Every finding on record at Manor Court of Rochelle

Based on observation, interview, and record review, the facility failed to ensure residents incontinence briefs were changed in a timely manner for 1 of 19 residents (R67) reviewed for activities of daily living (ADLs) in the sample of 19.The findings include:On 5/11/26 at 11:02 AM, R67 was sitting in his high back wheelchair next to the nurse's station. R67's pants were wet from his crotch area extending down his left leg.On 5/11/26 at 11:21 AM, Surveyor asked V5, (Certified Nursing Assistant-CNA), when R67 was last changed. V5 said R67 was last changed when they got him up around 9:00 AM to 9:30 AM. Surveyor told V5 R67 was wet and V5 said she would check R67. V5 proceeded to leave the unit and returned a few minutes later walking with another resident.On 5/11/26 at 11:41 AM, R67 was still sitting at the nurses' station with wet pants.On 5/11/26 at 12:02 PM, V7, (CNA), wheeled R67 down to his room to change him. At 12:05 PM V5 entered R67's room with the mechanical lift. As V5 and V7 raised R67 from his wheelchair, R67's whole frontal area and down his left leg of his pants were soaked and a strong, foul, urine odor permeated the room. R67's wheelchair cushion and back of his pants, and the lift sling were all wet. Once R67 was lying on his bed and his pants were removed, his incontinence brief was visualized to be soaked with urine and as he was turned to his side, bowel movement was also present.On 5/12/26 at 12:16 PM, V2, (Director of Nursing-DON), said residents should be changed whenever they are soiled, and every two hours with rounding.R67's Minimum Data Set, dated [DATE] shows R67's cognition is severely impaired, he is dependent on staff for toileting hygiene, lower body dressing, and personal hygiene and is always incontinent of urine and frequently incontinent of stool. R67's care plan last reviewed/revised on 3/3/26 shows R67 is at increased risk for pressure ulcers related to decreased mobility and incontinence. R67's care needs are to be met on a daily basis.The facility's Personal Care of Residents Policy (revised 12/02) shows it is a policy of the facility to provide a plan of personal care for residents. The purpose is to provide that residents of the facility receive adequate care. Each resident shall have clean, suitable clothing in order to be comfortable, sanitary, odor free, and decent in appearance.

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services were provided to prevent further decrease in range of motion (ROM), mobility, and function for 1 of 3 residents (R9) reviewed for restorative care in the sample of 19. The findings include:On 5/11/26 at 9:48 AM V5 and V6, (Certified Nursing Assistants-CNAs) were providing incontinence care for R9. V6 said she does not believe R9 is on a restorative program. V5 said R9 is very contracted. R9 was unable to assist in his care at all, he was completely dependent on the CNAs to move him, including the use of a mechanical lift to transfer him, and provide hygiene. R9's legs were both bent at the knees and could not be straightened.On 5/12/26 at 11:54 AM, V8, (Restorative Aid), said when a resident is admitted , therapy evaluates them and gives restorative a treatment plan. V8 said there is no restorative nurse, she either goes to V2, (Director of Nursing-DON), or V10, (Director of Rehab/Physical Therapy Aid) for any restorative concerns. On 5/12/26 at 12:16 PM V2, (DON), was asked who oversaw their restorative program. V2 said they don't have a restorative program, they have [name of the facility's active range of motion (AROM) program] and she and the MDS (Minimum Data Set) nurse, V9, makes recommendations for the residents' fitness need/restorative needs. V2 said she does not have any restorative specific training, and she doesn't know if V9 does or not. V2 said they determine residents' needs based on observations; she thinks it's based on therapy. On 5/12/26 at 1:21 PM, V2 again said we don't have a restorative program, we have an AROM program. V2 said V8 is the AROM aid who provides the AROM. V2 said residents get passive ROM (PROM) during their care. V2 said if V8 has any issues, she comes to either herself or V9. V2 said they don't have a restorative policy, just the AROM policy.On 5/12/26 at 1:37 PM, V9, (MDS Coordinator), said they have two separate programs for restorative; [name of AROM program] is one done by V8 and the other program is done by the CNAs as they provide the residents' ADLs (activities of daily living), such as walking them. V9 said just the basic ADLs are done and the CNAs have no specialized training, just their CNA training. V9 said therapy will write them a program on what to provide for the residents. V9 said she is not sure how often residents are evaluated, she does not manage the programs, she just puts the restorative information provided by a sheet from [name of AROM program]. V9 said whenever V8, staff, or therapy feels a resident needs an evaluation, they are referred to therapy for an evaluation. V9 said she does not know how V8 became the restorative aid; she does not know her qualifications. V9 said if V8 came to her with questions or concerns about a resident's restorative needs, she would bring therapy into the discussion, as she does not know what's best for movements for the residents. V9 said she has not had any extra or specialized training for restorative nursing. On 5/12/26 at 2:28 PM, V1, (Administrator,) said when they discuss [name of AROM program], it's just a brand name for their restorative program. V1 said V8 is not a restorative aid, she is an [name of AROM program] aid. V1 said V9 oversees the [name of AROM program] program.On 5/12/26 at 2:29 PM, V9 said therapy gives her the recommendations and she puts it on the computer under the residents' care plan.On 5/13/26 at 9:44 AM, V8 said R9 cannot stretch his own legs, he cannot do AROM except to his left hand. V8 said R9 cannot straighten his knees and his right side is flaccid.On 5/13/26 at 10:26 AM, V1 said she spoke with R9's family and they don't want to pay for therapy or anything extra; they encourage the AROM.On 5/13/26 at 10:36 AM V8 said she does not know if therapy was informed about R9's decrease in ADLs function. V2 said they noticed a decrease in R9's ADLs, but family won't pay for therapy. V2 said she does not have any documentation whereby R9's family refused to pay for R9's therapy.On 5/13/26 at 10:44 AM, V10 said she screened R9 for therapy back in December of 2025 and she wanted to pick him up for contracture management but couldn't because they did not know R9's insurance benefits. V10 said she screened R9 again last month (April 2025) for contracture management. V10 said at this time, R9 is on the list to call his family about rehab. V10 said R9 can do AROM with his left arm, all three of his other limbs are contracted and he has limited range of motion and mobility in his legs and right arm. V10 said R9 should be on a passive range of motion program for his three contracted limbs. V10 said therapy last made restorative recommendations for R9 in September of 2024. V10 said if a resident is not on therapy caseload, therapy cannot make recommendations; they cannot touch the resident. V10 said they need to be able to touch the residents to fully evaluate them. V10 said the purpose of restorative care is to help [residents] maintain current functioning, and to help prevent further decline. V10 said she cannot say if there is/was more restorative care that could/can be done, because she cannot assess R9 properly. V10 said the CNAs let them know if a resident has a decline in function/mobility. V10 said when she screens a resident, she can only observe the resident. V10 said she does not know if a certified restorative nurse could assess a resident and change a restorative plan.R9's Observation Detail List Report: Functional Abilities/Restorative Programs with observation date of 9/24/25 completed 9/25/25 at 10:30 AM by V9 shows R9 can eat with setup or clean-up assistance, perform his own oral hygiene with partial/moderate assistance, can shower/bathe himself, dress his upper body, and move from sitting to lying with substantial/maximal assistance. This same report shows R9 has no impairment in functional limitation in ROM to his lower extremity (hip, knee, ankle, foot), has a need for restorative programs, has physical limitations, and is currently participating in AROM, bed mobility, and dressing/grooming. The current goals for programs are still appropriate.R9's Observation Detail List Report: Functional Abilities/Restorative Programs with observation date of 12/23/26 completed 1/23/26 at 2:48 PM by V9 shows R9 requires supervision or touching assistance to eat and is dependent on staff for oral hygiene, shower/bathing, upper body dressing, and moving from sitting to lying. This same report shows R9 has no impairment in functional limitation in ROM to his lower extremity (hip, knee, ankle, foot), has a need for restorative programs, has physical and cognitive limitations, requires hands on physical support, and is currently participating in AROM, bed mobility, and dressing/grooming. The current goals for programs are still appropriate.R9's Face Sheet (not dated) shows his diagnoses include, but are limited to, hemiplegia affecting right dominant side, contractures of the right and left knee, generalized muscle weakness, difficulty in walking, dysarthria, need for assistance with personal care, history of transient ischemic attack (TIA), Parkinson's disease, and Parkinsonism. R9's current care plan (last reviewed/revised 3/3/26) shows R9 has an AROM program for his lower extremities.The facility's Active Range of Motion Program (revised 04/2014) shows the MDS Coordinator (or designee) determines if the resident would benefit from PROM and/or AROM. Therapy staff may consult in AROM program development. The MDS Coordinator develops a program that includes objective, measurable goal(s) and approaches to address the identified loss of voluntary ROM or risk for loss of voluntary ROM. Training for staff must be documented. The ability to tolerate AROM should be discussed with the MDS Coordinator who reassesses and revises the residents' program.

Based on observation, interview, and record review, the facility failed to ensure staff changed gloves and completed hand hygiene during incontinence care for 1 of 19 residents (R9) reviewed for infection control in the sample of 19.The findings include:On 5/11/26 at 9:48 AM, V5 and V6, (Certified Nursing Assistants-CNAs) were providing incontinence care for R9. Using gloved hands, V5 wiped stool from R9's bottom as she removed his incontinence brief. V5 continued to wipe stool with a washcloth. Without changing her gloves or performing hand hygiene, V5 wiped R9's penis and frontal peri area.On 5/12/26 at 1:01 PM, V4, (Infection Prevention Nurse), said during incontinence care, staff should wash their hands, provide dirty care, then change their gloves and perform hand hygiene, then don clean gloves before moving to a clean area. V4 said the purpose is to ensure germs/pathogens are not transferred to places you don't want them.The facility's Standard Precautions Policy (revised 08/09) shows the objective is to prevent the spread of infectious agents among residents and healthcare personnel in the facility. Hand hygiene should be performed immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. Utilize hand hygiene between tasks and procedures on the same resident to prevent cross contamination of different body sites.

