Every finding on record at Meadowbrook Manor

Based on observation, interview and record review, the facility failed to follow sanitary practices during food storage in freezer, pots and pans storage and meal service.This apples to 225 residents that receive food prepared in the facility kitchen.The findings include: Facility's CMS Application Form for Medicare/Medicaid dated July 28, 2025 showed that the facility census was 226 residents. Facility provided information that there was one resident on NPO (nothing by mouth) status.1.On July 28, 2025 starting at 9:07 AM the initial tour was done in presence of V4 (Food Service Director).The walk-in freezer had ice built up on the floor at the entrance and at the back of the freezer. Two strips of the PVC (Polyvinyl Chloride) strip curtains inside the door at the entrance was torn and/or broken in half. Ice crystals were noted formed on the entire PVC strip curtains and also on several individual portion servings (4 ounce/serving) of vanilla ice-cream and chocolate nutrition treats that were stored on shelving in cardboard boxes. V4 stated that the ice built-up is due to the door not closing properly and the condensation from the pipes. V4 added that the maintenance is aware of it.In the dish room, there were two free standing racks with shelving that stored pots and pans which were inverted on the shelves that had brownish coloring that had the appearance of rust. V4 stated A lot of this stuff [racks] is old and needs to be replaced. 2. On July 28, 2025 at 11:40 AM, the tray line service was observed in the facility kitchen with V5 (Dietary Aide) and V6 (Cook) plating the lunch meal items. V5, wearing gloves, was plating the chili into bowls and the sauce from the chili was falling onto her gloves. With the same soiled gloves, V5 picked up corn bread from a tray and placed them on the plate and this process continued as she platted for several residents. V6 also had his gloves soiled with food items and was seen platting the salad onto the same plate that held the bowl of chili and cornbread and moving the salad with his soiled gloves onto the plate.On July 28, 2025 at 11:46 AM, V4 who was in the vicinity, was notified of the same and V4 stated that V5 and V6 should only use tongs during meal service. V4 also added that soiled gloves should be changed after washing hands.On July 30, 2025 at 12:07 PM, V18 (Dietitian) stated that the pots and pans storage racks should not have rust as there is potential that it can be flaked off to come on to the food storage pans. V18 added that the racks should be made of food grade material, or a barrier should be placed in-between the racks and the pots and pans. V18 added that utensils should be used to serve food. Facility policy titled Refrigerators and Freezers dated June 2021 included as follows:9. Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed.Facility policy titled Food Preparation and Storage included as follows:Food Service/Distribution: 6. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use.

Based on observation, interview and record review, the facility failed to assist residents, who were identified as needing assistance with incontinence care and nail care. This applies to 4 of 7 residents (R13, R30, R74, and R178) reviewed for ADL (Activities of Daily Living) in the sample of 35. Findings include: 1. The EMR (Electronic Medical Record) showed R13 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, cognitive communication deficit, dementia, and oropharyngeal dysphagia. R13's MDS (Minimum Data Set) dated May 9, 2025, showed R13 was cognitively intact. The MDS continued to show R13 was dependent on facility staff for toileting hygiene and was always incontinent of bladder and bowel. R13's incontinence care plan dated May 7, 2024, showed [R13] noted to be always incontinent both bowel/bladder with potential to improve continence, decreased balance, decreased functional mobility, decreased memory, decreased motivation, decreased strength, decreased toileting skills, functional incontinence, urge incontinence, dependent from staff with toileting needs, hygiene and incontinence care. The care plan continued to show multiple interventions dated March 24, 2025, including Staff to check and change approximately every two hours and as needed and report to nurse supervisor any unusual skin condition. During continuous observations on July 29, 2025, from 11:17 AM to 2:04 PM, R13 was sitting in the dining room in his wheelchair. No staff asked R1 if he needed to use the bathroom or to check his incontinence brief to see if it was soiled. On July 29, 2025, at 2:04 PM, V11 (CNA/Certified Nursing Assistant) transported R13 from the dining room to his room. V11 said she was going to provide R13 with incontinence care. V11 said she provided incontinence care to R13 earlier in the shift. R13's incontinence brief was visibly bulging under his shorts and R13 had a strong odor of urine. R13 had a total body mechanical lift sling underneath R13. V11 and V12 (CNA) transferred R13 into bed using a total body mechanical lift. V11 provided incontinence care to R13. V11 said R13's incontinence brief was saturated with urine. V11 placed a new incontinence brief, new shorts, and a new total body mechanical lift sling under R13. V12 put R13's soiled shorts and soiled total body mechanical lift sling in the soiled linen cart. V12 said the shorts and sling were wet with urine. On July 30, 2025, at 3:23 PM, V2 (DON/Director of Nursing) said residents who are incontinent of bowel and bladder should be checked to see if they require incontinence care at least every two hours. V2 said R13 should have been provided incontinence care sooner than over two hours, especially if his brief was saturated and clothing was wet with urine. 2. According to the Electronic Medical Records (EMR), R178 has multiple diagnoses including osteoarthritis, attention and concentration deficit, and dementia. The Minimum Data Set (MDS) dated [DATE], showed R178 had severe cognitive impairment and required maximal assistance for personal hygiene. The Care Plan dated January 18, 2021, showed R178 had functional and self-care deficit in performing ADL, and the interventions included staff to assist the resident with proper dressing and grooming every day, and ensure the resident is well groomed upon getting up daily and as needed. On July 28, 2025, at 12:56 PM. R178 was in the dining room sitting in the wheelchair, ate all his meal for lunch except the salad. Black substances were noted under R178's fingernails on both hands. R178 picked up crumbs of food from the table and put it in his mouth after his plate had been taken away. On July 29, 2025, at 12:14 PM. R178 was in the dining room sitting in the wheelchair eating lunch. Black substances were noted under R178's fingernails on both hands. R178 picked up the beef patty melt sandwich with his fingers which has the black substances under the nails. On July 29, 2025, at 12:16 PM, V15 CNA (Certified Nursing Assistant/Supervisor) said the CNAs takes care of grooming of the residents and as needed. She stated that the residents' nails should be trimmed, and fingernails should be free of black substances. 3. R30 had multiple diagnoses including central cord syndrome at C3 and C4 level of cervical spine, based on the face sheet. R30's annual MDS (minimum data set) dated July 3, 2025 showed that the resident was cognitively intact and required total assistance from the staff with personal hygiene. On July 28, 2025 at 11:18 AM, R30 was in bed, alert and oriented. R30's fingernails were long, jagged with black substances under the nails. R30 stated that he wants the staff to trim and clean his fingernails. On July 29, 2025 at 12:02 PM, R30 was in bed, alert and oriented. The resident's fingernails remained long, jagged with black substances under the nails. In the presence of V16 (LPN (Licensed Practical Nurse)/Wound care nurse), R30 stated that he wants the staff to trim and clean his fingernails. R30's active care plan initiated on September 22, 2024 showed that the resident has an ADL (activities of daily living) self-care performance deficit. The same care plan showed that R30 is dependent on staff with personal hygiene and to provide assistance with grooming. 4. R74 had multiple diagnoses including dementia without behavioral disturbance, based on the face sheet. R74's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition and required maximum assistance from the staff with personal hygiene. On July 28, 2025 at 11:33 AM, R74 was in bed, alert and verbally responsive. R74's fingernails were long, and some had black substances under the nails. R74 stated that she wants the staff to trim and clean her fingernails. On July 29, 2025 at 12:05 PM, R74 was in bed, alert and verbally responsive. R74's fingernails remained long with black substances under some of the nails. In the presence of V16, R74 stated that she wants the staff to trim and clean her fingernails. R74's active care plan initiated on March 2, 2022 showed that the resident has an ADL self-care performance deficit. The same care plan showed that R74 requires maximum assistance from staff with personal hygiene and for staff to provide assistance with grooming. The facility's ADL policy last revised by the facility in July 2025 showed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Under the guidance it showed, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: 1. Hygiene (Bathing, dressing, grooming, and oral and nail care: .3. Elimination (toileting). On July 30, 2025 at 11:05 AM, V2 (Director of Nursing) stated that it is part of the nursing ADL care and service of all residents at the facility to be assisted with their ADL care, including nail care. According to V2, staff are expected to provide ADL assistance to all residents to ensure and maintain the resident's hygiene and grooming.

Based on observation, interview, and record review, the facility failed to label and date medications to determine its expiration date and failed to store unopened insulins in the refrigerator. This applies to 7 of 7 residents (R176, R182, R207, R220, R226, R231, R232) reviewed for medication storage and labeling in the sample of 35.The findings include:On 7/29/25 from 4:31 PM to 5:28 PM, medication cart observations were conducted with V32, V33, V34, and V36 (All Nurses). The following were observed:1. R226's has two Budesonide Formoterol 160-4.5 mcg inhaler that were open and not dated. Pharmacy recommendation shows to discard when the dose counter reaches 0 or 3 months after it is taken out of its foil pouch, whichever comes first. 2. R176's one bottle of Systane 0.4%-0.3% eye drop and one bottle Brimonidine 0.2% eye were open and not dated. The medication plastic wrapper of both medications had a sticker which showed to date these medications when it was opened.3. R182's Humalog 100 units/ml was unopened but was stored in the cart. Pharmacy instruction showed to refrigerate until open, then store at room temperature.4. R231's Lantus Pen 100 units/ml was unopened but was stored in the cart. Pharmacy instruction showed to refrigerate until open, then store at room temperature.5. R220's Timolol Maleate Ophthalmic 0.5% eye drop was open and not dated. The medication plastic wrapper of this medication had a sticker which showed to date this medication when it was opened.6. R207's Latanoprost 0.005% was open and not dated. Pharmacy recommendation shows, date when opened and discard after 6 weeks. R207's Dorzolamide HCl 2% eye drop solution was open and not dated 7. R232's Brimonidine 0.2% eye drops was open and not dated. The medication plastic wrapper of this medication had a sticker which showed to date this medication when it was opened.On July 30, 2025, at 5:14 PM, V3 (Assistant Director of Nursing/ADON) stated staff must follow pharmacy recommendations with regards dating and labeling of medications to determine expiration dates this includes insulin, eye drops, and inhalers. The insulin should be refrigerated when it's not open to avoid premature expirations. Pharmacy Administration Guide for eye medications shows: Eye medication bottles/tubes with accelerated expiration dates must be dated/initialed upon opening. Follow manufacturer instructions, or facility policy. (e.g., Latanoprost - 42 days) Most common examples include: Artificial Tears, Tears Naturale, TheraTears Trusopt (dorzolamide) Combigan (brimonidine/timolol) Cosopt (dorzolamide-timolol) Alphagan (brimonidine) Zatidor (ketotifen) Lumigan (bimatoprost)

