program once the fracture was healed. We were going to initiate this program to strengthen her legs, but since they took away the restorative nurse, the program was never initiated. Now, R49 is still a mechanical lift even though the fracture is healed. I have fought and fought for this but I've gotten nowhere. 2. On 3/8/2020 at 11:30 AM, R42 was able to propel his own wheelchair using upper and lower extremities with some resistance to upper extremities. On 3/9/2020 at 8:30 AM, R42 was sitting in the wheelchair. R42 was not able to raise his arms above his shoulders. R42 stated, No, I cannot do that (raise arms above his shoulders), and I am not getting my exercises. R42's Rehab Restorative Assessments, dated 9/11/2019, 11/11/19, and 1/14/20, document, Overall physical condition: Poor posture, poor endurance, due to muscle weakness. Limited ROM (Range of motion) to hips and right shoulder. Rehab Restorative Program Recommendations: Active Range of Motion Exercises up to 7 days per week for the following: UE/LE (Upper extremities/Lower extremities) strengthening and ROM (Range of Motion) to maintain/improve joint ROM (Range of motion) and muscle strength. R42's MDS (Minimum Data Set), dated 12/13/2019, documents in Section G Functional Status that R42's Functional Limitation in Range of Motion, is coded a 2/2, which indicates ROM (Range of Motion) impairment in R42's bilateral upper and lower extremities. R42's MDS also documents in Section O Special Treatments, Procedures, and Programs that R42 is not receiving any ROM/Restorative programs. R42's Care plan, dated 2/22/2020, documents, R42 has bilateral knee instability that is related to [MEDICAL CONDITION]. R42's current medical record has no documentation of R42 receiving any ROM/Restorative programs for R42's ROM limitations. On 3/10/2020 at 10:00 AM, V7, CPC (Care plan Coordinator), stated, Based on my clinical observation and assessment, R42 was not able to perform full ROM to R42's bilateral upper and lower extremities. R42 cannot get his arms up above his shoulders, and R42 has weak lower extremities due to his weak hip flexors. On 3/10/2020 at 10:10 AM, V7, CPC (Care plan Coordinator), verified that R42's Rehab Restorative Assessment recommended that R42 be on a ROM/Restorative program, however, R42 is not on a ROM/Restorative program

Based on interview and record review the facility failed to administer physician ordered pain medication to one (R1) of three residents reviewed for pain in the sample of three. This failure resulted in R1 experiencing increased pain, inability to sleep, and increased anxiety. Findings include: The facility's Pain Management policy, revised 11-2009, documents In order to provide effective pain management for residents experiencing acute or chronic pain, (The Facility) will implement a comprehensive care process for pain management to include: Anticipating, preventing, minimizing pain; Administering pain medication prudently in order to meet the resident's pain goals while avoiding unacceptable adverse consequences. The facility's Pain Management procedure, revised 11-2009, documents The Nurse will: 4. Provide medication as ordered in a timely manner. The facility's Medications/Treatments Documentation, Rev (revised) 3-2010, documents 3. Document the omission of a medication or treatment for [REDACTED]. If the omission of a medication or treatment is due to a medication being unavailable, contact the pharmacy or the supervisor/DON/ADON (Director of Nursing/Assistant Director of Nursing.) R1's Face Sheet, dated 1/10/19, documents R1 with following diagnoses, not limited to: [MEDICAL CONDITION], Diabetes Mellitus, Morbid (Severe) Obesity, [MEDICAL CONDITION] to left shoulder, Restless Leg Syndrome, [MEDICAL CONDITION], and Anxiety. R1's Quarterly MDS (Minimum Data Set), signed and dated 12/31/18, documents R1 BIMS (Brief Interview for Mental Status) as a 15 out of 15 indicating R1 is cognitively intact. This MDS documents in section J0300 - J0400 as having pain frequently. Section J0500 documents yes to limited day-to-day activities because of pain. Section J0600 documents R1 with moderate pain. Section V