Based on interview and record review the facility failed to ensure a physician ordered medication was administered as prescribed and failed to document medication administration for 1 of 1 resident (R1) reviewed for medication administration in the sample of 5. The findings include: 1. R1's face sheet printed on 4/21/26 showed diagnoses including but not limited to multiple sclerosis, seizures, dementia without behaviors, and generalized anxiety disorder. R1's facility assessment dated [DATE] showed moderate cognitive impairment.R1's April 2026 physician order report showed an order for alprazolam 0.25 milligrams to be given once an evening at 9:00 PM (antianxiety medication).R2's April 2026 physician order report showed an order for alprazolam 0.5 milligrams to be given once a day at bedtime 9:30 PM. On 4/21/26 at 11:15 AM, V4 (Registered Nurse) stated he accidentally gave R1 the wrong dose of alprazolam on the evening shift of 4/15/26. V4 said he gave R1 double the amount she should have received. V4 said he grabbed the wrong alprazolam medication card. V4 said he realized the error 30-40 minutes later, when he went to administer alprazolam to R2. The count was off by one tablet, and he immediately realized what had happened. V4 said R1 and R2 get similar medications around 9 PM each evening. V4 said he immediately assessed R1 and called the physician. V4 was told to continue to monitor and report back if any change in condition was noted. V4 said he continued vital signs and assessed mental status every 60-90 minutes. R1 was pleasant and at her baseline throughout the shift. V4 said he notified the on-call nurse supervisor, V3 (Assistant Director of Nurses) the same evening. V4 said he completed a medication error form and was re-educated by V2 (Director of Nurses) the next day. 2. R1's April 2026 MAR (Medication Administration Report) showed the 9:00 PM dose of alprazolam was not given on 4/14/26 (evening before the wrong dose given). The MAR was signed by V5 (Licensed Practical Nurse). The reason for not giving the medication showed other N/A. There was nothing in R1's chart explaining why the medication was not given.On 4/21/26 at 11:37 AM, V5 (LPN) stated she was sure the alprazolam was given to R1 that evening. V5 said she was not familiar with the electronic charting system yet and had only worked with it for about one week. V5 stated she should have explained why it wasn't given if that was the case. V5 said it was likely a charting error on her part, and the medication definitely was given. V5 said the MAR needs to be correct to show what is happening with the resident. Accurate charting is especially important with something like alprazolam, which is a controlled medication. V5 said she needs to refresh herself on how to use the newer electronic application before her next shift.On 4/21/26 at 11:52 AM, V2 (Director of Nurses) stated R1 did get the wrong dose of alprazolam on 4/15/26. V2 relayed the same specifics of the medication error as reported by V4. V2 said residents should always receive medications as ordered. Accurate charting is important to ensure the health and safety of the residents. The facility's Medication Administration policy dated 02/04 stated: 6. All medications must be administered to the resident in the manner and method prescribed by the physician.11. Documentation of meds given will be done in a consistent manner by the nurse placing her initials in the appropriate space on the MAR. Documentation on the MAR will be done at the time of administration of the medication.

Based on observation, interview, and record review the facility failed to provide timely incontinence care and ensure a resident's urinary drainage bag was not touching the floor for 2 of 6 residents (R2 & R4) reviewed for incontinence care and catheters in the sample of 9.The findings include:1. On 3/19/26 at 9:27 AM, V7 Certified Nursing Assistant - CNA, V6 CNA, V4 Shift Coordinator came to R2's room to make the bed and transfer R2 from his padded wheelchair to his bed. V7 and V4 used a mechanical lift to transfer R2 from his padded wheelchair to his bed. The back of R2's pants were soaked in the buttock area and down his legs. The pad and sling in his padded wheelchair were wet. V6 told V7 and V4 that they would need a new pad for his chair. V6 said the pad in his chair and the sling that was on top of the pad were wet. V7 and V4 removed R2's soaked pants and incontinence brief. R2 had a large, reddened area to his right buttock.On 3/19/26 at 2:08 PM, V2 Director of Nursing - DON stated staff are to round on residents every two hours and try to toilet/provide incontinence care as close as they can to every two hours. The facility's 3rd Shift list/worksheet for the CNA showed R2 was one of the residents that the third shift gets up in the morningThe Face Sheet dated 3/19/26 for R2 showed diagnoses including right side hemiplegia, hypothyroidism, constipation, left and right knee contracture, parkinsonism, dysarthria and anarthria, atherosclerotic heart disease, cerebrovascular disease, hypertensive heart and kidney disease, heart failure, chronic kidney disease stage 3, hypertension, anemia, hyperlipidemia, major depressive disorder, adjustment disorder with anxiety, transient ischemic attack, dermatitis, insomnia, schizoaffective disorder, gastro-esophageal reflux disease, cognitive communication deficit, muscle weakness, cerebrovascular disease, Parkinson's disease, hyperlipidemia, and dysphagia.The Care Plan dated 3/3/26 for R2 showed he was at increased risk for skin breakdown, pressure ulcers related to decreased mobility, generalized muscle weakness, incontinence of bowel and bladder. Provide incontinence care after each incontinent episode.The Minimum Data Set, dated [DATE] for R2 showed he was dependent for activities of daily living except for eating; and always incontinent of bowel and bladder.The facility's Personal Care of Residents policy (12/2002) showed the purpose of the policy was to provide that residents of the facility receive adequate care. Procedure: each resident shall have proper daily personal attention and/or care.2. On 3/19/26 at 8:01 AM, R4 was sitting in her wheelchair at the dining room table. R4 had an indwelling urinary catheter drainage bag under her chair with no cover/dignity bag on it. The drainage bag was touching the floor. At 8:34 AM, V10 Registered Nurse - RN went over to R4 and pulled her wheelchair away from the table and pushed her across the dining room floor to the hall. V10 was stopped and asked if she noticed the bag was dragging on the floor. V10 stated she didn't and then looked under the wheelchair. V10 said there should be a bag covering the drainage bag and the drainage bag should not be touching the floor for infection control.On 3/19/26 at 2:08 PM, V2 DON stated catheter drainage bags should not be touching the floor for infection control reasons. The drainage bags have dignity bags and those are supposed to be used. There are extras available so there would be no reason for one not to be in place. The Face Sheet dated 3/19/26 for R4 showed medical diagnoses including Alzheimer disease, urinary tract infection, acute cystitis without hematuria, chronic obstructive pulmonary disease, altered mental status, deep venous thrombosis, edema, muscle weakness, basal carcinoma of skin, disorder of thyroid, morbid obesity, hyperlipidemia, anxiety disorder, glaucoma, hypertension, osteoarthritis, diarrhea, constipation.The Care Plan dated 3/3/26 for R4 showed R4 is on enhanced barrier precautions due to having colonized ESBL in the urine. Staff will be provided with appropriate PPE to provide for R4's care. R4 has a history of urinary tract infections. R4's care plan did not show that she had an indwelling urinary catheter or any interventions related to the catheter.The facility's Catheter Care policy (6/2005) did not show anything about keeping the drainage bag off the floor. The facility did not have any other policies related to catheters.

Based on observation, interview, and record review the facility failed to ensure enhanced barrier precautions - EBP were in place when handling residents' indwelling urinary catheters for 2 of 3 residents (R4 & R7) reviewed for infection control in the sample of 9.The findings include:1. On 3/19/26 at 8:01 AM, R4 was sitting in her wheelchair at the dining room table. R4 had an indwelling urinary catheter drainage bag under her chair with no cover/dignity bag on it. The drainage bag was touching the floor. At 8:34 AM, V10 Registered Nurse - RN went over to R4 and pulled her wheelchair away from the table and pushed her across the dining room floor to the hall. V10 was stopped and asked if she noticed the bag was dragging on the floor. V10 stated she didn't and then looked under the wheelchair. V10 said there should be a bag covering the drainage bag and the drainage bag should not be touching the floor for infection control. V10 tried to place the drainage bag up more so it wasn't on the floor. V6 Certified Nursing Assistant - CNA came over to help her with the drainage bag. V10 and V6 did not have personal protective equipment on when touching the uncovered drainage bag.On 3/19/26 at 2:49 PM, V11 Assistant Director of Nursing - ADON stated EBP should be followed; gown and gloves should be worn when handling catheters. This is done for infection control.The Face Sheet dated 3/19/26 for R4 showed medical diagnoses including Alzheimer disease, urinary tract infection, acute cystitis without hematuria, chronic obstructive pulmonary disease, altered mental status, deep venous thrombosis, edema, muscle weakness, basal carcinoma of skin, disorder of thyroid, morbid obesity, hyperlipidemia, anxiety disorder, glaucoma, hypertension, osteoarthritis, diarrhea, constipation.The Physician Orders for R4 showed an order was placed on 2/19/26 for an 18 French, 15 cc, 3 way indwelling urinary catheter.The Care Plan dated 3/3/26 for R4 showed R4 is on enhanced barrier precautions due to having colonized ESBL in the urine. Staff will be provided with appropriate PPE to provide for R4's care. R4 has a history of urinary tract infections.The Progress Note dated 3/18/26 at 1:53 PM for R4 showed she remains on prophylactic antibiotics for urinary tract infection.The facility's Enhance Barrier Precautions policy (3/28/24) showed enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce the transmission of multidrug resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multidrug resistant organism - MDRO. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.2. On 3/19/26 at 2:35 PM, R7 was sitting up in her recliner in her room. V12 Registered Nurse - RN was next to her with gloves on trying to get a urine sample by aspirating it from the tube with a syringe. V12 had the catheter tubing clamped off distally so it would not drain into the bag. When V12 was done she was asked if the resident was on enhanced barrier precautions and she said she wasn't sure; she thought R7 might be. V12 stated a gown, and gloves should be worn anytime she does anything with the catheter. There was a sign on the resident door that said EBP and what they should wear and when it should be worn.On 3/19/26 at 2:49, V11 Assistant Director of Nursing - ADON stated EBP should be followed; gown and gloves should be worn when handling catheters. This is done for infection control.The Care Plan dated 3/3/36 for R7 showed resident Care Information: Enhanced barrier precautions per facility protocol.The Progress Notes dated 3/19/26 for R7 showed she was presenting with a new onset of hematuria, and the doctor ordered a urinalysis and to push fluids.The March 2026 Physician Orders for R7 showed she has an 18 French, 10 cc indwelling urinary catheter.The Face Sheet dated 3/19/26 for R7 showed diagnoses including rhabdomyolysis, congestive heart failure, wedge compression fracture of lumbar vertebra, paroxysmal atrial fibrillation, hypercholesterolemia, hypertension, hypothermia, pneumonia, obesity, muscle weakness, deep venous thrombosis, urinary tract infection, acute respiratory failure with hypoxia, bullous disorder, lymphedema, venous insufficiency, fall.The facility's Enhance Barrier Precautions policy (3/28/24) showed enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce the transmission of multidrug resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multidrug resistant organism - MDRO. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.