Based on observation, interview and record review, the facility failed to serve portion sizes of pureed chili as planned for the lunch meal.This applies to 5 of 5 (R17, R41, R46, R72, R223) residents reviewed for pureed diets in the sample of 35.The findings include:Daily Menu Spreadsheet for Week 2 Monday showed that pureed meals should receive #6 scoop of pureed Homemade Chili.Facility Dipper/Ladel Equivalents chart showed that dipper /scoop #8 =1/2 cup or 4 fluid oz/ounce and dipper/scoop #6=2/3 cup or 5.3 fluid oz. On July 28, 2025 starting at 11:40 AM, the lunch meal tray line service was observed in the facility kitchen with V5 (Cook) serving the main entree that included Homemade Chili. V5 used a #8 scoop and served R17, R41, R46, R72, R223 pureed Homemade Chili.On July 28, 2025 at 12:07 PM, V4 (Food Service Director) stated that V5 should have used a #6 scoop to serve pureed Homemade Chili if the menu showed the same.On July 30, 2025 at 12:03 PM, V18 (Dietitian) stated that the facility should follow the menu spread sheet. V18 stated that the staff should have used the #6 scoop as the menus are planned ahead to provide the appropriate nutrients that is needed. Facility policy and procedure titled Serving Portions included as follows:Policy: Food will be served in portions indicated on the cycle menu and on standardized recipes.Procedure: Serving portions will be controlled by use of the following utensils: Ladles, Scales, Scoops, Spoodles. Prior to serving the meal, the director of food and nutrition services or person in charge will check the serving utensils to ensure that the correct ones will be used. Facility Client Listing Report of diet orders of residents printed on July 28, 2025 showed that R17, R41, R46, R72 and R223 were on pureed diets.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices related to EBP (Enhance Barrier Precaution) policy, hand hygiene, and glove use during provisions of care and medication administration. This applies to 7of 35 residents (R2, R13, R127, R162, R176, R178, R204) reviewed for infection control in the sample of 35. The findings include: 1. On July 28, 2025, at 10:42 AM, during initial facility rounds, R176 was in bed resting. There was an EBP signage at his door. V27 (Certified Nursing Assistant/CNA) stated R176 was on EBP because he has gastrostomy tube (g-tube), indwelling urinary catheter, pressure ulcer to his buttocks and wounds to both anterior part of his lower legs. On July 29, 2025, at 9:37 AM, R176 remained on enhance barrier precautions. V26 (Nurse) assessed R176's gastric-tube (g-tube) and checked his vital signs. After she checked the g-tube placement and vital signs, V26 administered nutritional supplement via g-tube. V26 did all these tasks without wearing a gown. 2. On July 29, 2025, at, 10:37 AM, R127 was resting in bed, she was receiving enteral feeding through g-tube. There was an EBP signage at her bedroom door. V27 (CNA) placed an enteral the enteral feeding on hold and proceeded to provide bed bath to R127. V27 cleaned R127 from head to toe, she wore gloves but did not wear a gown all throughout the care. 3. On July 29, 2025, at 11:42 AM, R204 was resting in bed, there was and EBP signage at her bedroom door. V25 (Nurse) assessed R204 for g-tube placement, then she flushed the g-tube and administered medications. V25 only wore a pair of gloves and did not wear a gown all throughout the procedure. On July 29, 2025, at 4:20 PM, V2 (Director of Nursing/DON), stated the staff must follow the EBP (Enhance Barrier Precautions) protocol of wearing complete PPE (Personal Protective Equipment) such as gowns and gloves during provisions of care and administration of medication. This must be done for infection prevention. The Enhance Barrier Precautions signage shows: Providers and staff must wear gloves and gown for the following High-Contact Resident Care Activities. - Bathing/Showering - Device care or use: urinary catheter and feeding tube 4. The EMR (Electronic Medical Record) showed R13 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, cognitive communication deficit, dementia, and oropharyngeal dysphagia. R13's MDS (Minimum Data Set) dated May 9, 2025, showed R13 was cognitively intact. The MDS continued to show R13 was dependent on facility staff for toileting hygiene and was always incontinent of bladder and bowel. On July 29, 2025, at 2:04 PM, V11 (CNA/Certified Nursing Assistant) said she was taking R13 to his room to provide R13 with incontinence care. V11 and V12 (CNA) performed hand hygiene and donned gloves and transferred R13 back to bed. V11 removed R13's soiled incontinence brief. V11 said R13's incontinence brief was saturated with urine. V11 wiped R13 with premoistened wipes. V11 said she wiped feces from R13's buttocks. V11 applied ointment to R13's buttocks, applied a new incontinence brief, adjusted R13's bed linens, put on new shorts, and transferred R13 back to the wheelchair, with the same soiled gloves and without performing hand hygiene between care. On July 30, 2025, at 3:23 PM, V2 (DON/Director of Nursing) said during incontinence care, staff should change gloves and perform hand hygiene after removing soiled items, after cleaning the resident, and after care. V2 said V11 should have performed hand hygiene and changed her gloves when going from dirty to clean during R13's incontinence care, including after wiping the R13 and before applying skin ointment to R13. V2 said V11 should not have worn the same gloves throughout the incontinence care. 5. The EMR showed R162 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus, urinary tract infection, and partial traumatic amputation of two or more right lesser toes. R162's Order Summary Report dated July 30, 2025, showed an order dated July 30, 2025, for Enhanced Barrier Precautions (EBP): related to chronic wound to left heel. Everyone must clean their hands before entering and leaving the room. Providers and staff must wear PPE (Personal Protective Equipment) during high contact resident care activities. R162's EBP care plan dated July 30, 2025, showed [R162] Enhanced Barrier Precautions: related to chronic left heel wound. The care plan continued to show multiple interventions dated July 30, 2025, including Wound care: any skin opening requiring a dressing. On July 30, 2025, at 12:54 PM, R162's door had a sign showing Enhanced Barrier Precautions. Everyone Must: clean their hands, including before entering and when leaving the room. Providers and Staff must also: wear gloves and a gown for the following High-Contact Resident Care Activities. Wound Care: any skin opening requiring a dressing. V16 (Wound Nurse) and V21 (CNA/Certified Nursing Assistant) entered R162's room without wearing a gown. V16 provided wound care and V21 held R162's leg while V16 provided wound care. V16 said R162's wound was debrided by the wound doctor yesterday. V16 and V21 did not wear a gown throughout R162's wound care. 6. According to the EMR (Electronic Medical Records), R178 has multiple diagnoses including osteoarthritis, attention and concentration deficit, and dementia. The Minimum Data Set (MDS) dated [DATE], showed R178 had moderate cognitive impairment and was dependent on staff for toileting. The ADL (Activities of Daily Living) Care Plan dated January 8, 2024, showed that R178 had functional and self-care deficit in performing ADL and was dependent on staff with incontinence care and toilet hygiene. On July 29, 2025, at 3:11 PM, V13 and V14 both CNAs (Certified Nursing Assistant) performed incontinence care for R178. R178 had some healing rashes and redness on his buttock. V14 cleaned R178's buttock with wipes wearing gloves and then applied some cream to R178's buttocks using the same gloves she wore to clean the resident's buttocks. R178 was lying on his back and both R13 and R14 removed their gloves, performed hand hygiene using hand sanitizer, donned gloves, then began to apply a clean incontinence brief for R178. R178 started urinating, V13 placed a clean washcloth over R178's penis and enlarged scrotum to catch the urine. V14 cleaned the urine on R178's enlarged scrotum with some wipes, without removing the soiled gloves and without performing hand hygiene, proceeded to assist V13 to finish applying and strapping the clean incontinence brief for R178. 7. Based on the face sheet R2 has multiple diagnoses including unstageable pressure injury on the sacral region. On July 30, 2025 at 8:42 AM, an EBP (Enhanced Barrier Precaution) sign was posted on the outside door of R2's room. The EBP sign instructions showed that everyone must, Clean their hands, including before entering and when leaving the room. The same instructions showed, providers and staff must also wear gloves and a gown for the following high-contact resident care activities including, wound care: any opening requiring a dressing. At 8:56 AM, V16 and V24 (both LPN [Licensed Practical Nurse]/Wound care nurses) entered R2's room to provide wound treatments to the resident. Upon entering R2's room, V24 immediately put on a pair of gloves without performing hand hygiene (hand washing or hand sanitation). Both V16 and V24 did not wear a gown. V24 assisted R2 with turning and repositioning in bed for the wound care, while V16 administered multiple treatments to R2's wounds including the unstageable pressure injury on the sacrum which had approximately 80% sloughing and 20% bright pink/red tissue with minimal bleeding. During the entire wound treatment, and turning and repositioning of R2, both V16 and V24 were not wearing gown. R2's active order summary report showed an order dated July 24, 2025 for, EBP related to indwelling medical devices and unhealed wounds. The same order showed, Everyone must clean their hands before entering and leaving the room. Providers and staff must wear PPE (Personal Protective Equipment) during high contact resident care activities, every shift for care. R2 had an active care plan in place initiated on May 14, 2025 that showed that the resident is on EBP. The same care plan under interventions showed, Clean hands, including before entering and when leaving the room and Ensure that gown and gloves are used during high-contact resident care activities. The facility's policy regarding Enhanced Barrier Precaution last reviewed by the facility on April 2025 showed, Enhanced Barrier Precautions (EBP) are a proactive infection control strategy designed to reduce the spread of multidrug-resistant organisms (MDROs)in nursing homes. Unlike Standard Precautions, which are based on anticipated exposure to blood or body fluids, EBP target high-contact care activities that have been shown to transfer MDROs – even when no visible exposure is expected. The policy showed that, EBP involves the use of gown and gloves during high-contact resident care activities including, Residents at increased risk for MDROs, such as those with wounds, indwelling medical devices, or who require extensive hands-on care. The same policy showed, These precautions are intended to supplement, not replaced, Standard Precautions and are implemented even in the absence of active infection, recognizing that MDRO colonization may occur without symptoms.

Based on interview and record review, the facility failed to follow their policy to offer and administer influenza and pneumococcal vaccines in accordance with CDC (Centers for Disease Control and Prevention) guidelines.This applies to 4 of 5 residents (R13, R63, R90, and R126) reviewed for immunizations in the sample of 35. The findings include:1. The EMR (Electronic Medical Record) showed R126 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including dementia, malignant neoplasm of breast, acute embolism and thrombosis of right femoral vein, and heart disease.R126's Immunization Report dated July 30, 2025, showed R126 had not received the influenza vaccine and had not received a pneumococcal vaccine.The facility does not have documentation to show R126 or R126's resident representative was provided education and offered the influenza immunization during the 2024/2025 influenza season. The facility does not have documentation to show R126 or R126's resident representative was provided education and offered the pneumococcal vaccine. 2. The EMR showed R90 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, patent foramen ovale, and dependence on supplemental oxygen.R90's Immunization Report dated July 30, 2025, showed R90 had not received a pneumococcal vaccine and R90's pneumococcal vaccine was pending immunization. R90's Consent/Education Pneumonia Vaccine dated October 3, 2024, showed R90's resident representative consented for R90 to receive the pneumococcal vaccine.As of July 30, 2025, at 2:00 PM, R90 had not received the pneumococcal vaccine.3. The EMR showed R63 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including atherosclerosis of aorta, dementia, and history of nicotine dependence.R63's Consent/Education Influenza Vaccine dated June 12, 2024, showed R63's resident representative refused for R63 to receive the influenza vaccine because the influenza season was over.The facility does not have documentation to show R63 was provided education and offered the influenza vaccine during the 2024/2025 influenza season. R63's Immunization Report dated July 30, 2025, showed R63 received the PCV13 (13-Valent Pneumococcal Conjugate Vaccine) on January 17, 2020. As of July 30, 2025, at 11:30 AM, the facility does not documentation to show R63 was provided education and offered an additional pneumococcal vaccine.4. The EMR showed R13 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, alcohol abuse, and type 2 diabetes mellitus.R13's Immunization Report dated July 30, 2025, at 2:22 PM, showed R13 had not received a pneumococcal vaccine.The facility does not have documentation to show R13 was provided education and offered the pneumococcal vaccine prior to July 30, 2025, at 11:30 AM.On July 30, 2025, at 10:09 AM, V29 (Educator) said he is responsible for resident immunizations. V29 said he assumed the responsibility of resident immunizations within the last couple of weeks, and prior to V29, resident immunizations were the previous DON's (Director of Nursing's) responsibility. V29 said the facility follows CDC guidelines for immunizations.On July 30, 2025, at 3:23 PM, V2 (DON) said residents should be educated and offered vaccines in accordance with the facility's policies and CDC guidelines. V2 said R90 should have been given the vaccine she consented to receive, and R13, R63, R126 should have been educated and offered the vaccines.The CDC's Pneumococcal Vaccine Timing for Adults dated October 2024, showed Adults 50 years or older, Complete pneumococcal vaccine schedules: No prior vaccines, Option A: PCV20 (Pneumococcal 20-valent Conjugate Vaccine) or PCV21 (Pneumococcal 21-valent Conjugate Vaccine); Option B: PCV15 (Pneumococcal 15-valent Conjugate Vaccine) then one year or later PPSV23 (23-valent Pneumococcal Polysaccharide Vaccine). Prior Vaccines: PCV13 only, Option A: one year or more later PCV20 or PCV21.The facility's policy titled Influenza Vaccination dated April 2025, showed General: All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Policy: The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (residents' legal representatives); for example, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy. Procedure: 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized.The facility's policy titled Pneumococcal Vaccination dated April 2025, showed General: To provide information on the process for giving the pneumococcal vaccinations. Policy: All residents will be offered pneumococcal vaccines to air in preventing pneumonia/pneumococcal infections. Guidance: 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission if not conducted to prior to admission. 3. A consent will be obtained and serves as the education tool for the vaccine. If the resident has previously received any of the pneumonia vaccines previously, the date and location will be entered into the Immunization Tab of the EHR (Electronic Health Record). 4. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. 5. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per or facility's physician-approved pneumococcal vaccination protocol. 6. Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. 8. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

Based on interview and record review the facility failed to ensure that a resident that was receiving hemodialysis was weighed daily as ordered by the medical provider.This applies to 1 of 3 residents (R16) reviewed for dialysis in the sample of 35. Findings include:R16's admission record showed R16 was admitted on [DATE] with diagnoses that included chronic kidney disease, stage 3 unspecified, type 2 diabetes mellitus with diabetic neuropathy, and polyneuropathy.R16 had an active physician order dated April 26, 2025 that showed the following: Daily weight related to dialysis, one time a day related to chronic kidney disease, stage 3 unspecified.The facility did not provide documentation that showed R16's daily weight was checked as ordered by the physician.On July 30, 2025 at 4:14 PM, V2 (Director of Nursing) stated that the nursing staff is responsible for weighing residents. V2 stated he expects nursing staff to follow physician orders. V2 stated that residents who are on dialysis, are at risk for fluid overload. V2 stated that they do not have any other recorded weights done for R16 other than the weight summary provided to the surveyor and weights done by the dialysis provider on resident's dialysis days.The facility's Physician Orders policy dated April 2025 showed the following: Physician orders are followed as written: if there is a question about the order, contact the physician for clarification.

Based on interview and record review, the facility failed to educate a resident regarding the consequences of refusal of wound treatment, for a resident with a worsening facility acquired pressure injury.This applies to 1 of 9 residents (R11) reviewed for pressure injury in the sample of 35. Findings include:R11's admission record showed R11 is [AGE] years old and was admitted to the facility on [DATE], with multiple diagnoses including metabolic encephalopathy, personal history of transient ischemic attack (TIA) and cerebral infarction without residual affects, bilateral osteoarthritis of knee, hydronephrosis with renal and ureteral calculous obstruction, acute osteomyelitis left ankle and foot and generalized atherosclerosis.R11's MDS (Minimum Daily Set) dated May 13, 2025, showed R11 was cognitively intact and required assistance with ADLs (Activities of Daily Living) including set up assistance with eating, supervision with oral hygiene, partial assistance with personal hygiene, substantial assistance with bathing, rolling left to right, and upper body dressing and dependent on staff assistance for toileting hygiene, and lower body dressing and resident refused the sitting up while in bed. On July 30, 2025, at 3:36 PM, V16, (RN Wound Care Nurse) stated R11 developed a DTIP (Deep Tissue Injury due to Pressure) on his coccyx identified on December 5, 2024. V16 stated R11 was on a regular pressure redistribution mattress at the time. V16 stated R11 previously was getting up out of bed and sitting in the wheelchair when he was first admitted but at the time of the wound development had stopped getting out of bed. V16 stated R11 was incontinent of bowel and also developed MASD (Moisture Associated Dermatitis) on his coccyx around the same time. V16 stated R11 was offered a low air loss mattress but that R11 had refused. V16 was unable to provide documentation that R11 was educated on the need for repositioning, need for pressure reducing mattress and need to manage fecal incontinence to prevent further wound decline and nor was educated on the consequences of refusal of care. V16 could not describe what type of bed, what was used to reduce friction and shear during bed mobility or interventions for fecal incontinence management were offered. V16 could not provide documentation regarding education of R11 for consequences of refusals of care.V16 provided a Risk Notification document, dated December 5, 2024, that showed it was reviewed with R11's POA (Power of Attorney), but did not indicate the risk factors were reviewed with the resident. V16 stated R11's POA visited once or twice a month.R11's Wound Assessment Details report dated January 1, 2025, documented by V37 (RN 2nd Wound Care Nurse) showed R11 had a facility acquired pressure ulcer stage 3 identified on December 5, 2024. The Wound Assessment showed R11's wound had declined. R11's note showed R11 refused repositioning and refused a low air loss mattress however did not include if education was provided regarding consequences for continued refusals. The wound assessment showed the coccyx wound measured 6.0 cm (centimeter) x 2.00 cm x 0.10 cm, length x width x depth.R11's care plan initiated on December 5, 2024, showed R11 developed a pressure injury to the coccyx, and had a Braden score of 11, indicating at risk for developing pressure ulcers, and was at risk for developing unavoidable skin breakdown. The care plan did not address resident refusals regarding repositioning until the care plan was updated on May 20, 2025.R11's care plan dated February 3, 2025, showed R11 agreed to add a low air loss to the bed. The wound healthcare provider progress notes dated February 27, 2025, showed R11's coccyx wound was worse due to the low air mattress staying inflated and a new low air loss mattress had to be ordered.R11's healthcare provider wound care note dated July 9, 2025, showed R11's coccyx wound was reclassified as an unstageable pressure injury to sacrococcygeal extending to the buttocks. The wound measured 13 cm x 12 cm x 2 cm with undermining of 2.8 cm from 12:00 o'clock to 3oclock with 70% necrotic tissue and 30% granulation tissue.The facility's policy titled Wound Prevention and Healing dated April 2025, showed Procedures .9. Continue/Ongoing Treatment.a.Nurse.will evaluate the plan of care based on the effectiveness of treatment.d. if patient is not responding to established treatment regimen the Wound MD/NP nurse/therapist shall evaluate for .d. re-assess need for interdisciplinary services and/or appropriate DME.