indicates Pain as a triggered care area for R1. R1's Current Care Plan, documents a Problem area for R1 as (R1) has potential for alterations in her level of comfort r/t (related to) Pain and Potential causes of pain for her may include: BLE (bilateral lower extremity) [MEDICAL CONDITION], profound obesity, joint pain, falls, immobility. The Interventions documented as Administer pain meds as ordered. R1's POS (physician's orders [REDACTED]. The MAR for R1, dated (MONTH) 2019, includes documentation that R1's [MEDICATION NAME] was not given three times a day as ordered from 2/20/19 through 2/23/19. R1's Narrative Nurse's Progress Notes, dated 2/21/19 at 11:05 pm, documents Scheduled [MEDICATION NAME] unavailable. Note dated 2/22/19 at 6:00 am, documents [MEDICATION NAME] at this time not available. The Pharmacy Shipping Manifest for R1, documents R1's [MEDICATION NAME] order was received on 2/23/19 at 8:59 pm and was received by the facility on 2/24/19 verified by signature. R1's Pain Assessment, dated 1/10/19, documents R1 pain control goal as a 4 out of ten on the numeric pain scale with 10 being the worst possible pain. On 3/6/19 at 1:30 pm, R1 stated (R1's) [MEDICATION NAME] 25mg was increased to three times a day, from twice a day, on 2/11/19 because the previous dose was not helping (R1's) pain. R1 stated (R1) did not receive (R1's) [MEDICATION NAME] on 2/20/19 through 2/23/19 and when (R1) asked (R1) was told the pharmacy had not brought it yet. R1 stated (R1's) pain was generally a three or four out of ten but during these dates (R1's) pain ranged from eight to ten on the 0-10 numerical pain scale. R1 stated (R1) was unable to sleep, legs were constantly moving, and (R1's) anxiety went through the roof. On 3/6/19 at 11:14am, V2 DON (Director of Nursing) stated R1 was receiving [MEDICATION NAME] 25mg twice a day for (R1's) leg pain but it wasn't helping much so it was increased to three times a day. V2 stated he has inserviced the Nurses that they are to notify the physician, the pharmacy and the DON if a resident's medication is not available. V2 stated he was not made aware until yesterday 3/5/19 when R1 asked him to come to (R1's) room to talk. On 3/6/19 at 3:45pm, V8 Pharmacy Technician, stated the 2/23/19 date on R1's [MEDICATION NAME] medication card represents the date the Pharmacy received the Physician's signed order for (R1's) [MEDICATION NAME] and it would have been delivered to the facility that evening.

Based on interview and record review, the facility failed to timely implement pressure ulcer prevention interventions, perform weekly skin checks, assess and document the weekly status of pressure ulcers, revise the care plan after the development of pressure ulcers, and conduct a risk assessment according to facility procedures and professional standards of practice for one of three residents (R1) reviewed for pressure ulcers in the sample of three. These failures resulted in R1 developing three pressure ulcers, one of which worsened from a stage II to an unstageable pressure ulcer while residing at the facility. Findings include: The facility's Pressure Ulcer/Wound Management policy (revised (MONTH) 2004) documents the following: The Nurse will: 1) Do a complete skin assessment of each new resident upon admission to identify any wounds present including pressure ulcers, stasis ulcers, surgical wounds, etc. 2) Document the size and description of the wound in the nurse's notes. 3) Initiate a Wound Documentation form (Nurs-093), identifying the type of wound, the size, the location, and the status of the wound. 4) Obtain orders for appropriate treatment according to (facility's) Wound Care Protocols or physician's instructions. 5) Implement appropriate Pressure Ulcer Prevention Protocols per policy (pressure relief, dietary supplements, etc.) 6) Notify Rehab Nurse and/or Director of Nursing of residents admitted with pressure ulcers or other wounds. 7) Complete skin assessments on all residents weekly after showers or as assigned to check for new skin integrity impairment. Document results in nurses notes. 8) Follow procedures 2-5 for any resident who develops a house acquired pressure ulcer. 