Based on observation, interview and record review the facility failed to monitor post fall neurological checks, failed to notify the physician of an unwitnessed fall and failed to follow care plan interventions for one resident (R3) of three residents reviewed for falls in the sample of three.This Failure resulted in R3 sustaining a left hip fracture from an unwitnessed fall in the unit dining room at 3am in the morning.Findings include:Physician Order Report Summary indicates R3 was admitted to the facility 11/29/23 with diagnoses that include Anxiety, Arthritis, Severe Dementia with Agitation, and Insomnia.Comprehensive Cognitive assessment dated [DATE] indicates R3 is severely cognitively impaired.On 7/24/25 at 1:05pm R3 was observed sitting in a wheelchair during a church group activity. R3's head was down and appeared to be sleeping.On 7/24/25 at 1:10pm V4, RN (Registered Nurse) stated prior to R3's fall, R3 ambulated slow and steady with her walker, rarely using a wheelchair.Nurse Note dated 7/1/25 at 3:30am documented by V5, Agency Nurse indicates V5 was called by a CNA (Certified Nursing Assistant) with information that R3 had fallen. Note indicates V5 arrived in the lobby area of the unit to find R3 seated on the floor against a chair which is by the wall. Note indicates R3 is alert and oriented. When V5 asked R3 what happened, R3 responded that she had been walking around with her walker and fell. Note indicates V5 and CNA staff assisted R3 into a chair by the wall and V5 collected vital signs which were documented as: (blood pressure) 126/70, Pulse 70. Temperature 97.3F (Fahrenheit) and Respirations 20. Note indicates R3 is later escorted to her room.Nurse Note dated 7/3/25 at 5:58pm as documented by V9, (Nurse Supervisor) Recorded as Late Entry on 7/7/25 at 2:49 pm) indicates Verbal statement by V5, RN (Registered Nurse) as follows:At approximately 3am on 7/1/25, (V5) was called by CNA staff with information that (R3) had fallen. (V5) arrives to the dining area of the unit to find (R3) seated on the floor against a chair which was by the wall. (R3) is alert and oriented. When (V5) asks (R3) what happened, (R3) said she was walking around with her walker and fell. (V5) and CNA staff assisted (R3) on to the chair and (V5) collected vitals. (V5) assessed LOC (Level of Consciousness) to conclude that R3 is alert to person and place. R3 is able to participate in getting up from the floor as V5 and CNA assist her. R3 is calm and compliant during transfer. R3 skin is intact with no wounds or openings. No injuries noted. (R3) c/o (complains of) pain to back and side, gave pain medication to (R3) and later escorted to her room by this nurse who assess(es) her movements for any limping. No limping noted as (R3) independently uses walker with nurse to her side.On 7/24/25 at 2:30 pm V9 stated she called V5 (on 7/3/25) to confirm V5's documentation was complete. V9 confirmed at that time that V5 did not complete neurological checks and did not notify the physician of R3's fall. V9 also confirmed there was no follow up documentation of R3's complaints of back and side pain and there was no medication administration documentation that pain medication was administered for R3's complaints of pain. Nurse Note dated 7/1/25 at 7:28am (documented by V3, LPN/Licensed Practical Nurse) indicates R3 refused to get up this am due to extreme pain at left hip/thigh area. Note indicates ROM (Range of Motion) completed, but with complaints of pain. Note indicates R3 does have pain at times, but usually does not refuse to get out of bed. Note indicates physician notified requesting X-rays and granted; POA (Power of Attorney) updated. R3 transferred to via ambulance to obtain X-rays. Report to hospital; Administrator notified of transfer.On 7/24/25 at 2:50pm V3, LPN stated, I did not receive any nurse/shift report regarding (R3's) fall until after I was told by my dayshift CNA's that there was something wrong with (R3). V3 stated the dayshift CNA's were waiting for her to arrive (the morning of 7/1/25), barely had time to take off my coat when the dayshift CNA's stopped me in the hallway, so I went directly to (R3's) room. V3 stated R3 was in severe pain and was most likely in pain all night. V3 stated she had one of the CNA's stay with R3 while she immediately contacted the physician regarding R3's pain. V3 stated, I didn't know what was wrong with (R3) but she needed to be sent out. V3 stated after she made arrangements to have R3 transported to the hospital. V3 stated she finally received report from V5 and all V5 reported was that (R3) fell and was put back in bed. Nothing else.Attempts made to contact V5 for interview on 7/24/25 were unsuccessful.On 7/24/25 at 2:20pm V8, CNA stated R3 does get up sometimes at night and will come out of her room without her walker. V8 stated, (R3) is not supposed to walk around by herself.Current Care Plan indicates R3 requires assistance of one with walker or ambulation. Care Plan indicates R3 has a history of falls prior to admission and is at risk for falling related to poor safety awareness, doesn't use the call light and has a diagnosis of Dementia. Care plan also indicates observe frequently and place in supervised area when out of bed (date initiated 1/17/25).Incident Report dated 7/1/25 indicates R3 was last seen at 2am in the unit Living Room with other residents.No documentation was found or presented to indicate why R3 was ambulating unsupervised in the dining room at 3am in the morning. Facility Policy/Emergencies: Immediate Care of the Resident/Falls dated 4/3/2018 documents: If a fall is unwitnessed, notify the physician and initiate neurological checks at least every four hours for twenty four hours, or until stable, or as otherwise ordered by the physician.

Based on interview and record review the facility failed to monitor post fall pain and failed to notify the physician of complaints of post fall pain for one resident (R3) of three residents reviewed for falls in the sample of three.This failure resulted in a lack of pain management post fall for 5 hours after R3 sustained a left hip fracture.Based on interview and record review the facility failed to monitor post fall pain and failed to notify the physician of complaints of post fall pain for one resident (R3) of three residents reviewed for falls in the sample of three. This failure resulted in a lack of pain management post fall for 5 hours after R3 sustained a left hip fracture.Findings include:Physician Order Report Summary indicates R3 was admitted to the facility 11/29/23 with diagnoses that include Anxiety, Arthritis, Severe Dementia with Agitation and Insomnia.Comprehensive Cognitive assessment dated [DATE] indicates R3 is severely cognitively impaired.Nurse Note dated 7/3/25 at 5:58pm as documented by V9, Nurse Supervisor Recorded as Late Entry on 7/7/25 at 2:49 pm) indicates Verbal statement by V5, RN (Registered Nurse) as follows:At approximately 3am on 7/1/25, (V5) was called by CNA staff with information that (R3) had fallen. (V5) arrives to the dining area of the unit to find (R3) seated on the floor against a chair which was by the wall. (R3) is alert and oriented. When (V5) asks (R3) what happened, (R3) said she was walking around with her walker and fell. (V5) and CNA staff assisted (R3) on to the chair and (V5) collected vitals. (V5) assessed LOC (Level of Consciousness) to conclude that R3 is alert to person and place. R3 is able to to participate in getting up from the floor as V5 and CNA assist her. R3 is calm and compliant during transfer. R3 skin is intact with no wounds or openings. No injuries noted. (R3) c/o (complains of) pain to back and side, gave pain medication to (R3) and later escorted to her room by this nurse who assess(es) her movements for any limping. No limping noted as (R3) independently uses walker with nurse to her side.Nurse Note dated 7/1/25 at 7:28am (documented by V3, LPN/Licensed Practical Nurse) indicates R3 refused to get up this am due to extreme pain at left hip/thigh area. Note indicates ROM (Range of Motion) completed, but with complaints of pain. Note indicates R3 does have pain at times, but usually does not refuse to get out of bed. Note indicates physician notified requesting X-rays and granted; POA (Power of Attorney) updated. R3 transferred to via ambulance to obtain X-rays. Report to hospital; Administrator notified of transfer.On 7/24/25 at 2:50pm V3, LPN stated I did not receive any nurse/shift report regarding (R3's) fall until after I was told by my dayshift CNA's that there was something wrong with (R3). V3 stated the dayshift CNA's were waiting for her to arrive (the morning of 7/1/25), barely had time to take off my coat when the dayshift CNA's stopped me in the hallway so I went directly to (R3's) room. V3 stated R3 was in severe pain and was most likely in pain all night. V3 stated she had one of the CNA's stay with R3 while she immediately contacted the physician regarding R3's pain. V3 stated I didn't know what was wrong with (R3) but she needed to be sent out. V3 stated after she made arrangements to have R3 transported to the hospital, she finally received report from V5 and all V5 reported was that (R3) fell and was put back in bed. Nothing else.Nursing Note dated 7/1/25 at 12:35pm indicates V3, LPN was informed that R3 had been admitted to the hospital for left hip fracture.Medication Administration Record dated 6/28/25 to 7/1/25 indicates the following pain medications were ordered for R3 at the time of the fall on 7/1/25: Tylenol (analgesic) 650mg (milligrams) every six hours as needed for pain and; Tramadol (opioid analgesic) 50mg every six hours as needed for pain.Medication and Treatment Administration Records June 28/2025 through July 1, 2025 found no assessment of R3's pain post fall 7/1/25 at 3am despite R3 complaining of back/side pain post fall and no documentation of any pain medication administered post fall.Current Care Plan had no active problem of pain management prior to or after R3's fall on 7/1/25.No nursing notes were found or presented to describe descriptors or intensity of back and side pain.Attempts made to contact V5 for interview on 7/24/25 were unsuccessful.Facility Policy/Pain Management dated 3/3/2022 documents: Purpose - To identify residents experiencing pain to establish control of pain to the resident's satisfaction and to relieve related symptoms. Staff Responsible: All staff. Procedure: Residents will be observed/asked about pain at a minimum of each shift by the nurse using a standardized 0-10 scale or Verbal Descriptor Scale to determine pain intensity. The physician will then be contacted, if needed, regarding the pain indicators. Licensed staff will document any contact with the physician and the physician's response. Residents will be monitored until pain is resolved or is under control and periodically thereafter. Licensed staff will document any complaints of pain and the resident's response to the medication/treatment in the resident's record.