Based on observation, interview, and record review, the facility failed to provide appropriate diet consistency for a resident with risk for aspiration and failed to implement safety intervention for a resident identified with high- fall risk.This applies to 2 of 5 residents (R6 and R13) reviewed for accidents and supervision in a sample 35.The findings include:1. The EMR (Electronic Medical Record) showed R13 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, cognitive communication deficit, dementia, and oropharyngeal dysphagia. R13's MDS (Minimum Data Set) dated May 9, 2025, showed R13 was cognitively intact. The MDS continued to show R13 was on a mechanically altered diet. R13's Order Summary Report dated July 29, 2025, showed an order dated October 9, 2024, for Low Concentrated Sweets diet, pureed texture, nectar consistency, until seen by speech therapist for aspiration. R13's nutritional problem care plan dated May 14, 2025, showed [R13] has nutritional problem or potential nutritional problem, on a therapeutic mechanically altered diet, NCS (No Concentrated Sweets) pureed, nectar thickened liquid diet per physician. Decreased ability to chew/swallow properly, noted, staff to provide supervision for safety precautions. Oral intake to be adequate, fair, staff to provide encouragement to eat adequately per nursing. Enjoys consuming liquids, requires assistance feeding, per staff. Particularly orange juice, per staff. Will follow. The care plan showed multiple interventions dated May 9, 2025, including Provide and serve diet as ordered. On July 29, 2025, at 2:31 PM, R13 was sitting in his wheelchair in the dining room. R13 was served ice cream. On July 29, 2025, at 2:34 PM, R13 started eating his ice cream. R13 had melted ice cream dripping down his chin. On July 29, 2025, at 2:35 PM, V22 (Activity Aide) said she provided R13 with the ice cream. V22 said she provided R13 the same ice cream as all the other residents in the dining room, R13 did not get a special ice cream. V22 said she did not know R13 needed thickened liquids or needed to be supervised while eating. On July 30, 2025, at 11:19 AM, V23 (Director of Rehab/Speech Therapist) said R13 was most recently seen by speech therapy on March 19, 2025, to April 17, 2025, and speech therapy's recommendation at the end of services was for a pureed diet with nectar thick consistency. V23 said R13 needs a pureed diet with nectar thick consistency for swallow precautions due to oropharyngeal dysphagia. V23 said staff are requesting for R13 to be evaluated by speech therapy again because R13 is coughing while consuming nectar thick liquids. V23 said plain ice cream is considered a thin liquid and should not be served to someone on nectar thick consistency. V23 said R13 is at risk for aspiration if he consumes thin consistency liquids. On July 30, 2025, at 2:28 PM, V23 said R13 was evaluated by speech therapy and R13 still requires nectar thick consistency. On July 30, 2025, at 3:23 PM, V2 (DON/Director of Nursing) said R13 should not have received ice cream if he is on a nectar thick consistency diet. The facility's policy titled Physician Orders dated April 2025, showed General: Physician orders may be written by the provider or received by telephone by a licensed nurse or other licensed or registered health care specialist who are legally authorized to do so. Policy Explanation and Compliance Guidelines: 1. Physician orders are followed as written; if there is a question about the order, contact the physician for clarification. 2. According to the (EMR) Electronic Medical Records, R6 has multiple diagnoses including, history of falling, unsteadiness on feet, other polyosteoarthritis, dementia, encounter for palliative care. The (MDS) Minimum Data Set, dated , May 8, 2025, showed had moderate cognitive impairment, used a wheelchair for mobility, and required maximal assistance for mobility transfers. R6's Resident/Family Notification Fall Risk assessment dated [DATE], showed a score of 24 and he was high risk for falls. The facility's Incident Reports showed R6 had falls on May 18, 2025, April 19, 2025, and February 18, 2025. The reports showed on May 18, 2025, R6 had an unwitnessed fall and was found on the floor in his room. On April 19, 2025, R6 had an unwitnessed fall, sustained an abrasion to the right side of his head, and was found lying on the floor in his room. On February 13, 2025, R6 also had an unwitnessed fall and was found on the floor in his room. The Fall Care Plan dated March 8, 2024, showed R6 is at risk for falls due to unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, and abnormal posture. ADL (Activities of Daily Living) Care Plan dated March 10, 2024, showed R6 required maximal assistance of 1 staff for transfer using gait belt. The ADL (Activities of Daily Living) Care Plan interventions initiated on May 18, 2025, included, staff to assist resident back to bed after meals and remove wheelchair away from resident for safety. The POS (Physician Order Sheet) dated May19, 2024, showed, Alert high-risk fall, staff to assist resident back to bed after meals and remove wheelchair away from resident for safety. Resident needs assistance with ADLs transferring please ensure to communicate with staff, CNA [Certified Nursing Assistant] etc. toilet or check and change. On July 29, 2025, at 3:26 PM. R6 was lying in bed, with the bed in the lowest position, and his wheelchair positioned right next to the bed. R6 had his lower extremity from waist to the feet positioned close to the edge of the bed. On July 29, 2025, at 4:16 PM, R6's wheelchair was right next to his bed. R6 was sitting at the edge of his bed while holding on to the wheelchair with his right hand, and R6 was attempting to get out of bed. V19 (CNA) was at the nurses' station and was notified to assist R6. V19 came into R6's room and stated that R6's wheelchair was positioned right next to his bed because R6 always attempts to get out of bed and might fall attempting to get to his wheelchair if positioned away from him. On July 29, 2025, at 4:19 PM, V14, (CNA) said she was the assigned (CNA) for R6, and she had been told to put wheelchairs of residents who are at risk for falls in the hallway and she did not know if R6 was at risk for fall. There was a yellow falling leaf signage with the letter B on R6's doorframe. When asked why R6 had the yellow signage on his doorframe, V14 responded that she did not know, and her best guess was that it meant R6 was in bed B. On July 29, 2025, at 4:24 PM, V13 (CNA) said the yellow falling leaf signage with the letter B on R6's doorframe meant R6 is at risk for fall. On July 29, 2025, at 4:17 PM, V20, RN (Registered Nurse/Fall Coordinator) said she was in charge of reviewing residents' fall care plans and entering interventions for each fall and providing education and in-services for the nursing staff regarding falls. V20 stated that she was aware that R6 had history of falls. V20 stated the fall prevention interventions that has been put in place for the R6 included, staff should assist R6 back to and remove the wheelchair away from the resident for safety and put it in the hallway so that the resident can call staff for assistance. V20 added that there is a fall risk signage on residents' door if they are at risk for falls. She also stated that she created a green binder for each nurses' station with interventions for CNAs to check and know the residents at risk for fall and the interventions for each resident. V20 stated that she also provides education and in-services to the nursing staffs, including (CNAs), especially when they float to different units. On July 30, 2025, at 3:10 PM, V2 DON (Director of Nursing) stated that staff and CNAs should follow the orders and care plan interventions for R6 and should remove the wheelchair away from the resident's bedside for safety. The facility's Fall Prevention and Management policy (revised on June 2025) included the following: 2. Fall interventions b. High-Risk Precautions d. Interventions will depend on identified and assessed risk factors, including root cause/s every after each fall or when a pattern has been identified. c. High-Risk for Fall interventions i) All Universal and High-Risk Precautions Interventions, plus the following: falling leaf sign on doorframe, headboard as indicated. Nurse to communicate and endorse to staff during stand up/huddle meetings and shift to shift report.

Based on observation, interview and record review, the facility failed to assess a resident with cognitive deficits for risk of entrapment prior to installation of bed rails. This applies to 1 of 1 resident (R18) reviewed for bed rails in the sample of 35. The findings include: R18's diagnoses include unspecified dementia, unspecified severity, with other behavioral disturbance, depression, bipolar disorder, other symptoms and signs involving cognitive functions and awareness, other symptoms and signs involving appearance and behavior, need for assistance with personal care. R18's quarterly Minimum Data Set, dated [DATE], showed that R18 is moderately impaired in cognition and requires supervision or touching assistance for bed mobility. On July 28, 2025, at 10:30 AM, R18's room door was closed. On entering the room, R18 was lying in bed with the left side of bed against wall. R18's bed had (half) bed side rails raised up in the middle of the bed on both sides. A bed alarm was on the bed. R18 stated I am tired, I did not sleep for two nights, they kept waking me up asking stupid questions. R18's wheelchair was at side of bed and R18 stated I can get up by myself. I hold on to wheelchair while walking. On July 28, 2025, at 10:30 AM, V9 (Certified Nursing Assistant) was in the dining room with other residents who were at activities. When asked about R18's side rails, V9 stated that bed rails are put down (raised up) at side of bed as R18 is a fall risk. V9 stated that R18 is able to get up by herself. When asked, how R18 is able to get out of bed with the side rails up in the middle of the bed, V9 responded that R18 can slide down to the foot of the bed and get out through the (small) space beyond the bed rail at the foot of the bed. V9 added that when R18 attempts to get up out of bed we hear the bed alarm, and we go and check. V9 was made aware that the door was closed and the possibility of hearing the alarm was questionable. On July 29, 2025, at 11:17 AM, and on July 30, 2025, at 3:18 PM, V10 (Restorative Director) stated that the side rails are put down (raised up) on right side while resident is in bed to assist with bed mobility during care. V10 stated that the bed rails can be put down even while the resident is sleeping after care. V10 also stated that if the resident wants to get out of bed while side rails are up, she can move to the bottom of the rails and get out. When asked if V10 has assessed R18 for entrapment as R18 is confused, V10 stated that even though R18 is confused, so far nothing has happened. V10 also stated that the facility does not have a separate risk assessment form for entrapment prior to installation of bed rails. V10 stated she considered the consent form signed by R18's Power of Attorney as the risk assessment form. R18's Devise Observation, Education and Consent form dated May 26, 2025, included that 1/2 (half) side rail was added as an intervention: utilize bilateral partial side rails for bed mobility and repositioning in bed from lying to seated and vice versa, and to serve as bed parameters during care. Provide a hand hold for getting into or out of bed. Additional comments or notes for the same included: Resident impulsive, attempting to get up from chair and bed unattended, gait unsteady. Resident in frequent need of reorientation, poor safety awareness diagnosis of Dementia with other behavioral disturbances, bipolar disorder, anxiety disorder. R18's ADL (activities of daily living) care plan revised March 6, 2025 included the following: R18 has ADL Self Care Performance Deficit [related to] impaired balance, limited mobility, weakness, decreased strength/endurance, AMS (altered mental status). Able to walk with assist wheelchair for mobility.Interventions included as follows: To utilize bilateral partial side rails for bed mobility and repositioning in bed from lying to seated and vice versa, and to serve as bed parameters during care. Provides a hand hold for getting into or out of bed, cognitively impaired: Resident is confused and due to cognitive deficits, resident will be unable to use call light effectively (revised January 31, 2024). R18's mood/behavior care plan initiated on February 3, 2025, included that [R18] has diagnosis that includes dementia. Resident is evidencing flux in mentation as well as overestimation of her physical abilities. She is at risk to make poor choices and at risk for self-injury with her self-determination. Care plan-initiated on October 11, 2024, included that R18 has alteration in thought process and cognitive communication status issues related to resident is disoriented and/or confused. The resident's memory appears impaired. Consequently, the resident has problems with decision making, insight, logic, calculation, reasoning, planning, organization, sequencing, social skills and judgement. This problem is related to diagnosis of Alzheimer's disease or other form of Dementia. Facility's policy titled Bed or Side Rails revised April 2025 included as follows: General: The facility shall provide adequate management of Bedrails to ensure that residents attain or maintain the highest practical physical, mental, and psychological well-being. Procedure: 2. If a bed or side rail is used, the facility will ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.a) Assess the resident of risk of entrapment from bed rails prior to installation. 3. Facility will allow side rails to aid in positioning, turning, transfers and or mobility.

Based on observation, interview, and record review, the facility failed to follow physician order with regards to dosage of a resident's nasal spray and failed to follow medication administration policy and procedures during medications pass. There were 26 medication opportunities with 6 errors resulting to 23.07% error rate. This applies to 2 of 5 residents (R6, R95) reviewed for medication pass in the sample of 35. The findings include: 1. On July 28, 2025, at 5:49 PM, V30 administered medications (Allopurinol, Hydralazine, Torsemide) to R6. V30 placed these medications in a small plastic bag and crushed it all together. V30 then mixed it with pudding and gave it to R6. Facility's Medication Administration Policy and Procedure dated April 2025 shows:General: Facility will ensure that medications are administered in a safe and timely manner and as prescribed. Procedure: 23. Medications may be crushed with MD/NP order. Each medication should be crushed separately and administering each with food.2. On July 29 at 9:24 AM, V31 (Nurse) administered medications to R95 which include Spiriva Respimat Inhaler, Symbicort Inhaler, and Fluticasone Propionate nasal spray. During the medication administration V31 administered 2 sprays of Fluticasone to each nostril of R95. V31 then administered 2 puffs of Symbicort inhaler with 3 seconds interval between puffs, followed by Spiriva inhaler 15 seconds later. V31 administered 2 puffs of Spiriva with 5 seconds interval between puffs. R95's Medication Administration Record (MAR) dated July 2025, shows Fluticasone Propionate Nasal Suspension 50 MCT/ACT. Give 1 spray each nostril one time a day for respiratory condition/symptom. Facility's Medications through Metered Dose Inhalers Policy and Procedure dated April 2025 shows: General: The purpose of this procedure is to provide guidelines for the safe administration of inhaled medications.Procedure: 15. Repeat inhalation, if ordered. Allow at least one (1) minute between inhalations of the same medication and at least 2 minutes between inhalations of different medications. On July 29, 2025, at 4:03 PM, V2 (Director of Nursing/DON), stated the nurse must follow physician order for medication administration, and the 5 rights of medication administration such as the right resident, medication, dose, time, and route. Medications should be crushed separately to prevent potential negative interactions to one another. When staff is administering two different inhalers, the staff should wait 5 minutes in between administrations of 2 different inhalers. For the same inhaler the staff must administer 1 minute interval in between dose. This is for better absorption of medication and prevent potential side effects.