9) Notify Rehab Nurse and/or Director of Nursing of residents who develop a house acquired pressure ulcer. 10) Perform treatments as ordered. This same policy documents: The Rehab/Restorative Nurse will: 1) Do a complete skin assessment of each new resident upon admission to identify any wounds present including pressure ulcers, stasis ulcers, surgical wounds, etc. 2) Evaluate the treatment order and determine if it follows (facility's) Wound Care Protocols. 3) Re-assess the wound weekly or more often as necessary to measure progress or decline in wound status. 4) Document the wound status on the Wound Documentation Form (Nurs-093) weekly. 5) Record the wound on the Weekly Pressure Ulcer Report (DON-064) or the weekly Skin Report (DON-064A) per policy. 6) Contact the physician when a Pressure Ulcer progresses from one stage to another or when there is any significant change in the condition of a wound. 7) Contact responsible party when there is a significant change in the condition of a pressure ulcer or any wound. 8) Contact the physician when a pressure ulcer or other wound fails to respond to treatment after 2-3 weeks. 9) Ensure that appropriate Pressure Ulcer Prevention Protocols have been implemented including a dietary supplement to promote healing. 10) Follow procedures 2-9 for any resident who develops a house acquired pressure ulcer. The facility's Skin Care Prevention of Pressure Ulcers policy (Revised (MONTH) 2003) documents the following: Repeat the Pressure Ulcer Risk Assessment quarterly or when significant changes in condition (such as declines in activities of daily living, skin condition, nutritional status) make re-evaluation appropriate. According to the article, Pressure Injury Prevention Points (2016), from the National Pressure Ulcer Advisory Panel; when assessing a resident, Repeat the risk assessment at regular intervals and with any change in condition. Base the frequency of regular assessments on acuity levels: Long term care weekly for four weeks, then quarterly. R1's Face Sheet dated 4/28/17 documents that R1 was admitted to the facility 3/3/17 and was discharged on [DATE]. This same form documents R1's [DIAGNOSES REDACTED]. R1's Wound Documentation Form (Nurs-093) documents R1 developed the following pressure ulcers on the following dates: On 3/24/17, a stage II pressure ulcer on R1's coccyx; On 3/31/17, a stage II pressure ulcer on R1's left ischium; and on 4/17/17, an area of shearing on R1's sacrum. On 3/6/18 at 8:45 AM, V3 (Wound Nurse) stated that R1's coccyx pressure ulcer was healed on 4/10/17, but R1 was discharged from the facility with the pressure ulcer on R1's ischium and the shearing on R1's sacrum still present. R1's Pressure Ulcer Risk Assessment form dated 3/3/17 documents during R1's stay at the facility, this risk assessment was completed just once, on 3/3/17. This same assessment documents a score of 11, indicating R1 is at moderate risk for development of a pressure ulcer. This form also documents the following: Moderate Risk- Implement Appropriate Preventative Protocols- on reverse side of form. This form's reverse side is blank and has no documentation of any prevention protocols or interventions implemented. R1's Wound Documentation Form (Nurs-093) documents on 3/24/17 and 3/31/17, an assessment was conducted on R1's coccyx pressure ulcer. This same form documents on 3/31/17, 4/9/17, 4/10/17, 4/17/17, 4/22/17, and 4/24/17 an assessment was conducted on R1's left ischium pressure ulcer. This form also documents on 4/17/17 and 4/24/17 an assessment was conducted on the area of shearing on R1's sacrum. R1's Physician order [REDACTED]. R1's monthly Treatment Administration Records dated (MONTH) (YEAR) - (MONTH) (YEAR) do not document weekly skin checks were completed. These forms document that skin checks were performed on R1 on the following days: 4/8/17, 4/9/17, and 5/4/17. R1's nurse's notes dated 3/3/17 - 5/6/17 do not document weekly skins checks. R1's Wound Documentation Form (Nurs-093) documents R1's stage II left ischium pressure ulcer measured 2 centimeters x 1 centimeter on 4/9/17; and worsened to an unstageable measuring 