Based on interview, and record review the facility failed to identify a resident with a change in condition resulting in a delay in treatment from 5-11-2025 to 5-12-2025. This applies to 1 of 3 (R1) residents reviewed for quality of care in the sample of 3. This failure resulted in R1 needing to be hospitalized for removal of a denture appliance under anesthesia. The findings include: R1's current Resident Face Sheet shows R1 is a [AGE] year-old male resident with a medical history of Parkinson's, tremor, and vascular dementia with mild behavioral disturbance admitted to the facility on [DATE]. On 5/19/2025 at 2:36PM, V4 Certified Nursing Assistant (CNA) said he took care of [R1] on 5/9/2025 into the morning of 5/10/2025. V4 said he did assist [R1] with oral care and placed [R1's] dentures in this mouth that morning, noting they fit well. V4 said [R1] does require assistance with his dentures as he has Parkinson's and has tremors. On 5/19/2025 at 10:14AM and 1:47PM, V5 CNA said she was working with [R1] on 5/10/2025 and 5/11/2025 on night shift. V5 said the first day she noticed [R1] didn't have his dentures was Sunday morning [5/11/2025]. V5 said she did not report the missing dentures to anyone. V5 said she thought they had just been misplaced. V5 said [R1] was not in any distress when she worked with him, and he was not clearing his throat. V5 said she got [R1] up in the morning when she worked with him. On 5/19/2025 at 1:25PM, V12 CNA said he helped put [R1] to bed on Sunday night [5/11/2025]. V12 said he did assist [R1] with oral care that night, brushing his teeth, but didn't see any dentures. V12 said they were very busy that night and he didn't check the report sheet that has patient information such as if they have dentures or not. V12 said he does not normally work that unit and is unfamiliar with the resident. V12 said he did hear some gurgling sounds but thought it was related to brushing [R1's] teeth. V12 said [R1] was breathing normal and did not appear to be in any distress. On 5/19/2025 at 2:46PM, V13 CNA said she was working on Mother's Day weekend with [R1] but did not provide [R1] with oral care that day because they were really behind that day. V13 said family had approached her regarding the resident having a gurgling sound and she reported it to [V10]. V13 said [V10 assessed [R1]. V13 said [R1] needs assistance with his dentures. V13 said [R1] seemed present on Saturday but was more tired on Sunday during 'lay downs'. On 5/19/2025 at 8:57AM, 10:44AM, and 12:38PM, V10 Registered Nurse (RN) said [R1's] family had reported he had some gurgling noises on Sunday [5/11/2025]. V10 said she went to see [R1], and he didn't appear to be in any distress or having breathing issues. V10 said [R1's] lung sounds were diminished, and she messaged V14 Physician about a chest x-ray, which was ordered. V10 said the x-ray was not a stat order and the x-ray company said they would be in the following day [5/12/2025] to do the x-ray. V10 said non stat x-rays are done in about 24 hours normally. V10 said [R1] had lost his upper dentures about a month ago and only had his bottom denture which was a partial. On 5/19/2025 at 1:00PM, V6 RN said on 5/12/2025 [R1's] family approached her about him sleeping in the dining room and asked what the x-ray showed. V6 said she explained she didn't have any x-ray results because it wasn't done over the weekend. V6 said she went to check on [R1] and he was sleeping in the chair. V6 said his lung sounds were diminished with audible congestion. V6 said she called [V14] regarding transfer to the hospital for evaluation and [V14] was ok with transfer. On 5/19/2025 at 4:17PM, V7 Licensed Practical Nurse (LPN) said [R1] was sent out on 5/12/2025 because he was having increased lethargy and some crackles. V7 said [R1's] oxygen saturation was 98% prior to leaving with paramedics on 5/12/2025. On 5/19/2025 at 3:05PM, V14 (Physician) said [R1] did have a foreign body in his airway or above it that needed to be removed. V14 said he wasn't close to serious harm or death with slightly abnormal breath sounds, stable vital signs, and was still oxygenating. On 5/20/2025 at 8:36AM, V18 Fire Department Lieutenant read the report for the 5/12/2025 at 9:18AM for [R1]. V18 said [R1] was picked up for difficulty breathing and was classified as emergent, but not critical or unstable. V18 said two oxygen saturations were documented one at 96% on room air and another at 89% and 3 liters of oxygen via nasal cannula was started. V18 said [R1] was arousable with sternal rub initially and then was following commands and tracking with his eyes. V18 said [R1] had bilateral rhonchi noted and difficulty breathing. V18 said they gave [R1] a GCS (Glasgow Coma Scale) of 10. V18 said if someone can follow commands, they would still have a gag reflex and artificial airway placement would be contraindicated. V18 said a GCS of 8 or less would indicate intubation would be appropriate. V18 stated [R1's] vitals were listed as 97.9 temperature, 95 heart rate, 154/76 blood pressure, 22 respiratory rate. On 5/20/2025 at 10:15AM, V2 Director of Nursing (DON) said [R1] requires assistance with oral care and would not be responsible for them himself. V2 said staff should report missing dentures. V2 said abnormal breath sounds should be followed up on and assessed by nursing staff. R1's Search Vitals Results 5/5/2025 to 5/20/2025 show vitals of 98.1 temperatures, 68 heart rate, respiratory rate of 22, blood pressure of 105/51, and an oxygen saturation of 97% on 5/12/2025 at 8:34AM. R1's current care plan shows [R1] has generalized muscle weakness, fatigue, poor activity tolerance, and decreased mobility [dated 11/8/2024] . and approach of mouth care: staff will assist with oral care as needed. [R1] has top and bottom dentures. R1's hospital records shows resident was transferred from the facility to [a local area hospital] for foreign body aspiration on 5/12/2025. Hospital records state the resident has been gurgling over the past couple of days and CT chest showed the dental denture within the pharynx. Therefore, the patient was transferred to [another local area hospital] to receive a higher level of care. R1's hospital procedure notes state on 5/12/2025 [R1] was brought to the operating room and monitoring anesthesia care with sedation was administered. Time out performed. The pharynx was examined with a Glide laryngoscope and thick secretions were suction. The intact dental appliance was visible in the hypopharynx, and it was removed without trauma with a [NAME] forceps. The hypopharynx and larynx were inspected and found to be free of mucosal trauma or other foreign bodies. The patient was turned over to anesthesia to transport back to his room. There were no complications. The dental appliance was given to the patient's son who verified that it was fully intact. R1's 5/12/2025 hospital records show [R1] was noted to have pneumonia and was started on antibiotic therapy related to pneumonia.

Based on interview and record review the facility failed to address the loss of a resident's denture and formulate a plan for replacement. This applies to 1 of 3 (R1) in the sample of 3 reviewed for denture care. The findings include: On 5/20/2025 at 11:13AM, V9 Social Services Director said [R1's] upper denture was reported missing on 4/13/2025. V9 said she investigated the missing dentures on 4/14/2025 and they were unable to find the missing upper denture for [R1]. V9 said when residents are admitted to the facility it is explained to them the facility is not liable for missing or lost items unless the facility is liable. V9 said she was unaware if the facility was going to pay for the lost dentures or not. On 5/20/2025 at 10:15AM, V2 Director of Nursing (DON) said [R1] requires assistance with oral care and would not be responsible for them himself. V2 said staff should report missing dentures. The facility failed to provide documentation of any conversation with [R1's] family regarding the lost dentures and replacement/payment agreement prior to the initiation of the survey on 5/19/2025. The Loss Control/Damage Report (Form #NH-553) shows the investigation was began on 4/14/2025 for a missing upper denture plate which was identified on 4/13/2025 and the report was signed off on 4/15/2025. The report does not indicate a resolution or liable party for missing dentures. The facility provided copy of the Admission Agreement contact states. W. Indemnification: The Resident will defend, indemnify and hold the Facility harmless from any and all claims, demands, suit and actions made against the Facility by any person resulting from any damage or injury caused by the Resident to any person or property of any person or entity (including the Facility), except in the case of negligence of the Facility's employees and agents. The facility provided Loss/Damage of Dentures revised 6/1/2022 states, the facility shall not be held responsible for replacement/cost of repair of dentures unless the loss or damage is determined to be the result of negligence on the part of the facility, or loss and/or damage occurs when the resident has provided dentures to the facility for safekeeping.