Based on observation, interview, and record review, the facility failed to ensure a resident received dental care for teeth that were painful and decaying.This applies to 1 of 1 resident (R236) reviewed for dental care in the sample of 35.The findings include:R236's face sheet showed that R236 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, unspecified, unspecified dementia, unspecified severity, with agitation, aphasia following cerebral infarction edema, cerebral infarction without residual deficits, chronic systolic heart failure, and type 2 diabetes mellitus.On July 28, 2025 at 10:22 AM, R236 stated he needs to see a dentist. R236 stated he has been telling the staff for a while that he has tooth pain and needs to see a dentist and they have not done anything about it. R236 stated they wrote it on a piece of paper, but nothing else has happened. R236 stated this is important because it hurts when he chews. R236 stated he told the staff last 3 days ago. On July 30, 2025 at 10:10 AM, V8 (Social Services Director) stated that she arranges dental appointments for residents. R236 has not seen a dentist since he has been in the facility. V8 stated that R26 is not on the facility's dental insurance to be seen by the dentist that comes to the facility. On July 30, 2025 at 11:24 AM, V17 (Ward Clerk) stated she is responsible for making appointments for residents to see dentist outside of the facility and she also helps the social worker for doing inside dental appointments with their Dentist that comes into the facility. V17 stated that R236 has not ever seen an outside dentist, nor has he seen their inside dentist. On July 30, 2025 at 2:22 PM, viewed R236 teeth more closely and observed R236 has missing lower teeth and one of his lower left molars had a large black area on the top eating surface that covers about 90% of the tooth. On July 30, 2025 at 2:24 PM, V37 (Licensed Practical Nurse) stated that R236 was put on an antibiotic today for decaying teeth. On July 30, 2025 at 4:41 PM, R236 reiterated and stated that his teeth have been hurting for about three months, and he was telling the staff that he was in pain and needed to see the dentist. The facility's routine dental care policy dated April 2025 showed the following: each resident will receive routine dental care. Routine dental care includes, but is not limited to, preventative care and treatment.

Based on interview and record review, the facility failed to provide education and offer a resident the COVID-19 immunization.This apples to 1 of 5 residents (R126) reviewed for immunization in the sample of 35. The findings include:The EMR (Electronic Medical Record) showed R126 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including dementia, malignant neoplasm of breast, acute embolism and thrombosis of right femoral vein, and heart disease.R126's Immunization Report dated July 30, 2025, showed R126 had not received any previous COVID-19 immunizations.As of July 30, 2025, at 11:30 AM, the facility does not have documentation to show R126 or R126's resident representative was provided education and offered the COVID-19 immunization. On July 30, 2025, at 10:09 AM, V29 (Educator) said he is responsible for resident immunizations. V29 said he assumed the responsibility of resident immunizations within the last couple of weeks, and prior to V29, resident immunizations were the previous DON's (Director of Nursing's) responsibility. V29 said the facility follows CDC guidelines for immunizations.On July 30, 2025, at 3:23 PM, V2 (DON) said residents should be educated and offered vaccines in accordance with the facility's policies and CDC guidelines. V2 said R126 should have been provided education and offered the COVID-19 vaccine.The facility's policy titled COVID Vaccination dated April 2025, showed General: To ensure the health and safety of all residents, staff, and visitors, the facility shall implement and maintain a COVID-19 vaccination policy in alignment with the latest guidance from the Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP), and applicable state and local health authorities. Policy: All eligible individuals, including residents and staff, are encouraged to receive the most recent seasonally updated COVID-19 vaccine, as appropriate based on age, prior vaccination history, and immunocompromised status. Guidance:. 3. The number of updated 2024-2025 COVID-19 vaccine doses and individual needs is based on age and vaccination history. For residents who are not moderately or severely immuno-compromised: a. Routine COVID-19 vaccination: i. CDC recommends a 2024-2025 COVID-19 vaccine for most adults ages 18 and older. ii. It is especially important to offer COVID-1 vaccination to residents if they are 65 years and older, are at high risk for severe COVID-19, or have never received a COVID-19. 4. The recommendations for updated 2024-2025 COVID-19 vaccine doses for individuals who are moderately or severely immunocompromised, based on age and vaccination history, are as follows: a. Unvaccinated: Should receive a multidose initial series with an age-appropriate 2024-2025 COVID-19 vaccine and one does of a 2024-2025 COVID-19 vaccine since months (minimal interval two months) after completing the initial series. b. Previously completed an initial series: should receive two doses of an age-appropriate 2024-2025 COVID-19 vaccine, spaced six months (minimal interval two months) apart. c. May receive additional age-appropriate 2024-2025 COVID-19 vaccine doses under shared clinical decision-making.

Based on interviews and record reviews, the facility failed to implement safety interventions and provide supervision to prevent two residents from injury. These failures resulted in R2 sustaining a laceration and a displaced bilateral nasal bone fracture and acute fracture of the bony nasal septum and R3 sustaining a head laceration requiring 5 staples and being admitted to the hospital. This applies to 2 of 6 residents (R2 and R3) reviewed for falls in a sample of 12. The findings include:1.R2's records showed that she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses including dementia, psychosis, restlessness and agitation. R2's record showed that on 5/29/25, R2 fell from her bed. R2's 5/29/25 FRI (Facility Reported Incident) to the Illinois Department of Public Health showed that V5 CNA (Certified Nurse's Assistant) reported that she removed the floor mats and began providing ADL (activities of daily living) care to R2. During care, V5 realized she did not have all the necessary supplies. V5 turned towards the dresser to retrieve the remaining items, the resident fell from the bed and struck her face on the floor. R2 was taken to the local community hospital. R2's 5/29/25 hospital records showed that R2 sustained a laceration to her forehead and acute mild displaced bilateral nasal bone fracture and acute fracture of the bony nasal septum with leftward bowing. R2's 5/29/25 progress notes showed that R2 returned to the facility with sutures (number of sutures not indicated) in place to be removed in 7 days. R2's 10/18/24 care plan showed a focus on high risk for falls/injury/trauma with interventions including provided with high/low bed with floor mattress to further meet resident's safety needs.On 6/25/25 at 2:57 pm V5 said that she was providing care for R2, and she had removed the mat from the side of R2's bed, had R2's bed in a high position and then took 1 or 2 steps away from R2's bed to get wipes and a brief off the dresser. V5 said that she had her back turned away from R2 when R2 fell off the bed and hit the floor. V5 said that she saw blood and went and got the nurse. V5 said that R2 was awake at the time and that R2 has a tendency of trying to get out of the bed and falling.On 6/25/25 at 1:58 pm V9 NP (Nurse Practitioner) said that R2's laceration and nasal fracture was caused by the staff not putting the mat back next to the bed and putting bed rails up before walking away from the resident. V9 said by V5 not having the safety measures in place it caused R2 to fall causing a laceration and fractured nose.On 6/27/25 at 4:15 pm V1 (Administrator) said that V5 should have gotten the wipes and briefs before attempting to provide incontinence care for R2. V1 said that V5 should have lowered the bed and put the mats back in place and made sure the bed rails were up before she stepped away to get the needed items. V1 said that when R2 fell out of the bed it caused a fracture to her nose and a laceration. V1 said that R2 has a history of falling and attempting to get out of the bed causing falls. V1 said that staff should have been monitoring her even closer knowing she had the behaviors of attempting to get out of bed. V1 said that if V5 had put all those interventions in place, it could have prevented R2 from falling.On 6/27/25 at 1:34 pm V2 (Assistant Director of Nursing) said that when R2 fell on 5/29/25 the fall caused a nasal fracture to R2. V2 said that V5 should have brought the items to provide care before starting. V2 said that V5 should not have walked away, leaving the bed in a high position, the bed rails not up, and not putting the mats back. V2 said if those safety precautions were in place, V5 would have been proactive and that would have kept R2 safe and kept her from falling.2. R3's electronic health records showed that he is a [AGE] year-old male admitted to the facility with diagnoses including Parkinson's disease, dementia, restlessness, agitation, and history of falls. R3's 6/14/25 FRI Final report that was sent to the Illinois Department of Public Health showed that on 6/14/25 around 7:30 PM R3 was being pushed in his wheelchair when he fell forward out of his wheelchair hitting his head on the floor and sustained a laceration to his forehead. R3 was sent to the hospital and admitted to the hospital. R3 received five staples to his forehead from the laceration. R3's 6/14/25 hospital report shows that on 6/14/25 R3 was being pushed in a wheelchair by staff when R3 caught his foot on the floor and fell forward out of the wheelchair, hitting the front of his head on the ground. R3 sustained a large laceration to the frontal scalp and was admitted to the hospital. R3's 6/15/25 5:43 pm progress note showed that R3 returned to the facility with five staples to his forehead. R3's 6/14/25 care plan showed R3 had a risk for falls related to Parkinson's disease, dementia with agitation, anxiety, confusion and a history of falls. R3's intervention's included anticipate resident's needs, resident needs a safe environment with even floors, and staff to recline high back chair when moving resident and ensure proper positioning in chair.On 6/25/25 at 2:46 PM V7 CNA (Certified Nurse's Assistant) said that she was the CNA for R3 on 6/14/25 and she had asked V3 CNA to help her transfer R3 to bed. V7 said that V3 was pushing R3 in his wheelchair and she saw that R3's feet were on the floor and not on the footrest. V7 said that she did not tell V3 that R3's feet were on the floor and not on the footrests and she should have.On 6/25/25 at 4:37 PM V3 CNA said that on 6/14/25 when he was pushing R3 in his wheelchair he did not look were R3's feet were when he started pushing him. V3 said as he was pushing R3, R3 started going forward trying to get out of the wheelchair and then fell out of the wheelchair.On 6/26/25 at 1:58 pm V9 NP said that if R3's feet were on the footrest they would not have caught on the floor causing R3 to fall. The fall caused the laceration to R3's forehead.On 6/27/25 at 4:15 pm V1 (Administrator) said that V7 should have told V3 that R3's feet were on the ground when she saw V3 pushing R3. V1 said that could have prevented R3 from falling. V1 said V3 should have stopped pushing R3 when he saw R3 trying to get out of the chair. V1 said if staff had provided those two interventions it could have prevented R3 from falling and obtaining a laceration to his forehead.On 6/27/25 at 1:34 PM V2 (Assistant Director of Nursing) said that R3's feet should have been on the footrest. V2 said that the CNA should have put R3's feet on the footrest before pushing him down the hall so his foot would not have caught on the floor causing him to fall. V2 said that V7 should have told V3 that R3's feet were on the floor when he was pushing the wheelchair to prevent R3 from falling.