1.5 centimeters x 2.3 centimeters on 4/10/17. R1's most current care plan dated 3/22/17 was not updated until 4/3/17 regarding R1's coccyx pressure ulcer and left ischium pressure ulcer. This same care plan has no mention of R1's area of shearing on R1's sacrum. On 3/6/18 at 8:45 AM, V3 (Wound Nurse) stated that no new pressure ulcer prevention interventions were implemented when R1 developed the Stage II pressure ulcer to R1's coccyx on 3/24/17, the stage II pressure ulcer to R1's left ischium on 3/31/17, or the shearing to R1's sacrum on 4/17/17. V3 stated that new interventions for R1's coccyx and left ischium pressure ulcers were only initiated on 4/10/17, when R1 was seen by V4 (Wound Physician). V3 also confirmed that R1's left ischium pressure ulcer declined from a stage II to an unstageable pressure ulcer on 4/10/17. V3 then stated that the facility's protocol requires a Pressure Ulcer Risk Assessment be conducted upon admission, then weekly for three weeks, followed by quarterly. V3 verified that the only Pressure Ulcer Risk Assessment conducted on R1 was on 3/3/17, and stated, (R1) should have had three weekly assessments completed after R1 was admitted , and again after R1's pressure ulcers developed. And that didn't happen. V3 verified that weekly documentation of R1's pressure ulcers was not completed and stated, There should have been an assessment documented for (R1's) coccyx pressure ulcer on 4/7/17. And there should have been an assessment documented for (R1's) left ischium pressure ulcer and shearing on R1's sacrum on 5/1/17. These assessments were missed. V3 then confirmed R1's care plan was not revised regarding R1's coccyx and left ischium pressure ulcer until 4/3/17, and wasn't revised to mention R1's sacral shearing.

Based on observation, interview, and record review, the facility failed to identify a pressure ulcer, prevent a pressure ulcer from worsening, obtain a physician ordered treatment for [REDACTED]. This failure resulted in R23 being admitted to the hospital with [REDACTED]. Findings include: The facility's Pressure Ulcer/Wound Management policy, dated 10/2004, documents, Optimal Wound management will include: Assessment of the skin and wound; Use of standardized protocols; Regular reassessment to monitor effectiveness of interventions. Treatment objectives to promote optimal wound healing are: Relieve pressure; Protect healthy tissue. The policy also documents, Staging of Pressure Ulcers: Stage II: Partial thickness loss of skin layers (epidermis or dermis). The ulcer is superficial and presents as an abrasion, blister, or shallow crater. Stage III: Full thickness loss involving damage to or necrosis of subcutaneous tissue. Stage IV: Full thickness skin loss (deeper than the dermis) with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structure (such as tendons). Ulcers with eschar or extensive necrosis cannot be accurately staged. 1. The Pressure Ulcer/Wound Management policy, dated 10/2004, documents, The nurse will: Do a complete skin assessment of each new resident upon admission to identify any wounds present including pressure ulcers, stasis ulcers, surgical wounds, etc.; Document the size and description of the wound in the nurse's notes; Initiate a Wound Documentation form, identifying the type of wound, the size, the location, and the status of the wound; Obtain orders for appropriate treatment according to the Facility's Wound Care Protocols or physician's instructions; Implement appropriate Pressure Ulcer Prevention Protocols per policy (pressure relief, dietary supplements, etc.). The policy also documents, The Rehab/Restorative Nurse will: Re-assess the wound weekly or more often as necessary to measure progress or decline in wound status; Contact physician when a Pressure Ulcer progresses from one stage to another or when there is any significant change in the condition of a wound; Ensure the appropriate Pressure Ulcer Prevention Protocols have been implemented including a dietary supplement to promote healing. The facility's Quick Reference guideline for Pressure Ulcers/Skin Tears, no date available, documents, Stage II: Intact Blister: Apply