Based on interview and record review the facility failed to provide adequate staffing to meet the needs of the residents. This failure has the potential to affect all 76 residents residing in the facility. The findings include: The facility completed entrance form titled Facility Data Sheet and the Resident Roster shows the facility census on 5/14/25 was 76. On 5/14/25 at 8:36 AM, V4 CNA (Certified Nursing Assistant) said generally for the Liberty Lane unit which has 27 residents on it they have only 2-3 CNA's for the whole unit. V4 said the unit has a lot of heavy care residents including mechanical lifts. V4 said when staffing is low sometimes showers are missed, and residents have to wait longer because they have to prioritize who they get to first and can lay down. On 5/14/25 at 8:48 AM, V5 and V6 both CNA's said the Liberty Lane unit is a very heavy patient care unit of the facility and they are 13 residents requiring mechanical lifts on that unit. V6 said, When we have only two CNA's that is a big problem because two of us have to be in the room together when we are transferring residents into and out of bed to lay them down and do cares. There are also residents who need feeding assistance and if they are in helping other residents then there are simply not enough staff to get to everyone. V5 said they have to prioritize who gets changed going off from who was last changed. V6 said residents families get upset with us about residents having to wait and we explain it to them why it is. Both said it is very often that the facility is running short of CNA's to care for the residents. V6 said residents should get changed every couple hours and receive showers twice a week and when there is not enough staff this doesn't happen. On 5/14/25 at 9:10 AM, R2 said, I have never been so unhappy in my entire life. I came here after another facility I was at closed down. I wait a long time when I put my call light on. Last evening I put my light on to talk to a nurse at 4 PM and I am still waiting today for that nurse to come. Last Monday I didn't get my shower/bath I asked the CNA's about it and they both looked at each other and didn't say a word. While interviewing R2 she pulled out packets of paper to show this surveyor where she documents everything that happens during the day. R2 had documented that she was last checked or changed at 5:15 AM today and prior to that it was 9:30 PM last evening. R2 said she waits long periods for call lights to be answered, 30 minutes or more, and she can tell when the facility is short staffed which is most days. R2 said she refrains from making a big fuss about the lack of care and staffing at the facility because she feels like she gets dismissed as a [AGE] year old senile resident. R2 said, I have my wits about me. I know what is going on around me. On 5/14/25 at 11:21 AM, V8 (CNA Scheduler) and V2 (Director of Nursing) said staffing is a challenge at the facility especially when there are call ins. V8 went over the recommended staffing numbers which she said is census and not acuity based. There are 4 sections to staff, the Bounce Back wing A and B, Liberty Lane and Memory Lane. V8 said they recommended staffing is 4 CNA's and 2 nurses on Bounce Back for days and evenings and on nights 2 CNA's and 1 Nurse. Liberty Lane staffing is for 1 nurse, and they try to get 3 CNA's but prefer 4 CNA's on days and evenings and 2 CNA's and 1 nurse for night shift. V2 said, We have been trying to have 4 CNA's on each side on days and evenings. On Memory Lane there is 1 nurse and 2-3 CNA's, on days and evenings and a nurse floats over to Memory Lane for med pass on night shift and there are 2 CNA's. V2 said they do hear complaints that there is not enough staff at the facility. V2 said it is company policy that residents get two showers a week. V8 said on 5/9/25 day shift there was numerous call ins, and the facility was short staffed. V2 said she was the only CNA with the 2 nurses for a couple hours on the Bounce Back wings, and the Liberty Lane had only 2 CNA's and a nurse who was training a new staff nurse. V8 said it can be difficult to get everything done on time when there are only 2 CNA's on a unit especially on Liberty Lane because it is a heavier care hallway with lots of residents needing to be transferred via mechanical lifts. V8 said if the staff cannot get to showers, they should offer them on the next shift or the next day. 2 weeks of master staffing schedules showing call ins and the actual staff who worked, from 4/30/25-5/14/25 were reviewed. The schedules show on the following dates the facility did not have the facility recommended number of CNA's to provide care to the residents: 5/1/25, 5/3/25, 5/5/25, 5/9/25, 5/10/25, 5/11/25. On 5/14/2025 at 12:08PM, V3 Registered Nurse (RN) said she was working on 5/9/2025 with (R1). V3 said a family member came to get her to report a resident had fallen. V3 said (R1) was found in his room on the floor next to his bed. V3 said (R1) stated he was trying to go to the bathroom and had hit his head when he fell . V3 said (R1) should not have been left in his room unsupervised because of his fall history. V3 said (R1) was sent out to the hospital and returned the same day and all tests were negative. V3 said they were short staffed that day and I'm sure that didn't help the situation. On 5/14/25 at 1:54 PM, V10 CNA said it happens all the time that the facility is short staffed, and they have told administration many times that they need more help. V10 said on 5/9/25 they were so short staffed that 3 residents (R3, R11 and R12) did not get showers done. V10 said they were not able to get the residents toileted or incontinence care done on a timely basis and the meal trays sat for a long period of time before they were able to pass them because every unit was short staffed. V10 said there was also a fall (R1) had been left in his room unsupervised after therapy and he is someone who is supposed to be observed. V10 said her and another CNA were in resident rooms in the afternoon putting people to bed and could not supervise R1 and the next thing she knew he had fallen and was lying on the floor of his room. A facility provided fall log shows R1 had falls on the following dates, 3/18/25, 4/3/25, 4/19/25, 4/26/25, 4/30/25, 5/9/25, and 5/11/25. On 5/15/25 at 2:03 PM, R10 said it happens a lot that she waits 40-45 mins for her call light to be answered, and she was told last Friday 5/9/25 that she couldn't get a shower because they didn't have enough staff. The facility provided showers sheets show that 2 showers were not done a week for R1 and R2. R1's shower sheets show he received showers on 4/18/25, 4/26/25, 4/30/25, 5/3/25, and 5/11/25. R2's shower sheets show she received showers/bed baths on 4/7/25, 4/14/25, 4/21/25, 4/24/25, 4/28/25, and 5/1/25 there are no documented showers/bed baths for her after 5/1/25. On 5/14/25 V2 (Director of Nursing) was asked for shower sheets for R3, R10 and R11 for 5/9/25 which was a scheduled shower day for all them. V2 said they did not have any shower sheets for those residents for that day. The facility provided Staffing policy revised on 9/18 shows staffing should be based on number, acuity and diagnosis and the facility should ensure adequate staffing will be met to provide resident care.

Based on interview and record review the facility failed to ensure showers were provided for 5 of 8 residents (R1, R2, R3, R10, R11) reviewed for Activities of Daily Living (ADL's) in the sample of 11. The findings include: On 5/14/25 9:10 AM, R2 said, I am supposed to get two showers a week on Mondays and Thursdays and that doesn't always happen. Last Monday I asked about my shower and the CNA's (Certified Nursing Assistants) just looked at each other and didn't say a word. R2 said she keeps track of what happens at the facility by writing things down, so she has the correct days and times to reference to. On 5/14/25 at 8:36 AM, V4 (CNA) said when the facility is not staffed well enough there are times that they cannot get to residents to get the showers done. On 5/14/25 at 11:21 AM, V8 (CNA Coordinator) said residents should get showers twice a week. If a shower is missed or a resident refused, they should attempt again on the next shift or next day. V8 said if a shower is refused it should be documented in a shower sheet. On 5/14/25 at 1:54 PM, V10 (CNA) said the facility was very short staffed on Friday 5/9/25 and they were not able to do showers for 3 residents including R3, R10 and R11. V10 said that day they were not able to get to everyone on time to do incontinent cares or feeding due to having very low numbers of CNA's working. V10 said R10 had followed her asking about her shower and she felt so bad telling her that she could not do it because they were short staffed. On 5/14/25 at 2:03 PM, R10 said she was told last Friday that she couldn't get a shower because they didn't have enough staff. R10 said, I don't refuse showers we should get them twice a week. The facility provided shower schedule for the Liberty Lane wing shows that residents should receive showers twice a week. R1 should receive showers on Wednesday and Saturday, R2 should receive showers on Monday and Thursday and R3, R10 and R11 should receive showers on Tuesdays and Fridays. The facility provided showers sheets show that 2 showers were not done twice a week for R1 and R2. R1's shower sheets show he received showers on 4/18/25, 4/26/25, 4/30/25, 5/3/25, and 5/11/25. R2's shower sheets show she received showers/bed baths on 4/7/25, 4/14/25, 4/21/25, 4/24/25, 4/28/25, and 5/1/25 there are no documented showers/bed baths for her after 5/1/25. On 5/14/25 V2 (Director of Nursing) was asked for shower sheets for R3, R10 and R11 for 5/9/25 which was a schedules shower day for all of them. V2 said they did not have any shower sheets for those residents for that day. The facility provided Personal Care of Residents Policy revised 12/02 shows each resident shall have proper daily attention and care including as many baths and hair washes as necessary for hygiene needs.

Based on interview, and record review the facility failed to provide supervision for a resident who was a fall risk, resulting in subsequent falls. This applies to 1 of 3 (R1) residents in the sample of 11 reviewed for falls. The findings include: R1's Resident Face Sheet printed on 5/14/2025 lists the resident as an [AGE] year-old male with medical diagnoses of unspecified dementia, severe, with anxiety and altered mental status admitted on [DATE]. On 5/14/2025 at 12:08PM, V3 Registered Nurse (RN) said she was working on 5/9/2025 with (R1). V3 said a family member came to get her to report a resident had fallen. V3 said (R1) was found in his room on the floor next to his bed. V3 said (R1) stated he was trying to go to the bathroom and had hit his head when he fell . V3 said he did have a small bump on the right side of his head. V3 said (R1) should not have been left in his room unsupervised because of his fall history. V3 said (R1) was sent out to the hospital and returned the same day and all tests were negative. V3 said they were short staffed that day and I'm sure that didn't help the situation. On 5/14/2025 at 12:17PM, V8 Certified Nursing Assistant (CNA) Scheduler said she was working on (R1's unit) on 5/9/2025 helping the two CNAs that were on the unit that day because there had been call-ins. V8 said they would normally have 3 or 4 CNAs on that unit and that day they had two, plus her helping. V8 said she got pulled away from the unit to help off the unit with something and when she came back (R1) had fallen. V8 said (R1) is a fall risk. On 5/14/2025 at 1:54PM, V10 CNA said we were short staffed on the 5/9/2025. V10 said (R1) should have been supervised and was not. V10 said we found him on the floor in his room. V10 said there were only 2 CNAs that day and we were putting people back to bed so (R1) was not supervised and should have been. 5/14/2025 at 1:26PM, V16 RN said on she was working on 5/11/2025 and was the nurse for (R1). V16 said (R1) had been restless that day and was to be kept in the common area. V16 said (R1) was wheeling himself around, stood up and fell . V16 said staff couldn't get to him before he fell . V16 said (R1) fell back and hit his head and there was some bleeding. V16 said (R1) was sent out to the hospital and returned the same day. V16 said the CT scan was negative, and they couldn't find any lacerations. V16 said (R1) did not get any stitches, glue and no fractures. V16 said he should be supervised. V16 said the unit only had 2 CNAs that day at the time of the fall which was around 6:35PM. V16 said 2 CNAs on that unit is not enough. R1's progress notes dated 5/9/2025 at 1:47PM, shows resident was noted on the floor next to the bed. Resident stated he was trying to get up and lost his balance and stated he hit his head. Physician contacted ok to send to emergency room for CT scan. Progress notes from 6:19PM states resident returned from the hospital no new orders and CT scan was negative. R1's Care Plan dated 2/14/2025 to 5/14/2025 shows, resident at risk for falling [related to] weakness from recent illness and new environment started on 2/12/2025. The facility provided All Falls for Facility document printed on 5/14/2025 shows falls for 5/11/2025 and 5/9/2025 for [R1].