Based on interview and record review, the facility failed to protect the residents' right to be free from neglect when the facility failed to ensure medications were obtained and hospice orders were followed for 2 (R1, R2) residents, admitted to the facility for a hospice respite stay. This failure resulted in R1 experiencing seizures after not receiving anticonvulsant medications and requiring hospitalization. This applies to 2 of 4 residents (R1, R2) reviewed for neglect in the sample of 8. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] for a respite stay. The EMR continues to show R1 was transferred to the local hospital on May 23, 2025 due to experiencing a seizure at the facility. R1 did not return to the facility. R1 had multiple diagnoses including cognitive social deficit following cerebral infarction, epilepsy not intractable, with status epilepticus, depression, bilateral peripheral vertigo, Type 2 diabetes, chronic respiratory failure, dementia, frontotemporal neurocognitive disorder, cerebral infarction, aphasia, and hemiplegia affecting his right, dominant side. R1's Discharge MDS (Minimum Data Set) dated May 23, 2025 shows R1 had moderately impaired cognition, required partial/moderate assistance with eating, substantial/maximal assistance with oral hygiene, and was dependent on facility staff for toilet hygiene, lower body dressing, and personal hygiene. R1 was always incontinent of urine and frequently incontinent of stool. The EMR shows, on May 14, 2025, V21 (Admissions Director) uploaded R1's history and physical provided by the hospice provider to R1's medical record for R1's respite stay. V22's (Physician) history and physical documentation dated April 1, 2025 shows R1 took multiple medications, including, Lantus insulin, 20 units subcutaneously once a day, and levetiracetam (Keppra) (anti-seizure medication) 500 mg. (Milligrams), 1 tablet orally every 12 hours. On May 22, 2025, at 2:40 PM, V19 (RN-Registered Nurse) documented, [R1] arrived by ambulance to the facility at 10:10 [AM] and was taken to [room number]. I performed a head-to-toe assessment. Patient is nonverbal but follows directions. He is alert to self. Calm and cooperative. He laughs at everything you say to him. Eyes are PERL (Pupils Equal and Reactive to Light). No glasses with him. Hearing is WNL (Within Normal Limits) bilaterally. He has his own teeth that are in poor condition. His lungs are clear in all fields. Heart tones are strong and rhythmic with no peripheral edema noted. Bowel sounds are active in four quadrants. Skin is intact. Resident does not display any signs of discomfort or distress. Resident was wet before exam. Incontinent of bowel and bladder. Vitals taken and charted. Resident will not be able to use his call light effectively. Endorsed to oncoming nurse that we did not receive a diet, official med list, and no report was received about resident. Nurse stated understanding. The facility does not have documentation to show V19 (RN) attempted to locate R1's home medications in his belongings. The facility also does not have documentation to show V19 notified the physician or hospice provider that R1 did not have medications from home, or clarified R1's respite medication orders, or that V19 attempted to order R1's medications from the pharmacy. On May 22, 2025 at 10:45 PM, V20 (RN) documented, Per admission Director, med list and the rest of medications discuss with [V3] (Daughter of R1), who supposed to come later tonight, however, no show up. Writer then called hospice supervisor/manager and made aware, also left a message to the daughter with no return call yet. Comfort package available, the resident in good disposition and aura, no agitation/restlessness noted. Per CNA(Certified Nursing Assistant), the resident was fed with good food and fluid intake, diet verified with the hospice supervisor/manager to be regular/thin/take meds whole. Still anticipating daughter would come with the rest of meds to be reconciled and put in the system. The facility does not have documentation to show V20 (RN) attempted to locate R1's home medications in his belongings. The facility does not have documentation to show V20 notified the physician or hospice provider that she was unable to locate R1's medications from home, clarification regarding R1's respite medication orders, or that V20 attempted to order R1's medications from the pharmacy. On June 4, 2025, at 4:19 PM, V21 (admission Director) said, R1's hospice company sent his admission paperwork to the facility prior to R1's admission. V21 continued to say she uploaded the hospice paperwork to the EMR so R1's medical information and medication list was available to the nurse who admitted R1. V21 said, I confirmed with the hospice company that the medications listed were the most up-to-date list of medications. I provide an admission notification sheet with all of the resident's specific information and everything that is important about the person and gave one to the receptionist and one to the nurse. The sheet showed [R1] was coming to the facility at 10:00 AM on May 22, 2025, and that the family was bringing the medications. On June 6, 2025, at 9:38 AM, V21 (Admissions Director) continued to say, Every hospice respite resident has a written report from me that shows everything about the resident, including if the family is providing the medications. The written report is given to the nurses. The reason the family brings the medications from home is because the medications are paid for by the hospice company. We ask the families to bring the medications in their original pharmacy bottle that is labeled with the resident's name on it and the medication instructions. Everyone here knows this is how respite residents are done. I couldn't make it any easier for the nursing staff. The medications and the resident's medical information are all scanned into the medical record before the resident ever comes to the facility. On June 4, 2025 at 12:40 PM, V3 (Daughter of R1) said, [R1] went to the facility from home. It was a respite stay for five days. Hospice arranged for him to go there. I sent the actual medications in a bag with his belongings, and they called and said they could not find them. I have done a respite stay at this facility before, and I know how it works. Even if they weren't able to find the medications, they could have looked at the medication list provided by hospice and ordered the medications. [R1] has not had a breakthrough seizure in over 20 years. [V10] (Hospice Manager of Admissions) said she called the facility and spoke to [V19] (RN), and he started reading the medications they didn't have. Obviously, he had the list if he was reading the medications from it, and he could have ordered the medications from that list if he couldn't find the medications I sent. On June 4, 2025 at 1:01 PM, V10 (Hospice Manager of Admissions) said, On May 22, 2025, I received a call from [V19] (RN), and he said we have your patient here and the family only sent his comfort pack medications. I said the family was given clear instructions to send all the medications. I asked which medications they were missing, and we went through the list, including the insulin and seizure medication. I reached out to [V3] (Daughter of R1), and she said she realized she had forgotten to include the insulin in the package with the medications because it was in her refrigerator, but the rest of the medications were in the resident's belongings. She said she would have her daughter drop off the insulin later in the day. I called the facility three times after that to speak to [V19] and each time I was never able to speak to him, just left on hold. I finally called again and left my name and number for him to call me back. Around 9:30 PM, I received a call from the facility that [R1's] medications had still not arrived. I said, check the bag because the family said the medications were in there. The nurse asked when the medications should be taken and was able to say the names of the medications. I said, please check his bag, or otherwise, we need to put in a stat order for the medications. She said she would get back to me, but she never did. The next morning, I received a call around 9:30 AM to 10:00 AM from the nurse and was told [R1] was different than usual. The next thing I know, I got a call around 12:30 PM from the facility that they had to send [R1] out 911 because he was found non-responsive and having a seizure. I reached out to the emergency room to tell them they were getting our hospice patient, and they told me he was already at the hospital and had a witnessed seizure and he required Versed (central nervous system depressant). This respite stay had been in the works for weeks before his arrival to the facility. The responsible and right thing to do was to provide the medications. On June 4, 2025 at 3:01 PM, V20 (RN) said she worked a double shift from 2:00 PM to 10:00 PM on May 22, 2025, and 10:00 PM on May 22, 2025 to 6:00 AM on May 23, 2025. V20 continued to say R1 was under her care during the two shifts she worked. V20 said, When I came that day and got report from the nurse on the prior shift, the nurse was confused and overwhelmed. Apparently, [R1] came from home, and no one gave report or a recent medication list. I worked 16 hours and had the resident the whole time. I did not give him any medications that night. From the medication list that came with [R1], I saw he takes Keppra (anti-seizure medication). I did not look through [R1's] belongings for his medications. If I am not the admitting nurse, I don't have to go through the patient's belongings. This should have been taken care of prior. I did not think it was an emergency that [R1] was not getting his medications. On June 4, 2025 at 3:28 PM, V23 (RN) said, I worked from 6:00 AM to 2:00 PM on May 23, 2025. The CNA came to me and said something was wrong with [R1]. I went to see the resident and he appeared to be having a seizure. I called for [V13] (NP-Nurse Practitioner) to come see the resident and she said to send him out 911. I called [V10] (Hospice Manager of Admissions) and said I needed the medications for [R1]. We had a medication list in the admission packet, and it showed [R1] needed insulin and Keppra and other things. I dug through [R1's] belongings and found all of his medications. They were here with his things the whole time. On May 23, 2025 at 9:00 PM, V18's (Physician) hospital documentation shows R1 presented to the emergency room with a witnessed seizure requiring Versed 2 mg. [R1] is a [AGE] year-old male presenting with witnessed seizure. EMS (ambulance) reports patient was post-ictal upon their arrival and had another seizure that required 2 mg. of Versed and resolved with this. Granddaughter is at bedside; states patient was recently transferred to the nursing home and has not had his medications for the past 36 hours. Patient's daughter is on the phone and states patient usually takes Keppra and has not had a breakthrough seizure for 30 years. No fall or injury from witnessed seizure per EMS. Hospital documentation shows R1's blood sugar was 219 (reference range 70-99 mg/dL (milligrams/deciliter) upon admission to the hospital. Facility documentation dated May 23, 2025 at 9:55 AM shows R1's blood sugar was 180 mg/dL (Milligrams/deciliter). R1's May 2025 MAR (Medication Administration Record) shows R1 did not receive any medications, including his insulin or levetiracetam while residing in the facility. On June 5, 2025 at 10:47 AM, V14 (Pharmacist) said, R1's insulin was a long-acting insulin, meant to control his blood sugar over the course of time, and that R1's Keppra medication should not be stopped and if a dose is missed, a seizure is possible. On June 5, 2025 at 3:14 PM, V15 (Pharmacist/General Manager) said, elevated blood sugars are possible when insulin doses are missed, and some people will have breakthrough seizures when anti-seizure medication such as Keppra doses are missed. V15 continued to say had the facility staff ordered R1's medications STAT, the medications could have been available to the facility staff for administration to the resident within four hours. On June 5, 2025 at 9:59 AM, V13 (NP) said, I went to see [R1] on May 23. He was seizing. I asked if he had an order for IV (Intravenous) Ativan (benzodiazepine medication). He did not. He was actively seizing, so he had to go the emergency room. If they would have called me for medication orders, I would have ordered them. He missed doses of his seizure medication, and he ended up having a seizure. What more is there to say? 2. The EMR shows R2 was admitted to the facility on [DATE] for a hospice respite stay and was discharged to her home on April 19, 2025. R2 had multiple diagnoses including heart failure, type 2 diabetes, hypertension, repeated falls, hallucinations, stress incontinence, and the presence of an automatic implantable cardiac defibrillator. R2's MDS dated [DATE] shows R2 had severe cognitive impairment, required supervision with eating, partial/moderate assistance with oral hygiene, was dependent on facility staff for toilet hygiene, and required substantial/maximal assistance with all other ADLs (Activities of Daily Living). R2 was frequently incontinent of bowel and bladder. On April 10, 2025 at 4:05 PM, V20 (RN) documented R2 was admitted to the facility from home after going to the emergency room following a fall. V20 continued to document R2 was admitted to the facility under hospice care. On June 5, 2025 at 1:52 PM, V5 (Son of R2) said, on April 10, 2025 R2 was getting ready to leave home for a respite stay at the facility. V5 continued to say just before R2 left home, she sustained a fall in the bathroom and had to be taken to the emergency room prior to going to the facility. R2 received staples, in the emergency room, to close a laceration on her head prior to going to the facility. V5 said, R2's medications were with her belongings when she went to the facility. When she returned home from the facility on April 19, 2025, her home medications had remained with her belongings, untouched, with the same number of pills in the bottles, and other medications were present in her belongings, some of which R2 had not taken for over four years. The Client Medication Report for R2, provided to the facility by the hospice company on April 10, 2025 shows multiple medication orders for R2, including the following: Quetiapine 50 mg. every night at bedtime for restlessness, and Ambien 5 mg. every night at bedtime for insomnia. The facility does not have documentation to show the order for R2's scheduled Quetiapine or Ambien were ever entered into the EMR or that R2 ever received the Quetiapine and Ambien as shown on the hospice Client Medication Report. The EMR shows the facility had two medication lists for R2; one list from the emergency room dated April 10, 2025, and one list from the hospice provider dated April 10, 2025. The facility does not have documentation to show the facility called the hospice provider to clarify which medications R2 should have received while residing at the facility. On June 9, 2025 at 9:18 AM, V4 (Hospice Nurse) said, R2 had her home medications with her when she went from the emergency room to the facility. V4 said, I had called the facility to notify them [R2] had to be rerouted to the hospital due to her fall at home. I reminded them her medications were with her in her luggage, and she would be a little late getting to the facility. On June 10, 2025 at 10:22 AM, V4 (Hospice Nurse) said, [R2] has not been of sound mind for a long time. As she was transitioning to her later stages in the hospice process, [R2] was getting more anxious and restless. At one point, at home, she was found outside, trying to shovel snow. We discontinued her Trazadone, and we put her on scheduled doses of Quetiapine and Ambien as comfort measures for her end-of-life process. She started having more falls, including two at the facility between April 10 and April 14, 2025, due to her restlessness with the dying process, and it was important she received those medications. If she was not receiving those medications, she would have become more anxious and uncomfortable. The plan for hospice patients is to keep them comfortable. On June 9, 2025 at 10:04 AM, V24 (Former DON-Director of Nursing) said, he was always notified when a resident was coming to the facility for a respite stay. V24 said he assisted R2's nurse and entered all of R2's medication orders into the EMR. V24 said, The nurse should have called the doctor and asked which medication list she should follow, the one from the emergency room, or the one from hospice. The nurse didn't communicate that to me. I was just helping out and put in the orders. I did not call the doctor to clarify the orders. On June 9, 2025 at 12:51 PM, V13 (NP) read the facility's Abuse and Neglect policy and said if the facility's Neglect Policy shows neglect is the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress, then the residents should have gotten their medications or technically that is neglect. V13 continued to say, The nursing staff should have brought up the medication concerns to higher up people such as the DON (Director of Nursing) or the supervisor and obtained the medications. They have the definition of neglect right in their policy. The facility's Abuse Policy and Procedure dated 10/24/2022 and reviewed on 2/18/25 shows: The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents, including verbal, mental, sexual, or physical abuse, corporal punishment, and involuntary seclusion. The facility has a no tolerance philosophy: persons found to have engaged in such conduct will be terminated. Definitions: Neglect is a facility's failure to provide, or willful withholding of adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident. Neglect is also the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on interview and record review, the facility failed to ensure a hospice resident, admitted to the facility for a respite stay, was administered anticonvulsant medication and insulin as shown on the hospice records and provided by the resident's family. This failure resulted in R1 experiencing seizures after not receiving anticonvulsant medications and requiring hospitalization. This applies to 1 of 4 residents (R1) reviewed for medication administration in the sample of 8. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] for a respite stay. The EMR continues to show R1 was transferred to the local hospital on May 23, 2025 due to experiencing a seizure at the facility. R1 did not return to the facility. R1 had multiple diagnoses including cognitive social deficit following cerebral infarction, epilepsy not intractable, with status epilepticus, depression, bilateral peripheral vertigo, Type 2 diabetes, chronic respiratory failure, dementia, frontotemporal neurocognitive disorder, cerebral infarction, aphasia, and hemiplegia affecting his right, dominant side. R1's Discharge MDS (Minimum Data Set) dated May 23, 2025 shows R1 had moderately impaired cognition, required partial/moderate assistance with eating, substantial/maximal assistance with oral hygiene, and was dependent on facility staff for toilet hygiene, lower body dressing, and personal hygiene. R1 was always incontinent of urine and frequently incontinent of stool. The EMR shows, on May 14, 2025, V21 (Admissions Director) uploaded R1's history and physical provided by the hospice provider to R1's medical record for R1's respite stay. V22's (Physician) history and physical documentation dated April 1, 2025 shows R1 took multiple medications, including, Lantus insulin, 20 units subcutaneously once a day, and levetiracetam (Keppra) (anti-seizure medication) 500 mg. (Milligrams), 1 tablet orally every 12 hours. On May 22, 20256 at 2:40 PM, V19 (RN-Registered Nurse) documented, [R1] arrived by ambulance to the facility at 10:10 [AM] and was taken to [room number]. I performed a head-to-toe assessment. Patient is nonverbal but follows directions. He is alert to self. Calm and cooperative. He laughs at everything you say to him. Eyes are PERL (Pupils Equal and Reactive to Light). No glasses with him. Hearing is WNL (Within Normal Limits) bilaterally. He has his own teeth that are in poor condition. His lungs are clear in all fields. Heart tones are strong and rhythmic with no peripheral edema noted. Bowel sounds are active in four quadrants. Skin is intact. Resident does not display any signs of discomfort or distress. Resident was wet before exam. Incontinent of bowel and bladder. Vitals taken and charted. Resident will not be able to use his call light effectively. Endorsed to oncoming nurse that we did not receive a diet, official med list, and no report was received about resident. Nurse stated understanding. The facility does not have documentation to show V19 (RN) attempted to locate R1's home medications in his belongings. The facility also does not have documentation to show V19 notified the physician or hospice provider that he was unable to find R1's medications from home, clarification regarding R1's respite medication orders, or that V19 attempted to order R1's medications from the pharmacy. On May 22, 2025 at 10:45 PM, V20 (RN) documented, Per admission Director, med list and the rest of medications discuss with [V3] (Daughter of R1), who supposed to come later tonight, however, no show up. Writer then called hospice supervisor/manager and made aware, also left a message to the daughter with no return call yet. Comfort package available, the resident in good disposition and aura, no agitation/restlessness noted. Per CNA (Certified Nursing Assistant), the resident was fed with good food and fluid intake, diet verified with the hospice supervisor/manager to be regular/thin/take meds whole. Still anticipating daughter would come with the rest of meds to be reconciled and put in the system. The facility does not have documentation to show V20 (RN) attempted to locate R1's home medications in his belongings. The facility does not have documentation to show V20 notified the physician or hospice provider that she was unable to locate R1's medications from home, clarification regarding R1's respite medication orders, or that V20 attempted to order R1's medications from the pharmacy. On June 4, 2025 at 12:40 PM, V3 (Daughter of R1) said, [R1] went to the facility from home. It was a respite stay for five days. Hospice arranged for him to go there. I sent the actual medications in a bag with his belongings, and they called and said they could not find them. I have done a respite stay at this facility before, and I know how it works. Even if they weren't able to find the medications, they could have looked at the medication list provided by hospice and ordered the medications. [R1] has not had a breakthrough seizure in over 20 years. [V10] (Hospice Manager of Admissions) said she called the facility and spoke to [V19] (RN), and he started reading the medications they didn't have. Obviously, he had the list if he was reading the medications from it, and he could have ordered the medications from that list if he couldn't find the medications I sent. On June 4, 2025 at 3:01 PM, V20 (RN) said she worked a double shift from 2:00 PM on May 22, 2025 to 10:00 PM, and 10:00 PM to 6:00 AM on May 23, 2025. V20 continued to say R1 was under her care during the two shifts she worked. V20 said, When I came that day and got report from the nurse on the prior shift, the nurse was confused and overwhelmed. Apparently, [R1] came from home, and no one gave report or a recent medication list. I worked 16 hours and had the resident the whole time. I did not give him any medications that night. From the medication list that came with [R1], I saw he takes Keppra (anti-seizure medication). I did not think it was an emergency that [R1] was not getting his medications. On June 4, 2025 at 3:28 PM, V23 (RN) said, I worked from 6:00 AM to 2:00 PM on May 23, 2025. The CNA came to me and said something was wrong with [R1]. I went to see the resident and he appeared to be having a seizure. I called for [V13] (NP-Nurse Practitioner) to come see the resident and she said to send him out 911. I called [V10] (Hospice Manager of Admissions) and said I needed the medications for [R1]. We had a medication list in the admission packet, and it showed [R1] needed insulin and Keppra and other things. I dug through [R1's] belongings and found all of his medications. They were here with his things the whole time. On May 23, 2025 at 9:00 PM, V18's (Physician) hospital documentation shows R1 presented to the emergency room with a witnessed seizure requiring Versed 2 mg. [R1] is a [AGE] year-old male presenting with witnessed seizure. EMS reports patient was post-ictal upon their arrival and had another seizure that required 2 mg. of Versed and resolved with this. Granddaughter is at bedside; states patient was recently transferred to the nursing home and has not had his medications for the past 36 hours. Patient's daughter is on the phone and states patient usually takes Keppra and has not had a breakthrough seizure for 30 years. No fall or injury from witnessed seizure per EMS. Facility documentation dated May 23, 2025 at 9:55 AM shows R1's blood sugar was 180 mg/dL (Milligrams/deciliter). Hospital documentation shows R1's blood sugar was 219 (reference range 70-99 mg/dL upon admission to the hospital. On June 5, 2025 at 10:47 AM, V14 (Pharmacist) said, R1's insulin was a long-acting insulin, meant to control his blood sugar over the course of time, and that R1's Keppra medication should not be stopped and if a dose is missed, a seizure is possible. On June 5, 2025 at 3:14 PM, V15 (Pharmacist/General Manager) said, elevated blood sugars are possible when insulin doses are missed, and some people will have breakthrough seizures when anti-seizure medication such as Keppra doses are missed. On June 5, 2025 at 9:59 AM, V13 (NP) said, I went to see [R1] on May 23. He was seizing. I asked if he had an order for IV (Intravenous) Ativan (benzodiazepine medication). He did not. He was actively seizing, so he had to go the emergency room. If they would have called me for medication orders, I would have ordered them. He missed doses of his seizure medication, and he ended up having a seizure. What more is there to say? V13 continued to say if R1's medications were not available, facility staff should have attempted to contact her, and she would have given orders for all of his medications. The facility's policy entitled Respite Care, dated 06/01/2024 shows, Procedure: .2. Medications will be ordered from the facility's pharmacy unless otherwise specified by the family. If the family failed to supply the medications on time, the facility will use its pharmacy, and the bill will be charged to the family.