skin prep to area daily. Stage II Drainage none to minimal: Apply hydrogel; Cover with composite dressing; Change every day and as needed; or Apply [MEDICATION NAME] dressing; Change every three days and as needed. R23's Admission Assessment, dated 3/20/17, documents that R23 has blisters to R23's buttocks. R23's Pressure Ulcer Risk assessment, dated 3/20/17, documents that R23 is at low risk of developing pressure ulcers. R23's Medical records have no documentation of the physician being notified of R23's blistered areas upon admission nor of any physician's orders [REDACTED]. R23's Skin Integrity care plan, dated 3/22/17, documents that R23 has an area to R23's gluteal folds. However, the care plan has no documentation of any new interventions being implemented following the identification of R23's areas. On 4/11/17 at 10:20 a.m., E3 (Care plan coordinator) stated, No new interventions were put into place for (R23's) area. R23's Nurse's notes, dated 3/23/17, documents, In gluteal folds there was a blister which has now popped. R23's Nurse's notes has no documentation that the physician was notified regarding the change in R23's wound, nor was a new treatment order obtained. R23's Nurse's notes, dated 3/31/17 at 10:50 a.m., documents, (R23) has off white-yellow slough (tissue) between gluteal folds. The facility's Weekly Skin Report, dated 3/27/17 to 4/2/17, has no documentation of R23's gluteal fold wound being assessed or measured. The facility's Weekly Skin Report, dated 4/3-4/9/17, documents that R23 has an open lesion other than ulcers, rashes, or cuts to R23's gluteal fold. R23's Nurse's notes, dated 4/3/17 at 9:20 p.m., documents, Temperature 101 degrees Fahrenheit. Very excoriated buttocks with purulent drainage with foul odor. 911 called. R23's Nurse's notes, dated 4/4/17 at 12:25 a.m., documents, (R23) admitted to hospital with the [DIAGNOSES REDACTED]. R23's Hospital Progress note, dated 4/4/17, documents, (R23) with pressure injury to coccxygeal crease measuring 12 cm x 10 cm x 6 cm. Deepest aspect to center of wound with gray necrotic tissue to rim of base, deeper area with [MEDICATION NAME] moist tissue upon palpation of wound base. Bone is palpable, pressure injury is Stage IV. R23's Hospital History & Physical, dated 4/4/17, documents, Sepsis due to infected Sacral decubitus ulcer. On 4/9/17 at 11:40 a.m., Z2 (R23's family member) stated, (R23) first had blisters, and they did nothing. Then the blisters popped and were open, and they still didn't do anything. Now he's in the hospital [MEDICAL CONDITION] and a Stage four pressure ulcers. On 4/10/17 at 3:25 p.m., E4 (Registered Nurse) stated that on 3/23/17 she didn't notify the physician when (R23's) blister opened. E4 also stated that she did not feel like the area was a pressure ulcer, and that on 3/31/17 the wound was on R23's entire gluteal fold and it was weeping, odorous, and covered in slough (yellow tissue). On 4/11/17 at 1:00 p.m., E7 (Wound Nurse) stated, When the blisters were found they should have followed the facility protocol by notifying the physician and getting a treatment order. Normally we do skin prep until the blister pops. Then you notify the physician and change the treatment per protocol which would be hydrogel and a dry dressing. On 4/11/17 at 1:10 p.m., E2 (Director of Nursing) stated that R23's physician was not notified when blisters were noted on R23's buttocks at admission, and that any resident with wounds should be assessed with [REDACTED]. on a weekly basis. On 4/11/17 at 1:45 p.m., Z3 (R23's Physician) stated, I wasn't notified about (R23) having blisters on his buttocks then them popping and opening. I would have expected them to notify me when the wound was found and got a treatment order. Then when it popped they should have notified me and gotten another treatment order. Interventions should have been put into place to prevent it from worsening. On 4/11/17 at 2:55 p.m., E1 (Administrator) confirmed that the facility did not identify R23's area as a pressure ulcer. 