Based on interview and record review the facility failed to complete resident quarterly assessments in a timely manner. This applies to 4 of 4 residents (R17, R50, R58 and R224) reviewed for quarterly assessments in the sample of 18. The finding include: On 3/4/25 R17's Minimum Data Set (MDS) Assessment Tracking shows that R17's Quarterly Assessment was due to be completed on 1/1/25. It is listed as In Process. On 3/4/25 R50's Minimum Data Set Assessment Tracking shows that R50's Quarterly Assessment was due to be completed on 1/8/25. It is listed as In Process. On 3/4/25 R58's Minimum Data Set Assessment Tracking shows that R58's Comprehensive Assessment was due to be completed on 1/15/25. It is listed as In Process. On 3/4/25 R224's Minimum Data Set Assessment Tracking shows that R224's Quarterly Comprehensive Assessment was due to be completed on 1/15/25. It is listed as In Process. On 3/44/25 at 12:31 PM V2 (Interim Director of Nursing (DON)/MDS Coordinator) stated, Last week I think I sent out 2 emails that had 10+ people that showed that my part was completed. They were behind. I passed them off to the people that need to finish their parts. When I first started, we were about 3 months behind so that took some time to get caught up. At 1:30 PM V2 stated, When we lost our DON in September, I took over as interim DON but and I can't do both that and keep up with the MDSs.

Based on interview and record review the facility failed to complete resident significant change assessments in a timely manner. This applies to 4 of 4 residents (R24, R25, R48 and R49) reviewed for significant change assessments in the sample of 18. The finding include: On 3/4/25 R24's Minimum Data Set (MDS) Assessment Tracking shows that R24's Significant Change Assessment was due to be completed on 1/30/25. It is listed as In Process. On 3/4/25 R25's Minimum Data Set Assessment Tracking shows that R25's Significant Change Assessment was due to be completed on 1/29/25. It is listed as In Process. On 3/4/25 R48's Minimum Data Set Assessment Tracking shows that R48's Significant Change Assessment was due to be completed on 1/22/25 . It is listed as In Process. On 3/4/25 R49's Minimum Data Set Assessment Tracking shows that R49's Significant Change Assessment was due to be completed on 2/20/25. It is listed as In Process. On 3/44/25 at 12:31 PM V2 (Interim Director of Nursing (DON)/MDS Coordinator) stated, Last week I think I sent out 2 emails that had 10+ people that showed that my part was completed. They were behind. I passed them off to the people that need to finish their parts. When I first started, we were about 3 months behind so that took some time to get caught up. At 1:30 PM V2 stated, When we lost our DON in September, I took over as interim DON but and I can't do both that and keep up with the MDSs.

Based on interview and record review the facility failed to complete resident comprehensive assessments in a timely manner. This applies to 4 of 4 residents (R1, R21, R26 and R177) reviewed for comprehensive assessments in the sample of 18. The finding include: On 3/4/25 R1's Minimum Data Set (MDS) Assessment Tracking shows that R1's Comprehensive Assessment was due to be completed on 1/25/25. It is listed as In Process. On 3/4/25 R21's Minimum Data Set Assessment Tracking shows that R21's Comprehensive Assessment was due to be completed on 12/11/24. It is listed as In Process. On 3/4/25 R26's Minimum Data Set Assessment Tracking shows that R26's Comprehensive Assessment was due to be completed on 12/11/24. It is listed as In Process. On 3/4/25 R177's Minimum Data Set Assessment Tracking shows that R125's first Admission Comprehensive Assessment was due to be completed on 1/18/25. It is listed as In Process. On 3/44/25 at 12:31 PM V2 (Interim Director of Nursing (DON)/MDS Coordinator) stated, Last week I think I sent out 2 emails that had 10+ people that showed that my part was completed. They were behind. I passed them off to the people that need to finish their parts. When I first started, we were about 3 months behind so that took some time to get caught up. At 1:30 PM V2 stated, When we lost our DON in September, I took over as interim DON but and I can't do both that and keep up with the MDSs.

Based on observation, interview and record review the facility failed to provide incontinence care/toileting to a resident that required staff assistance for toileting for 1 of 18 residents (R65) reviewed for activities of daily living (ADLs) in the sample of 18. The findings include: R65's resident assessment dated [DATE] showed R65 required maximum staff assistance for toileting and transfers. R65 had a history of incontinence. The assessment showed R65 was cognitively impaired. On 3/3/25 at 9:17 AM, R65 was seated in a wheelchair in his room. A strong smell of urine was noted in R65's room. At 9:19 AM, V8 and V9 Certified Nursing Assistants (CNA) transferred R65 from his wheelchair to the toilet. The inner left groin and left buttock areas of R65's sweatpants appeared wet with urine. V9 CNA removed R65's brief and stated, Wow, that's (R65's brief) heavy. R65's brief was saturated with urine and a moderate amount of soft stool. R65's buttocks appeared red. V9 CNA looked at R65's pants and stated, These are wet. We need to change his pants. V8 CNA stated, This is my first time changing or toileting (R65) today. I am not sure when he was last changed. It would have been sometime on nights. He was up and dressed when I got here this morning. On 3/4/25 at 10:49 AM, V2 Director of Nursing (DON) stated staff are to toilet and/or provide incontinence care to residents every two hours.

Based on observation, interview, and record review the facility failed to ensure the narcotic reconciliation count was accurate. This applies to 1 of 1 (R274) in the sample of 18 reviewed for narcotics. The findings include: On 3/4/2025 at 8:15AM, the narcotic count was checked for the medication cart with V10 Licensed Practical Nurse (LPN). V10 pulled up R274's narcotic count sheet on their computerized charting. R274s' Tramadol 50mg card was selected. R274 had two Tramadol 50mg cards, one with 30 tablets and the second one had 19 tablets for a total of 49. V10 said the count was off this morning because a nurse forgot to sign out a medication. V10 said [R274] has scheduled Tramadol 50mg three times per day. V10 said she notified [V2 Director of Nursing] this regarding the count being off. On 3/4/2025 at 12:24AM, V2 Director of Nursing (DON) said she was made aware the count was off. V2 said she did investigate why the count was off. V2 said [V10] didn't sign out the Tramadol dose that was given during the 7:00AM - 10:00AM on 3/3/2025, which caused the count to be off. V2 said there was no misappropriation, the nurse just didn't sign out the dose. R274's 14 Day Administration History dated 3/4/2025 shows R274 received all doses of Tramadol 50mg from 2/19/2025 - 3/3/2025, and the AM dose on 3/4/2025. The facility provided Pharmaceutical Procedures revised 1/5/2023 states, . Controlled Substances . individual resident control sheets shall be utilized for all controlled substances. The record shall list for each prescription the following information: . number of doses remaining. a shift count will be done every shift by the off-going and on-coming nurses to verify doses remaining. A shift count form or electronic record will be used for this purpose and signed by both nurses.

Based on observation, interview and record review the facility failed to label an insulin pen with an opened date. This applies to 1 of 1 (R49) in the sample of 18 reviewed for insulin. The findings include: On 3/4/2025 at 8:00AM, R49's Humalog insulin pen was in the medication cart with no opened date, while checking the medication cart on the unit. V10 Licensed Practical Nurse (LPN) said the insulin pen should be dated when opened. On 3/4/2025 at 12:24PM, V2 Director of Nursing (DON) said insulin pens should be dated when opened. R49's Physician Order Report dated 2/3/2025 - 3/3/2025 shows an order for Humalog KwikPen Insulin (insulin lispro) started on 9/22/2025. The facility provided Insulin Administration Procedure revised 02/04 states, . Date insulin vials when opened. Loss of potency may occur when the bottle has been in use >30 days.

Based on observation, interview and record review the facility failed to ensure puree diet textures were smooth. This applies to 3 of 3 residents (R9, R176, R51) for puree diets in the sample of 18. The findings include: The facility's lunch menu for March 3, 2025 shows, Swiss steak with gravy, mashed potatoes and gravy, whole kernel corn, peanut frosted chocolate cake, beverage. The spreadsheet for the lunch meal shows, the same meal except creamed corn instead of whole kernel corn for pureed diets. On March 3, 2025 at 11:10 AM, V4 cook pureed Swiss steak for the noon meal. He pureed it until he thought it was pureed enough. He stated, It's gritty and I don't know how to get rid of the grittiness and plated the Swiss steak. The Swiss steak had small chunks of meat in it and the texture was not smooth. After the Swiss steak was pureed, V5 cook pureed the creamed corn for the noon meal. She pureed it some and stated, it's hard to puree and plated it. The creamed corn had hulls in it and was not smooth. On March 3, 2025 at 1:20 PM, V3 Dietary Manager stated, the puree at the noon meal was gritty and should be smooth. She also identified 3 residents (R9, R176 & R51) receiving pureed diets. The facility's pureed volume method procedure dated July 2020 shows, Objective: To provide guidelines to puree food to appropriate texture for meals. Description: The Pureed Diet is a mechanically altered diet. The diet is designed to permit easy chewing and swallowing. The Regular Diet is modified in consistency and texture by pureeing foods to a smooth mashed potato consistency with no lumps or particles visible .