Based on interview and record review, the facility failed to ensure a resident did not receive unnecessary medications. This applies to 1 of 3 residents (R2) reviewed for pharmacy services in the sample of 8. The findings include: The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE] for a hospice respite stay and was discharged to her home on April 19, 2025. R2 had multiple diagnoses including heart failure, Type 2 diabetes, hypertension, repeated falls, hallucinations, stress incontinence, and the presence of an automatic implantable cardiac defibrillator. R2's MDS (Minimum Data Set) dated April 19, 2025 shows R2 had severe cognitive impairment, required supervision with eating, partial/moderate assistance with oral hygiene, was dependent on facility staff for toilet hygiene, and required substantial/maximal assistance with all other ADLs (Activities of Daily Living). R2 was frequently incontinent of bowel and bladder. On April 10, 2025 at 4:05 PM, V20 (RN-Registered Nurse) documented R2 was admitted to the facility from home after going to the emergency room following a fall. V20 continued to document R2 was admitted to the facility under hospice care. On June 5, 2025 at 1:52 PM, V5 (Son of R2) said, on April 10, 2025 R2 was getting ready to leave home for a respite stay at the facility. V5 continued to say just before R2 left home, she sustained a fall in the bathroom and had to be taken to the emergency room prior to going to the facility. R2 received staples, in the emergency room, to close a laceration on her head prior to going to the facility. V5 said, R2's medications were with her belongings when she went to the facility. When she returned home from the facility on April 19, 2025, her home medications had remained with her belongings, untouched, with the same number of pills in the bottles that were there when the resident left home, and other medications were present in her belongings, some of which R2 had not taken for over four years. V5 continued to say, because the facility ordered the medications R2 was no longer taking and not on the hospice list, V5 was charged $150 by the pharmacy provider. The EMR shows the facility had two medication lists for R2. One list was from the local hospital emergency room, and one list was from the hospice provider. R2's After Visit Summary from the local hospital dated April 10, 2025 shows, Your Medication List - ASK your doctor about these medications. The After Visit Summary from the local hospital shows the following medications for R2: Acetaminophen (pain reliever) Albuterol inhaler (for wheezing) as needed Ascorbic Acid (vitamin supplement) Atorvastatin (cholesterol medication) daily Calcium carbonate (supplement) Carvedilol (cardiac medication) 3.125 mg (milligrams) twice daily Multivitamin Cholestyramine-Aspartame (bile acid binder) 4 grams daily Furosemide (diuretic) twice daily Gabapentin (peripheral pain medication) twice daily Nitroglycerin (cardiac medication) as needed Pantoprazole (stomach medication) twice daily Extended-release Potassium Chloride (electrolyte) daily Sertraline (antidepressant) daily Trazadone (antidepressant) daily Vitamin D (supplement) R2's Client Medication Report from the hospice provider, dated April 10, 2025 shows the following medication orders for R2: Acetaminophen daily at bedtime for pain Ambien (insomnia medication) daily at bedtime Bisacodyl (for constipation) as needed Furosemide twice daily Gabapentin twice daily Haloperidol (agitation medication) as needed Hyoscyamine (for secretions) as needed Lorazepam (for anxiety) as needed Morphine (pain medication) as needed Pantoprazole twice daily Prochlorperazine (for nausea) as needed Quetiapine (restlessness) daily at bedtime Senna (stool softener) daily as needed Sertraline daily The facility does not have documentation to show facility staff called the hospice provider to clarify which medications R2 should have received while residing at the facility for her hospice respite stay. R2's April 2025 MAR (Medication Administration Record) shows R2 received the following medications during her stay at the facility that were not on R2's hospice medication list: Atorvastatin - R2 received 6 doses from April 11, 2025 to April 18, 2025 Carvedilol - R2 received 13 doses from April 12, 2025 to April 19, 2025 Cholestyramine Aspartame - R2 received 8 doses from April 12, 2025 to April 19, 2025 Potassium Chloride - R2 received 9 doses from April 11, 2025 to April 19, 2025 On June 9, 2025 at 10:04 AM, V24 (Former DON-Director of Nursing) said, The nurse should have called the doctor and asked which medication list she should follow, the one from the emergency room, or the one from hospice. The nurse didn't communicate that to me. I was just helping out and put in the orders. I did not call the doctor to clarify the orders. On June 9, 2025 at 9:18 AM, V4 (Hospice Nurse) said, R2 had her home medications with her when she went from the emergency room to the facility. V4 said, I had called the facility to notify them [R2] had to be rerouted to the hospital due to her fall at home. I reminded them her medications were with her in her luggage, and she would be a little late getting to the facility. V4 continued to say the facility should have contacted the hospice provider to clarify what medications R2 was taking if there was any conflict between the medication list provided by the hospital and list provided by hospice since R2 was under contract with the hospice company. The facility's undated policy entitled Hospice Care Policy and Procedure shows, Policy: To establish protocols and procedures to ensure communication and provision of care between facility staff and hospice providers. Procedure: .3. The facility's Director of Nursing is the clinical staff member responsible for working with Hospice representatives to coordinate care to the resident provided by facility and hospice staff. The facility's Social Service Director is the staff member responsible for contact with Hospice agencies whenever there is a concern related to resident care. 4. The Director of Nursing and/or the Social Services Director will be responsible for .d. Obtaining the following information from Hospice: .vi. Hospice medication information specific to each resident.