2. The facility's Infection Control Dressing Changes, dated 11/1998, documents, To ensure the prevention of the spread of infection, the facility will utilize aseptic technique when changing a resident's dressings. Procedure: Gloves will be worn to remove old dressing; New gloves will be worn to put on new dressings; A change of gloves is required between multiple treatments on the same resident. R16's Admission Assessment, dated 3/3/17, documents that R16 does not have any open areas/ulcers. R16's Pressure ulcer risk assessment, dated 3/3/17, documents that R16 was at moderate risk for developing a pressure ulcer. R16's Wound documentation, dated 3/31/17 and 4/9/17, documents that R16 has an area to R16's left gluteal fold (left ischium) measuring 3 cm (centimeters) x 3 cm on 3/31/17, and 2 cm x 1 cm on 4/9/17. The facility's Weekly Skin Report, dated 4/3-4/9/17, documents that R16 has an open lesion other than ulcers, rashes, or cuts to R16's left gluteal fold. R16's Skin Integrity care plan, dated 3/28/17, documents that R16 has an open area to R16's left gluteal fold. However, R16's skin integrity care plan has no documentation of any new interventions being implemented following the development of R16's open area on 3/31/17. R16's Wound Care Specialist Initial Evaluation, dated 4/10/17, documents that R16 has an unstageable pressure ulcer due to necrosis of the left ischium that measures 1.5 cm x 2.3 cm. The evaluation also documents that the area is clearly a pressure injury. On 4/10/17 at 9:50 a.m., Z1 (Wound Doctor) stated, (R16's) left ischium wound measures 1.5 cm x 2.3 cm and it is an unstageable pressure ulcer covered with necrotic tissue. This ulcer was caused by prolonged sitting in (R16's) wheelchair. The facility is going to have to limit her time spent in the wheelchair. On 4/10/17 at 10:10 a.m., R16 had an irregular shaped wound to R16's left ischium with active bloody drainage. E4 (Registered Nurse) cleansed R16's wound with wound cleanser. Then, with the same gloves on, E4 used E4's right index finger to directly apply hydrogel to R16's wound bed and covered the wound with a border gauze dressing. On 4/10/17 at 10:15 a.m., E4 stated that she did not change her gloves during R16's wound care, and that she should have changed her gloves after cleansing R16's wound. On 4/11/17 at 9:45 a.m., Z1 stated, The sooner new interventions are put into place the better chance you have for it to work. When the area was discovered the facility needed to discuss a pressure reduction plan, and come up with new interventions to prevent the pressure ulcer from worsening. On 4/11/17 at 10:20 a.m., E3 (Care plan coordinator) stated, No new interventions were put into place after her area was discovered on 3/3/1/17. On 4/11/17 at 1:00 p.m., E7 (Wound Nurse) stated, (R16's) wound is an unstageable pressure ulcer on her left ischium. It's a pressure ulcer especially with being on a bony prominence. On 4/11/17 at 2:55 p.m., E1 (Administrator) confirmed that the facility did not identify R16's area as a pressure ulcer until R16 was seen by Z1 on 4/10/17.

Based on interview and record review, the facility failed to ensure that safety devices are in place for one of three residents (R3) reviewed for falls in the sample of 10 residents. As a result of this failure, the resident sustained [REDACTED]. Findings include: Care plan for R3, dated 11-7-11, documents an identified problem area of "At Risk for Falls" with the following intervention: "7/19/11 bed alarm to alert staff of attempts to transfer without assist." Care plan also documents that R3 had an identified problem area of "Cognitive skills for daily decision making moderately impaired--decisions poor; cues/supervision required related to dementia." On 2-1-12 at 1:30 PM, E3/CNA (Certified Nursing Assistant) stated that E3 was the staff member who found R3 lying next to the bed on 1-23-12 and that there was no alarm sounding at the time. E3 stated that R3 did not have a bed alarm on the bed as she usually did. ED (emergency department) Encounter Form documents that R3 had a 2 cm (centimeter) laceration, swelling and ecchymosis (bruising) to the left orbit/temporal, left hip pain, and 6 cm skin tear to the left knee as the result of "GLF (ground level fall) from bed to ground."