Based on observation, interview, and record review the facility failed to identify pressure ulcers prior to becoming advanced stages and failed to cleanse a stage two pressure ulcer in a manner to prevent cross contamination for two of five residents (R29, R17) reviewed for pressure in the sample of 15. This failure resulted in R29 waiting for assessment and treatment for an unstageable pressure ulcer. R17?? The findings include: 1. R29's face sheet printed on 1/19/23 showed diagnoses including but not limited to dementia, heart failure, chronic obstructive pulmonary disease, and stage 2 pressure ulcer of buttock. R29's facility assessment dated [DATE] showed severe cognitive impairment and extensive staff assistance required for bed mobility, transfers, and dressing. The assessment showed total staff dependence required for transfers, toilet use and personal hygiene. The facility assessment showed R29 was frequently incontinent of urine and bowel. R29's pressure score risk assessment dated [DATE] showed R29 was at risk. R29's physician orders showed an order start dated 1/12/23 for: Apply zinc barrier cream every shift and prn (as needed) to R (right) buttocks .Dx: Pressure ulcer of unspecified buttock, stage 2. On 1/17/23 at 10:17 AM, V5 and V6 (CNAs-Certified Nurse Aides) were observed while performing incontinence care for R29. V5 put on gloves, opened the urine soaked brief, and washed R29's groin area. V5 and V6 rolled R29 from side to side to remove the wet brief. V5 continued wearing the contaminated gloves to roll R29 while touching the bed linens and resident's gown. An eraser size open wound was observed on the right buttock. R29's buttocks and backside were visibly wet with moisture and urine. V6 applied barrier cream to the buttocks and R29 was again rolled from side to side while V5 continued wearing contaminated gloves. R29's new brief was put on with the buttocks still contaminated from the urine. V5 and V6 were asked by the surveyor to remove R29's socks for heel observations. A golf ball size, dark purple-reddish area was present on the right inner heel. V6 stated the discolored area had been there for a while so they try to keep the heel elevated. V5 and V6 put R29's socks back on, covered him with the blanket, and exited the room with the heels flat on the bed. On 1/17/23 at 11:25 AM and 2:34 PM, R29's heels were flat on the bed. On 1/18/23 at 8:39 AM and 11:27 AM, R29's heels were flat on the bed. On 1/19/23 at 8:55 AM, V7 (CNA) stated aides do skin checks during all resident cares. It is a full head to toe observation on shower days. We watch the buttocks, heels, and other high-pressure points carefully. Changes need to be reported immediately to stop it from becoming more severe. Incontinent residents are never left with urine on the skin. It can cause skin breakdown and infection. Dirty gloves are changed before touching clean areas to stop cross contamination of germs. On 1/19/23 at 8:20 AM, V4 (Registered Nurse) stated she had done the weekly skin check for R29 just yesterday (1/18). V4 said there was an opening on his bottom which was being treated with a zinc barrier cream. V4 said that is the only skin issue R29 has and there was nothing noted on his feet. V4 said the weekly skin checks are done by the floor nurses. It is a head-to-toe assessment. Any skin issues are immediately measured, and the doctor is notified for treatment orders. V4 said the CNAs do skin checks during all daily cares. Any skin changes or new areas found are to be reported immediately to the nurse. On 1/19/23 at 8:30 AM, V4 and the surveyor went to R29's room. R29 was lying in bed with his heels flat on the bed. R29's socks were removed and V4 stated, Wow, this is something new. V4 stated she would get another nurse for a second opinion and to get a tape to measure the wound. V4 and V3 (Registered Nurse) entered the room. Both nurses assessed and measured R29's right heel. Measurements were recorded by V4 as 3 centimeters by 3.5 centimeters, purple rusty. V4 stated she wound classify this as an unstageable pressure ulcer. V3 and V4 stated it was the first time they had knowledge of the pressure ulcer to the heel, and nothing had been reported prior to today. V3 and V4 said there are no treatment orders or interventions in place for the unstageable pressure ulcer to the heel. V3 and V4 said the aides should have reported it right away to prevent it from getting worse. On 1/19/23 at 10:46 AM, V2 (Director of Nurses) stated gloves should be changed between dirty and clean areas. Incontinence care involves cleansing both the front and back of residents. Urine left on open pressure wounds has the potential for infections and further skin breakdown. V2 said any new skin changes need to be reported immediately so it doesn't get worse. Skin that is dark purple or red and still closed like a blister is classified as unstageable. Finding wounds at advanced stages have the potential of becoming infected, residents can become septic, and have increased pain. R29's care plan showed a focus area of risk for increased pressure injuries relate to dementia, gout, depression, decreased mobility and generalized weakness. Interventions included weekly skin checks as ordered, provide incontinent care after each incontinent episode and compression socks on each morning and off each night. R29's 1/19/23 wound assessment (performed after report by surveyor) showed a 3 x 3.5 centimeter and 100% necrotic tissue area to the right heel. The report also showed two additional wounds discovered during the same assessment, one to the bottom of the right foot and another to the right great toe. The facility's Pressure Ulcer Prevention and Treatment Protocol policy revision dated 7/16 states under the objective section: To ensure that measures are taken to prevent skin breakdown and to provide guidelines for treatment of any pressure injury that might develop. The policy further states under the principles section: 3. All high and moderate risk residents may have the following, and if so, they will be addressed on the Care Plan. E. Skin checks. The facility was unable to provide any policy related to the frequency, process, or reporting for skin checks. The facility's Perineal Care policy revision dated 11/18 states: 4. Begin cleansing from the cleanest area in front to the most soiled area in back. The facility's Standard Precautions policy revision dated 8/09 states under the glove section; c. Change gloves between tasks and procedures on the same resident after contact with material that many contain infectious agents. 33761 2. On 1/17/23 at 2:45 PM, R17's wound was 2 x 1 cm (centimeters) with slough in the wound bed. On 1/17/23 at 10:45 AM, R17 said, They are doing a dressing on my right ankle. R17 was unsure how he got the pressure sore. R17's face sheet shows his diagnoses to include type 2 diabetes, muscle wasting, cognitive communication deficit, difficulty walking, thrombocytopenia, and dementia. R17's Facility Wound Summery Report shows, a facility acquired pressure ulcer starting on 11/06/22, measuring 5.2 x 5.3 cm with necrotic tissue in the wound bed. The skin surrounding the wound was dark purple. On 1/19/23 at 2:00 PM, V9 RN (Registered Nurse) said, she didn't know how the wound formed, it seemed to come from out of nowhere. 01/19/23 at 12:26 PM, V3 RN said, pressure ulcers should be found at a stage one or a reddened area, it should be found before it is an unstageable pressure ulcer.