Based on observation, interview, and record review, the facility failed to ensure residents receive showers as shown on the facility's shower schedule, and failed to ensure residents receive assistance with shaving and fingernail care. This applies to 4 of 4 residents (R1, R2, R3, and R4) reviewed for ADL (Activities of Daily Living) assistance in the sample of 4. The findings include: 1. On April 10, 2025 at 9:17 AM, R1 was lying in bed in his room. No sign was present to show R1 was in isolation. R1 had beard growth approximately 1/4 inch to 1/2 inch long, and long fingernails. R1's scalp hair had copious amounts of white flakes present. R1's hands were severely contracted and R1 said he is unable to perform personal care due to his contracted hands and paralysis. R1 said he does not like having long facial hair or fingernails. R1 also said he does not like receiving bed baths and he prefers to receive showers. R1 continued to say that since the facility moved him to a different room in March 2025, the level of care he has been receiving has been different and he has not been receiving showers, which he prefers. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 left the facility against medical advice on August 28, 2023. R1 was readmitted to the facility on [DATE] with multiple diagnoses including, displaced fracture of the first cervical vertebrae, functional quadriplegia, hallucinations, paresthesia of skin, major depressive disorder, UTI (Urinary Tract Infection), abnormal posture, need for assistance with personal care, hypertension, migraines, Covid-19, history of falling, nicotine dependence, morbid obesity, seborrheic dermatitis, COPD (Chronic Obstructive Pulmonary Disease), encephalopathy, and spinal cord injury. R1's MDS (Minimum Data Set) dated February 28, 2025 shows R1 is cognitively intact, dependent on facility staff for all ADLs including showering, has an indwelling urinary catheter, and is always incontinent of stool. R1's care plan for ADL self-care performance deficit, initiated on December 4, 2024 shows multiple interventions initiated on December 4, 2024 including, Bathing: Requires 2 staff participation with bathing. Dependent of 2+ staff for shower transfers using full body mechanical lift machine. Check nail length and trim and clean on bath day and as necessary. R1's care plan for actual impairment to skin integrity, initiated on December 4, 2024 shows multiple interventions initiated on December 4, 2024 including, Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. The EMR shows the following order for R1 dated March 26, 2025: Strict contact/droplet isolation due to Covid-19 x 10 days. All services to be provided in room. The EMR shows the following order for R1 dated April 7, 2025: Covid isolation discontinued. The facility's shower schedule shows R1 should receive a shower on Tuesdays during the afternoon (PM) shift (2:00 PM to 10:00 PM), and on Fridays during the day shift (6:00 AM to 2:00 PM). Based on the shower schedules provided by the facility, R1 should have received showers on March 4, 7, 11, 14, 18, 21, 25, and 28, 2025, and April 1, 4, and 8, 2025. R1's shower sheets show R1 received a bed bath on March 4, and 27, 2025. On March 11, and 18, 2025, V15 (CNA-Certified Nursing Assistant) documented R1 received a shower bath. R1's shower sheet dated March 28, 2025 shows R1 received a bed bath due to being in isolation. The facility does not have documentation to show R1 received his scheduled showers on March 21, 2025, April 1, 4, and 8, 2025, or that R1 refused to receive a bed bath/shower on those days. The facility does not have documentation in POC (Point of Care) to show R1 received a shower/ bed bath during the previous 30 days. On April 10, 2025 at approximately 3:10 PM, V15 (CNA) said when she writes shower bath on a resident's shower sheet, it means she gave a bed bath, not a shower. On April 14, 2025 at 9:47 AM, V2 (DON-Director of Nursing) said residents can still receive a shower if they are in isolation for Covid-19. 2. On April 10, 2025 at 9:15 AM, R2 was lying in bed in the room he shared with R1. No sign was present on R2's door to show R2 was in isolation. R2's breakfast tray was on the bedside table near his bed. The breakfast on the tray was not eaten. R2 said he could not reach his breakfast tray and was waiting for facility staff to set up the breakfast tray near him. R2 said he has not received a bed bath or shower for quite a few days. The EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses including, generalized osteoarthritis, unspecified head injury, diabetes, obstructive and reflux uropathy, gastritis, congenital stenosis and stricture of the esophagus, OSA (Obstructive Sleep Apnea), difficulty walking, cognitive communication deficit, repeated falls, weakness, presence of cardiac pacemaker, and heart failure. R2's MDS dated [DATE] shows R2 is cognitively intact, requires supervision with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with toilet hygiene, showering, lower body dressing, bed mobility, and transfers between surfaces. R2 has an indwelling urinary catheter and is always continent of stool. R2's care plan for ADL self-care performance deficit, initiated March 24, 2025 shows multiple interventions initiated on March 24, 2025 including, Bathing: [R2] requires substantial/maximal assistance from staff participation with bathing. Provide a sponge bath when a full bath or shower cannot be tolerated. [R2] requires substantial/maximal assistance from staff. The EMR shows the following order for R2 dated March 26, 2025: Strict contact/droplet isolation due to Covid-19 x 10 days. All services to be provided in room. The facility's undated shower schedule shows R2 should receive a shower on Tuesdays during the afternoon shift (2:00 PM to 10:00 PM), and on Fridays during the day shift (6:00 AM to 2:00 PM). Based on the shower schedules provided by the facility, R2 should have received showers on March 25, and 28, 2025 and April 1, 4, and 8, 2025. R2's shower sheets show R2 refused a shower on March 25, and had a bed bath on March 28 and April 1 due to being in isolation. The facility does not have documentation to show R2 received a shower or bed bath on April 4, or 8, 2025, or that R2 refused to receive a bed bath/shower on those days. The facility does not have documentation in POC to show R2 received a shower/bed bath since he was admitted to the facility on [DATE]. 3. On April 14, 2025 at 10:18 AM, R3 was lying in bed in his room. R3 had long fingernails. R3 had a dark substance underneath his fingernails. R3 said, They don't give you a shower twice a week. The EMR shows R3 was admitted to the facility on [DATE]. The EMR continues to show R3 was transferred to the local hospital on February 9, 2025 and returned to the facility on [DATE]. R3 has multiple diagnoses including left femur fracture, COPD (Chronic Obstructive Pulmonary Disease), atrial fibrillation, PVD (Peripheral Vascular Disease), anxiety disorder, diabetes, acute kidney failure, heart failure, chronic pain, depression, unsteadiness on feet, altered mental status, metabolic encephalopathy, and DVT (Deep Vein Thrombosis) of the left lower extremity. R3's MDS dated [DATE] shows R3 has moderate cognitive impairment, requires setup assistance with eating, partial/moderate assistance with oral and personal hygiene, substantial/maximal assistance with lower body dressing, and is dependent on facility staff for toilet hygiene, showering, bed mobility, and transfers between surfaces. R3 is occasionally incontinent of bowel and bladder. R3's care plan for ADL self-care performance deficit, initiated on November 3, 2024 shows multiple interventions initiated on November 3, 2024, including, Bathing: Requires 2 staff participation with bathing. Dependent of 2+ staff for shower transfers using full body lift machine. Bathing: Provide with a sponge bath when a full bath or shower cannot be tolerated. R3's care plan for actual impairment to skin integrity, revised on February 17, 2025 shows multiple interventions initiated on November 2, 2024 including, Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. The facility's undated shower schedule shows R3 should receive a shower on Wednesdays during the day shift (6:00 AM to 2:00 PM), and on Saturdays during the afternoon shift (2:00 PM to 10:00 PM). Based on the shower schedules provided by the facility, R3 should have received showers on March 19, 22, 26, and 29, 2025 and April 2, 5, and 9, 2025. R3's shower sheets show R3 refused to be showered on March 26, 2025. The facility does not have documentation to show R3 received a shower or bed bath on March 22, and 29, 2025 and April 2, and 9, 2025 or that R3 refused a shower/bed bath on those days. The facility does not have documentation in POC to show R3 received a shower/bed bath during the previous 30 days. 4. On April 10, 2025 at 3:25 PM, R4 was sitting up in a high-back wheelchair. R4 was unable to answer questions due to his cognitive status and medical condition. The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including, encephalopathy, UTI (Urinary Tract Infection), diabetes, pleural effusion, chronic Hepatitis C, Alzheimer's disease, gastrostomy tube, dementia, glaucoma, dysphagia, heart disease, history of kidney and prostate cancer, delirium, absence of kidney, and weakness. R4's MDS dated [DATE] shows R4 has moderate cognitive impairment and is dependent on facility staff for all ADLs. R4 has an indwelling urinary catheter and is always incontinent of stool. R4's care plans were reviewed. R4's care plan for ADL Self-care performance deficit, initiated on March 7, 2025 shows multiple interventions dated March 7, 2025 including, [R4] is totally dependent on 2 staff to provide a bath and as necessary, and provide with a sponge bath when a full bath or shower cannot be tolerated. [R4] is dependent from staff. The facility's undated shower schedule shows R4 should receive a shower on Mondays during the day shift (6:00 AM to 2:00 PM), and Thursdays during the afternoon shift (2:00 PM to 10:00 PM). Based on the shower schedules provided by the facility, R4 should have received showers on March 10, 13, 17, 20, 24, 27, and 31, 2025 and April 3, and 7, 2025. The shower sheets show R4 received bed baths on March 17, 20, 24, and April 3, 2025. The facility does not have documentation to show R4 received showers/bed baths on March 10, 13, 27, and 31, 2025 and April 7, 2025 or that R4 refused to receive a shower/bed bath on any of those days. The facility does not have documentation in POC to show R4 received a shower/bed bath during the previous 30 days. On April 10, 2025 at 10:57 AM, V5 (RN/WCN-Registered Nurse/Wound Care Nurse) said, When the CNA gives a shower, they fill out the shower sheet. If the resident has an open wound, then the nurse goes to the room and assesses the resident right away and will let me know. Either they bring me the shower sheets, or I pick them up every day. V5 continued to say the shower sheets she provided were the most up-to-date shower sheets she had and there were no outstanding shower sheets. The facility's undated shower schedules for residents residing on the floor where R1, R2, R3, and R4 reside show daily shower assignments based on the resident's room number. The shower schedule shows each resident has a day of the week and a shift when the resident should be showered. Each resident room shows two different days of the week when showers should take place. The shower schedules show: 1. Shave your residents including females when appropriate. 2. Remember to fill out the shower sheet and report any findings to nurse for the nurse to assess. 3. Please report any refusal in the beginning of the shift to your supervisor as showers need to be done 2 times a week. Please remember to also chart in POC. The facility's undated policy entitled, Shower Policy and Procedure shows, Policy: It is the policy of this facility that all residents be bathed and groomed appropriately on a regular basis. Purpose: To establish a mechanism for ensuring that residents receive baths/showers on a routine basis. To ensure that nursing is notified of residents who refuse showers, and to establish a mechanism for ensuring that residents who refuse showers are offered a shower the next shift/following day. Procedure: 1. A schedule of showers for each room/resident has been established to ensure that each resident receives at least one shower on the day shift and one on the PM shift per week.3. When showers are given, the staff giving the resident the shower/bed bath will document on the Point of Care that shower was given; refusals will also be documented on the Point of Care by the staff who attempted to provide the shower. 4. If a resident refuses a shower, the nurse on the unit will be notified and the following shift will attempt to give the resident his/her shower. 5. Should the resident continue to refuse showers; the Director of Nursing/Designee will visit the resident and attempt to intervene to determine reason for refusal and to provide resident education about importance of person hygiene. 6. In the event the resident continues to refuse showers/bed baths, the POA (Power of Attorney) will be notified, and his/her assistance will be requested to encourage the resident to take his/her shower/bed bath. 7. Continued refusal of showers will be documented on Point of Care and a care plan will be developed to address resident refusal.