Based on observation, interview, and record review the facility failed to supervise a resident, with a history of exit seeking behaviors, from eloping, and failed to ensure the emergency door alarms were alerting staff at all nurse's stations when the doors opened. These failures resulted in R2 exiting the facility through an alarmed door for an unknown amount of time in zero-degree Fahrenheit (windchill) weather on 1/22/22. This applies to 1 of 3 residents (R2) reviewed for safety/supervision in the sample of 3. The Immediate Jeopardy began on 1/21/22 at 10:25 PM The Immediate Jeopardy was identified on 2/8/22 at 9:00 AM. V1 Administrator was notified of the Immediate Jeopardy on 2/10/22 at 9:33 AM. The surveyor confirmed by observation, interview, and record review the Immediate Jeopardy was removed on 2/10/22, but non compliance remains at a Level Two because additional time is needed to evaluate implementation and effectiveness of the in-service training. The findings include: R2's Face Sheet printed on 2/7/22 showed R2 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses which include: cognitive communication deficit, anxiety disorder, and altered mental status. R2's Elopement Risk assessment dated [DATE] showed R2 is at risk for elopement due to Alzheimer's Disease/related Dementia, Moderately Impaired-decision making which needs staff cuing and required supervision, and behaviors of opening doors and setting off alarms of secured doors. On 2/8/22 at 9:45 AM, R2 was attempted to be interviewed. When asked if R2 remembered when she tried to leave the building, she replied with I like working here with all these girls, we are always busy. On 2/7/22 at 3:55 PM, V6 Registered Nurse stated she was working on the 300/400 unit for the night shift from 1/21/22 to 1/22/22. V6 stated she had seen R2 between 12:15 AM and 12:30 AM sitting in the recliner by the nurse's station with her Broda chair close by. V6 stated R2 is a fall risk and tries to self-transfer out of bed a lot. R2 sleeps better when in the recliner. V6 stated she rounded on a few residents down the hallway. V6 stated when she came back to the nurse's station around 1:00 AM, R2 was not in the recliner. V6 stated she checked R2's room, did not find her, and went to the Certified Nursing Assistants (CNAs) desk (on the other side of the unit) to get everyone to look for her. V6 stated V7 and V8 (CNAs) brought R2 back to the unit in her Broda chair about 1:30 AM. They said R2 was outside of the building by the 100-unit dining area door. V6 stated R2 she was cold to the touch, shivering intermittently, had increased confusion, and complained of chest pain. V6 stated R2 was sent to the local hospital and returned just prior to shift change (6:30 AM). V6 stated R2 has a history of trying to go through doors because she thinks her family is waiting out there to take her home. V6 stated R2 does have a baby doll in her room which is used to try to decrease R2's hallucinations about babies to show her the baby is safe. V6 stated R2 is usually alert and orientated times one most of the time, but does have a high level of confusion with her base line. On 2/9/22 at 7:30 AM, V7 CNA stated around 1:00 AM on 1/22/22 the nurse came to the desk asking where R2 was. We started looking on the 300/400 unit and did not find her. We started looking for her on the 100/200 unit. Once we were on the unit, we could hear the alarm going off. The 100/200 unit was not in use so there is nobody on that unit at all. We found R2 outside one of the emergency doors of the 100-unit dining areas. R2's chair was almost out of sight. The back edge of the chair could be seen at the end of the sidewalk about 10 feet from the door. R2 was still sitting in her chair with a long-sleeved shirt, pants, and one shoe on. R2's leg with no shoe on was exposed to the air from her foot to above her knee, and she had a blanket draped over the top of her head. We found R2's other shoe and a pillow were found in the grass about 4 feet away. V7 stated R2 does try to go through the unit doors to the lobby. When R2 attempts to go out R2 usually says she going to her family or hears babies crying. On 2/8/22 at 1:30 PM, V9 Licensed Practical Nurse (LPN) stated at about 1:00 AM on 1/22/22 V6 approached the CNA desk asking where R2 was. We could not find her in the unit, so we started looking for R2. V7 CNA brought R2 back to the unit about 1:30 AM, and stated she was outside the building by the 100 unit. R2's initial temperature was 94.8 degrees Fahrenheit (temporal reading). R2 was very cold to touch, shivering, confused, but a lot quieter than usual. R2's temperature was retaken after about ten minutes later while in bed and was 97.6 degrees Fahrenheit (temporal). After warming up, R2 started complaining of chest pain. The temporal thermometer was the only thermometer used to take temperatures. R2 was dressed in a long sleeve shirt and light sweat pants. V9 stated she did not remember seeing any coat or other clothing on R2 when she came back with the CNAs. On 2/8/22 at 1:40 PM, V6 confirmed R2's initial temperature taken by V9 was 94.8 degrees Fahrenheit. On 2/8/22 V2 at 12:45 PM, V2 Director of Nursing stated R2 has hallucinations and exit seeking behaviors which usually involves R2 thinking her family is waiting for her, her family helps her get out of bed, and seeing/hearing babies. V2 stated R2 has been doing these things since she started working in the facility since September of 2021. The Local Hospital Visit Summary dated 1/22/22 showed a visit complaint of hypothermia and altered mental status. R2's Facility assessment dated [DATE] showed R2 having no behaviors of hallucinations or wandering. R2's Care Plan dated 11/3/21 showed a concern of exit-seeking behaviors through unit doors because her family is waiting for her or because she hears her baby crying. On 2/9/22 at 12:00, V13 Medical Director stated elderly individuals are susceptible to cold weather conditions. A temperature reading of 94.8 could be considered hypothermic depending on the persons baseline temperatures. V13 stated R2 has a poor safety self-awareness, history of falls, exit-seeking behavior, and hallucinations which started just after being admitted . On 2/7/22 at 1:45 PM, V12 Maintenance Manager stated he arrived at the facility around 3:00 am (1/22/22). At that time the 100/200-unit doors were open. The alarm for 100/200 emergency door was going off. The door alarm was going off only at the 100/200-unit nursing station. V12 stated he did not know why it was only alarming at the 100/200 nurse's station and not at the 300/400 unit. Emergency doors alarm should go off at all nurses stations to alert staff a door has been opened, and so the staff can identify the location of the door in the facility. V12 stated the alarm log showed the door alarm was tripped at 10:30 PM on 1/21/22. V12 stated why door alarm was tripped is still unknown. When a door alarm is tripped the door becomes an open access which will not have the delayed opening safety measure in place, until the door/system is reset. V12 stated at the time R2 was missing (12:30 am-1:30 am) the door would have been an unlocked doorway. At 2:45 PM V12 stated none of the units in the facility are locked units. V12 stated the distance from 300/400-unit doorway to the 100-wing door R2 used to get outside is approximately 300 feet apart. V12 stated he used a laser measuring device to calculate the distance. To travel from the 300/400-unit doors to the door R2 used to exit the building a person must get to the other side of the building. The route from 300/400 unit goes through the lobby, past the therapy gym, around a corner (left), past 5 resident rooms, and through the 100-unit dining area which will bring you to the emergency door. The facility's Group Incident List dated 1/22/22 showed the 100-wing door alarm was tripped at 10:25 PM (1/21/22) and was reset at 3:15 AM (1/22/22). The Facility's Missing Resident Policy revised 2/25/19 showed Immediately following the alarm signal, staff shall check the alarm panel and respond to the door indicated. The Weather Underground Daily Observations report showed for 1/21/22 11:54 PM to 1/22/22 2:54 AM the temperature range was 15-18 degrees Fahrenheit with a wind 15-18 miles per hour. The wind chill calculator shows with the conditions the wind chill would have been around 0 degrees Fahrenheit. To remove the immediacy, the facility initiated the following steps: 1.) On 1/22/2022 at 0734 the Maintenance Director contacted the Alarm Company to add the 100 Dining Room exit door to the Nurses Station (call monitors) and to verify all exit door alarms were attached to the Nurses Station (call monitors). All Exit doors when opened and or activated sounds alarms to the Nurses Station (call monitors) 2.) 2/10/2022 Magnetic Door Alarm fixed to the double doors closest to the Nurses Station where the residents reside, for added security this device will be activated during hours when there are no front desk receptionist working. 3.) 2/10/2022 the roll up window at the Nurses Station is now in the open position for visualization into the common area. 4.) 1/27/2022 DON in-serviced all Nursing staff on Missing Resident policy/protocol. 5.) 1/24/2022 Administrator during Department Head Meeting in-serviced Management Team on Missing Resident Policy and Protocols 6.) 1/25/2022 Double Doors between common area and Neighborhoods are closed for added level of deterrent. Staff in-serviced on rounding in this area of the campus. 7.) 1/28/2022 Maintenance Director provided additional staff in-servicing on Missing Resident Policy and Protocol. 8.) 1/28/2022 Dietary Manager provided additional staff in-servicing on Missing Resident Policy and Protocol. 9.) 2/8/2022 at 5:45pm Administrator/DON in-serviced working staff on Missing Resident Policy. 10.) 2/9/2022 at 0700 the Maintenance Director conducted a Missing Resident Drill 11.) Resident Care Plan (DS) reviewed and updated to include behaviors, interventions appropriate to meet her needs. 12.) Care Plans for residents with exit seeking behaviors/elopement risks has been reviewed and updated. Staff educated on updates. Ongoing POC 1.) All Staff Meeting is scheduled for February 16, 2022 at 10:00am and 3:30pm, and will be ongoing for to include those that are on leave or vacation. 2.) During the daily stand up meeting, issues are reviewed, process updated, changed, or added. Monitoring of implemented plans will continue. The information is reviewed on a monthly basis, and brought to the Quarterly QA meeting which is scheduled for February 17, 2022 at 1:00pm 3.) All Agency staff will be in-serviced prior to the start of their shift on missing resident policy and protocol. This will be completed by February 17, 2022, and will be ongoing to include those that are on leave or vacation. 4.) All new Agency Staff will be in-serviced during their orientation prior to the start of their shift on an ongoing basis 5.) Monthly and as needed Missing Resident Drills will continue, findings will be addressed as needed with continued education and in-servicing of staff in response to each drill completed. All information will be reported to the Quarterly QA Committee. 6.) Exit Door Alarms will continue to be checked as scheduled, any issues found will be addressed at that time. Findings will be reported to the Administrator and reported to the Quarterly QA Committee. 7.) Staff is completing walk rounds on all neighborhoods for safety on all 3 shifts. This list will be reviewed and updated accordingly to meet the resident and facility needs.

Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 7. This failure resulted in R1 being held down and threatened by a Certified Nurse Assistant. R1 remains tearful at times, and fearful the staff member will return. The findings include: R1's face sheet documents he was admitted to the facility on [DATE] with heart failure and difficulty walking. His 11/3/21 facility assessment documents he is cognitively intact. The same assessment shows he requires one person assist for toilet use, dressing, transfers, and personal hygiene. The nursing progress note of 12/2/21 at 8:55 AM documents R1 was tearful and anxious and wanted to know where she was. When questioned R1 stated, the red head from last night got in his face and yelled at him that she was the f***ing boss now and he (R1) needed to answer to her (the red head). R1 told the nurse he was held down by his arms and could not move. On 12/17/21 at 10:15 AM, R1 said an aide had held him down by his arms and told him he was going do what she told him. R1 said no one has ever spoken to him that way and it scared the hell out of him. R1 said sometimes he gets fearful the aide will come walking through the door, he (R1) was not used to being treated like that. R1 appeared visibly upset when recalling the incident, he was rubbing his arms and shaking his head with a frowned look on his face. On 12/17/21 at 11:00 AM, V9 CNA (Certified Nursing Assistant) said on 12/2/21 between 4:00 AM and 5:00 AM, she was working with V7 CNA. V9 said V7 came out of R1's room and was upset R1 had no incontinence briefs in his room. V9 said V7 found briefs and returned to R1's room and was in the room for a long time. She reported V7 said R1 was bickering with her about not having the briefs available in the room and V7 was getting upset with R1. V9 said V7 told her she had grabbed R1 by his shirt and was telling him not to talk to her like that, and when she put him into bed, she pinned R1 down by his arms. V9 said V7 reported to her that as she was pinning R1's arms down (V7) told R1 there was no cameras in the room and nothing stopping her from hurting him. V9 said V7 was showing her how she then waived her fist in R1's face while she was threatening him. On 12/7/21 at 11:10 AM, V10 CNA said she was the day shift aide for R1 on 12/2/21. V10 said R1 had tears in his eyes and asked, where is that red headed [OBSCENITY] from last night?. V10 said R1 reported to her another CNA had pinned his arms down and told him she was the boss. V10 said R1 was very shook up and said he did not want that CNA back in his room. V10 said she immediately reported the incident to V8 (Human Resource Manager). On 12/17/21 at 10:45 AM, V2 DON (Director of Nursing) said she was notified of the allegation of abuse on 12/2/21 and began her investigation. V2 said V7 was an agency aide and immediately dismissed from all further shifts. V2 said during her investigation she interviewed staff and concluded the incident had occurred. V2 said V9 reported to her V7 said she had grabbed R1 by his shirt, raised her fist to him and threatened him. On 12/17/21 at 11:45 PM, V2 said V9 should have reported to the administrator immediately when V7 told her of the incident. V2 said since the incident was not reported, V7 was allowed to finish her shift after the abuse occurred with R1. The facility's 12/6/21 incident report documents the employee (V7) denied the alleged incident however, during the investigation, we acknowledged a statement by (R1) and confirmed statement by (V9) who was directly told about the details of the staff to resident interaction. Therefore, the facility is finding this allegation of abuse substantiated. The facility's 11/28/19 abuse policy states the facility actively prohibits resident abuse. The purpose of the policy is to protect residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restrain not required to treat the resident's symptoms.