Based on interviews and record review, the facility failed to protect residents from sexual abuse from a housekeeper (V4). This failure resulted in R1 and R2 being sexually abused by V4 on January 25, 2025. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse in the sample of 22. This resulted in Immediate Jeopardy. The Immediate Jeopardy began on January 25, 2025 when R2 reported to the facility that she was sexually assaulted by V4. V1 (Administrator), V3 (acting Director of Nursing) and V15 (Part-time Nursing Consultant) were notified of the Immediate Jeopardy on February 18, 2025 at 10:37 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on February 18, 2025, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R2 had multiple diagnoses including chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, thrombocytopenia and need for assistance with personal care, based on the face sheet. R2's admission MDS (minimum data set) dated November 21, 2024 showed that the resident was cognitively intact (BIMS (Brief Interview for Mental Status) of 15) and required maximum to total assistance from the staff with all her ADLs (activities of daily living). R2's progress notes dated January 25, 2025 at 3:10 PM created by V5 (LPN/Licensed Practical Nurse) showed in-part, Resident reported alleged inappropriate touching by staff, prompting immediate head-toe assessment, which showed no new bruising, and resident denied pain, or distress. [Physician] immediately notified and ordered to send her to ER (emergency room ) for evaluation, but resident refused to go to ER. Provided education resident continues to refuse to go. POA (Power of Attorney) made aware. R2's progress notes dated January 25, 2025 at 6:53 PM showed, Offered for resident to be sent to the ER for evaluation. Resident refused after multiple attempts. Notified son and [Physician]. R2's electronic records including, progress notes and care plans showed no documentation that the resident had behavior of falsely accusing staff and/or residents of any abuse or inappropriate behavior towards her or other residents. On January 30, 2025, at 2:08 PM, R2 was in bed, alert and oriented. In the presence of V3 (Acting Director of Nursing), R2 stated that on Saturday (January 25, 2025) a tall, black man wearing a mask, fondled her breast and placed his hand inside her disposable brief and touched her vaginal area. The same tall, black man told her (R2), It's been a long time since you had a penis. R2 stated that she asked the man to stop what he was doing. R2 added that after the sexual assault, the man told her, I will see you later. According to R2, the sexual assault happened after breakfast, and she believes that the tall black man who sexually assaulted her was a housekeeper because he had a mop or a broom with him. During the same interview, R2 stated that after her sexual assault, she heard her roommate (R1) saying, that hurts. R2 stated that she was unable to see what was going on with R1 because the curtain between them was drawn. R2 believes that the same tall black man was inside R1's room. R2 stated that she did not call for help and/or immediately reported the sexual assault because she was in shock of what had happened to her. According to R2, she only reported the incident to her (Family) and her (Family) called the nurse. R2 stated that after her (Family) informed the nurse of the incident, multiple facility staff and police had talked to her, then she reported her sexual assault and what she had heard from her roommate (R1). R2 stated that she was offered several times by the facility to go to the hospital after the sexual assault, but she refused. On February 11, 2025, at 10:52 AM, R2 was in bed, alert and oriented and once again R2 stated that on Saturday (January 25, 2025) she was sexually assaulted by a tall black man wearing a mask. R2 was unable to recall the specific time but believed it was after breakfast. R2 stated that she saw the tall black man enter her room and he started cleaning using either a mop or a broom. R2 stated that it is a daily occurrence for the housekeeper to clean her room, so she did not pay attention to what was going on. She closed her eyes to sleep, then she was awakened to find the same tall black man fondling her breast and sucking her nipple, while his other hand was inside her disposable brief, touching her vaginal area. According to R2 during the sexual assault, the man commented, It's been a long time since you had a penis. R2 stated that she told the man to stop and to go away and the man told her, I will see you later. R2 stated that after leaving her side of the room, she saw the tall black man went to her roommate's (R1) side of the room. R2 stated that the curtain between her and R1 was drawn, and she could not see what was going on in R1's room, but she heard R1 said, Ouch, it hurts then she saw the tall black man leave their room. R2 stated that she was in shock, and she just wanted the man to leave her alone. R2 stated, that she cried the next day because she cannot believe what happened. R2 added, even up to now, I would start crying when I remember it. According to R2 she was traumatized. During the same interview, R2 was asked about the added information that she shared with regards to her nipple being sucked during the sexual assault because this information was not mentioned when she was first interviewed by the surveyor on January 30, 2025 in the presence of V3. R2 responded, I thought that I told you guys about that. R2's late entry progress notes dated January 30, 2025 at 3:13 PM, created by V11 (Licensed Clinical Psychologists) showed in-part under summary and treatment, Resident was referred secondary to allegations of being sexually assaulted by a janitorial staff member. Resident open and willing to address her emotions. Reported an increase of racing thoughts at night, feels uneasy at times, also reported feelings of anger secondary to incident. R2's late entry progress notes dated February 4, 2025 at 1:22 PM, created by V11 (Licensed Clinical Psychologist) showed in-part, Resident continued to discuss and work through negative emotions secondary to incident that occurred a few weeks ago. She shared that the thoughts have affected her ability to sleep some nights. She also expressed feeling angry at times. The progress notes documented under statements that pertain to treatment goals showed, The other day I couldn't sleep because it kept going on in my mind. How do you expect me to feel? one day I'm ok and the next day I'm not. On February 19, 2025 at 11:39 AM, V11 stated that she first saw R2 on January 30, 2025 because the resident was referred by the facility. Stated that during her talk to R2, the resident told her that that a male housekeeping staff had touched her breast and had his hand inside her brief. V11 stated that during this initial meeting with R2, the resident had verbalized increased of racing thoughts at night, feeling uneasy and angry due to being touched without her consent by the housekeeper. According to V11, she made a follow up visit to R2 on February 4, 2025. V11 stated that during this visit, R2 expressed having difficulty sleeping at some nights and feeling angry at times because of being inappropriately touched by the housekeeper. R1 had multiple diagnosis including, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, flaccid hemiplegia affecting left non-dominant side, vascular dementia without behavioral disturbance and severe morbid obesity due to excess calories, based on the face sheet. R1's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition (BIMS of 7) and required total assistance from the staff with most of her ADLs. R1's progress notes dated January 25, 2025 at 9:08 PM created by V5 (LPN) showed, [Physician] called back and was notified that alleged staff was touching resident inappropriately. [Physician] stated to let nursing supervisor know and follow protocol. R1's progress notes dated January 26, 2025 at 9:47 AM, created by V9 (Physician) as a late entry showed that the resident was seen because of an unusual incident at the facility where R1's roommate (R2) alleged that a housekeeper had inappropriately touched her (R2). The progress notes documented that V9 examined R1 in the presence of the nurse and no new findings were documented. R1's transfer form dated January 28, 2025 at 11:55 AM, showed that the resident was sent to the hospital for evaluation for inappropriate touch. R1's progress notes dated January 29, 2025 at 10:27 AM, showed that the resident returned to the facility at around 1:20 AM post medical examination of alleged incident. There was no new order, and no result reported at the time. R1's hospital records dated January 28, 2025 showed that the resident was at the emergency department for further evaluation of possible sexual abuse and an SA (sexual assault) kit was performed per son's request. R1's electronic records including, progress notes and care plans showed no documentation that the resident had behavior of falsely accusing staff and/or residents of any abuse or inappropriate behavior towards her or other residents. On January 30, 2025 at 1:57 PM, R1 was in bed, alert and was able to respond verbally to simple questions and at times responds using gestures. In the presence of V3 (Acting Director of Nursing), R1 was asked if anyone had inappropriately touched her at the facility. R1 stated, he put his finger and using her right hand pointed at her disposable brief. R1 was asked if the person placed his finger inside her disposable brief and R1 nodded. R1 was asked if the person touched her vaginal area, and the resident nodded. R1 stated, he needs to be put away. R1 was asked to describe who had inappropriately touched her vaginal area and the resident stated, African American. R1 was not able to give further description, and she was not able to give the date and time of the incident. On February 11, 2025 at 11:14 AM, R1 was in bed, alert and was able to respond verbally to simple questions and would also respond using gestures. R1 was again asked if anyone had inappropriately touched her at the facility, R1 nodded. Using her right hand, she pointed at her disposable brief and stated, here. R1 was asked what the person did, and she responded, finger while pointing at her disposable brief. R1 described the person as, African American man. R1 was asked if the person placed his finger inside her brief and touched her vaginal area, R1 responded yes while nodding. R1 was not able to give further description, and she does not remember when the incident happened. On February 3, 2025 at 2:13 PM, V8 (Detective) stated that the local police department had received the allegation of sexual abuse on January 25, 2025 and a police officer had made the report. V8 stated that on January 27, 2025 he went to the facility to speak to R2. During his conversation with R2, the resident informed him that a black man, wearing a mask fondled her breast and placed his hand inside her brief and touched her vagina. R2 described the man as the worker that comes to clean her room. V8 stated that a photo lineup was established but R2 was not able to identify the person that touched her because of the mask. According to V8, during his interview with R2, the resident also told him that she heard her roommate (R1) saying, don't touch me but she cannot see what was going on in her roommate's area because the curtain was drawn. V8 stated that he talked to R1 (roommate) and the resident had informed him that her private area was touched by someone that worked there, but no other information was given by R1. V8 stated that the facility identified the male housekeeper working on January 25, 2025 at R1 and R2's unit, to be V4 (Housekeeper). V8 stated that he spoke to V4 on January 27, 2025. He was told by V4 that he was inside R2's room in the morning (he does not remember the exact time) of January 25, 2025 to clean the room. According to V4 while inside R2's room, cleaning, he (V4) noticed food spills on R2's gown by the chest area. He (V4) used a towel to clean the spill on R2's gown and during that time, R2 told V4 to stop and not to touch her. V8 stated that V4 was inside R2 and R1's room on January 25, 2025 and admitted that he had physical contact with R2. V8 added that V4 was a housekeeper and should have not touched R2. V8 was asked about R2's allegation of being touched on her vaginal area and he (V8) responded that he was still investigating and will be talking to V4 again. V8 was asked about R2's allegation regarding her roommate (R1). V8 cannot give any information about it and stated that his investigation for both R1 and R2's cases are still ongoing and no further information could be shared. According to V8, he had the video footage that the facility gave him but had not looked at the said video footage yet. V8 stated that his investigation of the case is still on going and that there is no final determination yet. According to V8, The good thing is that he (V4) acknowledged that he was inside their room. As a housekeeper he should not touch a patient. V8 added that there is no projected date when he can complete the investigation. On February 11, 2025, at 1:42 PM, V8 (Detective) stated the State Police sexual assault kit was performed for R1 at the hospital and the result will not be available in about five to six months. V8 stated that when he talked to V4 (housekeeper), he acknowledged that he was inside R1 and R2's room on January 25, 2025 to clean. V4 also admitted that he used a towel to clean the spill on R2's gown by the chest area, on January 25, 2025. According to V8, V4 admitted to having physical contact with R2, which should not have occurred because V4 was a housekeeper and not a nursing staff. During the same interview, V8 was asked if R2 had mentioned to him on January 27, 2025 when he talked to the resident about her allegation that the housekeeper had sucked her nipple and that the housekeeper told her, It's been a long time since you had a penis. V8 stated that R2 had told him about it. V8 stated that when he started to ask V4 about R2's allegation of being touched in her vaginal area, V4 requested to have an attorney and V4 was not questioned further about R1 and R2's case. According to V8 he had not shared any information to the facility about R1 and R2's case because the investigation was still an ongoing/open case. Review of the initial report to the State Agency made on January 25, 2025 at 7:20 PM, facility reported that on January 25, 2025 at 4:56 PM, R2 made an allegation of abuse. R2 alleged that a staff member spoke to her and touched her inappropriately. The initial report showed that no injuries and no complaints of pain was made by R2. The staff member was immediately suspended pending investigation. The Police was notified, and the Physician was made aware with order to send R2 to the hospital for further evaluation and treatment. R2's responsible party was also made aware. Review of the same initial report showed an addendum which read, Upon initial investigation it was alleged by resident that her roommate was also touched inappropriately. Roommate [R1] with head to toe assessment with no injuries or pain noted. Roommate did not indicate any concern. Resident with no concerns. [Physician] and responsible party aware. Review of the facility's final report to the State Agency made on January 30, 2025 at 5:52 PM, regarding R2's allegation of abuse on January 25, 2025 showed, Resident (R2) alleged to her family that a male staff member wearing a blue shirt touched her inappropriately. She also stated he spoke to her inappropriately. [R2] later stated, that her roommate [R1] had also been touched and spoken to inappropriately. [R2] would not have been able to determine this as the curtains between the beds were drawn. The residents were both assessed with no skin alterations, visible injuries, pain, and both remained at their baseline for cognition. Resident [R2] initially refused to go to the hospital and later went to appointment for medical treatment and currently being treated for UTI (urinary tract infection) with IV (intravenous) (antibiotic). [R1's] (Family) arrived and requested to have [R1] sent to ER (emergency room ) for (evaluation). Resident [R1] (primary care physician) and hospital evaluation with no findings. The same final report showed, Interviews with staff and residents could not substantiate abuse. The facility presented the statement of V4 obtained by V1 (administrator) via phone made on January 25, 2025 (no time was documented), as part of the facility investigation. V4's statement showed that V4 worked at the facility on January 25, 2025, during the morning shift as a housekeeper. V4 acknowledged that he swept and mopped inside R1 and R2's room. The statement documented in-part, While in there I did speak with the ladies by saying good morning while they were eating breakfast. After cleaning the room, I took the garbage out. I never spoke to the residents inappropriately or touched them inappropriately. After my workday I clocked out and left the building. The housekeeping schedule for January 25, 2025, showed that V4 was assigned to multiple rooms at the second floor east hallway, including the rooms of R1 and R2. V4's January 2025 time sheet showed that he clocked in on January 25, 2025 at 6:38 AM and clocked out the same day at 3:06 PM. Further review of V4's January 2025 time sheet showed no other activity past January 25, 2025. The facility presented documentation from Human Resources that on January 30, 2025, V6 (Housekeeping Supervisor) received a text message from V4 that he was resigning and will not be returning at the facility. On January 30, 2025, at 4:03 PM, V5 (Licensed Practical Nurse) stated that she was R1 and R2's nurse on January 25, 2025 during the morning (6:00 AM - 2:00 PM) and afternoon shifts (2:00 PM - 10:00 PM). V5 stated that on January 25, 2025 at around 3:00 PM, she received a call from V10 (Family of R2) telling her to check on R2 because the resident was scared because a black guy was in her room. She told V10 that she was just inside R2's room, and the resident did not say anything to her. After hanging up the phone with V10 she went to talk to R2. While V10 was listening on R2's phone, the resident informed her that a tall black guy touched her breast and placed his hand inside her brief and told her that she hasn't had a penis for a long time. V5 stated that after hearing R2's allegation she immediately informed V12 (Nursing supervisor) and then called V1 (Administrator) on his cellular phone to report the allegation. According to V5, since she also worked during the morning shift, she was aware that there was only one black male staff in the unit, and it was the housekeeper (V4). According to V5, he had seen V4 cleaning resident rooms. V5 stated that R2 did not report to her any abuse allegation during the morning shift and that she only learned about the allegation after R2's family (V10) called her to check on the resident. V5 stated that when she received the report from R2, V4 was no longer in the building. V5 stated that after she reported to V1 she went back to R2 to assess the resident. R2 informed her that she was touched on her breast and on her private area by a black guy holding a mop. R2 had no bruising, no bleeding and no visible injury and/or complaint of pain. According to R2, she was touched on her vaginal area and no object was inserted. According to V5, R2 did not say anything to her after the sexual assault because she was scared and that the tall black guy told her (R2) that he will be back. V5 stated that V12 notified R2's physician about the allegation and the physician ordered for R2 to be sent to the hospital for evaluation. V5 added that R2 refused and that V1 also offered to send R2 to the hospital, but R2 refused. V5 added that after she completed assessing R2, the resident told her to check on her roommate (R1). R2 told her, Just check on her (R1). V5 stated that she assessed R1 with V12 (Nursing Supervisor). According to V5, R1 was hard of hearing. She asked R1 in the presence of V12, if she saw a black guy in her room and R1 nodded indicating yes. She asked R1 if he was touched by the black guy that she saw in her room and R1 nodded indicating yes. She asked R1, where she was touched and R1 pointed to her private area below her waist. V5 stated that she is a regular second floor nurse and had been assigned to R1 and R2. V5 stated that R1 is oriented x 1 (to person) and R2 is cognitively intact, good historian and reliable. According to V5, R1 and R2 had never made any false allegations towards any staff or other residents in the past. On February 11, 2025, from 1:55 PM through 3:05 PM, the video footage for the second floor east hallway and dining room for January 25, 2025 was observed with V3 (acting Director of Nursing). V3 explained that he had reviewed the footage on February 4 and 5, 2025 and that the video footage time was indicating daylight saving time and that one hour should be deducted from the posted time on the video to determine the actual time. To be able to watch the video clearly and identify the staff, the video footage must be zoomed in. On January 25, 2025 at 12:10 PM (actual time), a tall black man wearing a blue shirt, parked the housekeeping cart outside of R1 and R2's room (east hallway) and went inside the said room carrying a mop. V3 identified the tall black man as V4 (housekeeper). After 26 seconds, V4 came out of the room with the trash can. At 12:11 PM, V7 (CNA/Certified Nursing Assistant) went inside R1 and R2's room. From 12:11 PM through 12:30 PM, both V4 and V7 were observed going in and out of R1 and R2's room. At 12:30:26 PM, V4 went out of R1 and R2's room without the mop that he brought in the room (at 12:10 PM), he then moved the housekeeping cart away from R1 and R2's room. At 12:30:49 PM, V7 came out of R1 and R2's room with a food tray. At 1:28 PM, V4 was cleaning tables inside the unit dining room. At 1:30:20 PM, V4 went out of the unit dining room towards the east hallway without taking his housekeeping cart. While walking along the east hallway, V4 pulled out something from his back pocket which V3 believed was a towel or rug and on the same back pocket a small rectangular item was left hanging which according to V3 looks like a mask. At 1:30:44 PM, V4 went inside R1 and R2's room. According to V3, he had reviewed the same video footage and confirmed that prior to V4 entering R1 and R2's room at 1:30:44 PM, no other staff had entered the said room. At 1:37:08 PM, V4 went out of R1 and R2's room and was observed walking back and forth in the east hallway. V3 stated that V4 was inside R1 and R2's room for approximately seven minutes without staff present and without his housekeeping cart outside of the room for easy access to the cleaning supplies. At 2:30:26 PM, the housekeeping cart was observed along the east hallway, V4 came out of another resident's room, placed a broom and a dustpan in the housekeeping cart, then went inside R1 and R2's room without any visible cleaning supplies. At 2:31:40 PM, V4 went out of R1 and R2's room without any visible items or cleaning supplies at hand. At 2:32 PM, V4 went inside R1 and R2's room and at 2:32:01 PM, went back out and proceeded to go inside another resident's room at the east hallway. At 2:33:37 PM, V4 again went inside R1 and R2's room and at 2:34:20 PM, V4 came out of the room with a garbage bag and talked to a staff identified by V3 as V13 (CNA). According to V3, he asked V13 what they were talking about and V13 stated that according to V4, R2 wanted to be boosted up in bed. At 2:35:12 PM, V4 again went inside R1 and R2's room and came out at 2:37:09 PM carrying a mop (which he brought in the room at 12:10 PM and was only taken out). During the review of the video footage, V3 stated that he was wondering why V4 kept on going in and out of R1 and R2's room, after he was inside the same room from 12:10 PM through 12:30 PM cleaning while V7 (CNA) was inside the room. V3 added that he wanted to ask V4 what he was doing going in and out of R1 and R2's room after 12:30 PM and what he was doing inside the room for at least seven minutes (from 1:30:44 PM through 1:37:08 PM). V3 stated that he attempted to call V4 on February 7, 2025, but he did not answer. On February 11, 2025 at 4:24 PM, V3 (acting Director of Nursing) stated that he had been working at the facility for two years. V3 stated that there was no documentation, and he was not aware of any history of false allegations from R1 and R2 towards any staff or other residents. According to V3 he only started to review the video footage for the second floor east hallway for January 25, 2025 on February 4, 2025 until February 5, 2025 after being asked by the surveyor on February 3, 3025, if he had seen the footage. V3 stated that V1 (Administrator) had conducted the sexual abuse investigation of R2, including R1. V3 stated that he had assisted with the interviews with the nurses and the CNAs (Certified Nursing Assistants). According to V3, he had not spoken to R1 and R2 during the investigation and stated that it was his first time hearing the allegation from R1 and R2 when he was with the surveyor on January 30, 2025. V3 stated that after hearing R1 and R2's sexual assault allegation on January 30, 2025 (with the surveyor), he immediately informed their nursing consultant (V14) who was in the building. V3 stated that he and V14 then informed V1 (Administrator) of what R1 and R2 told the surveyor. V3 stated that over the phone, he informed V1 that R1 had pointed at her private area when R1 was asked, if anyone had touched her inappropriately. V3 also told V1 that R1 made a comment that the person needs to be punished or put away. V3 added that he also informed V1 that according to R2 a tall, black man wearing a mask which she (R2) identified as a housekeeper had touched her breast and had placed his hand inside her brief and touched her private area. V3 stated, as far as I know, this is the same information that [V1] got from [R2]. On February 11, 2025 at 4:40 PM, V1 (Administrator) stated that he was not aware of R1 and R2 making any false allegations towards any staff or residents in the past. V1 stated that during the investigation process before February 4, 2025 (cannot give the date) he watched the video footage of the second floor east hallway for January 25, 2025 and I could not make anything out, to believe that anything had transpired. V1 stated that the sexual assault allegation was reported to the police, and it was up to the resident to press a case. According to V1, V8 (Detective) came to the facility to talk to the residents but he (V8) did not tell him anything about what the resident said during his interview. V8 however told him that he showed pictures to R2, but the resident cannot identify anybody. V1 stated that he gave V8, V4's information because he fit the description of what R2 had said. V1 stated that during his interview of R2, the resident said that a black male with a broom or a mop came over and touched the top of her gown and had his hand inside her brief. According to V1, he asked R2 if the black male went under her hospital gown and she said, no. V1 added that during his interview with R2, the resident said that the black male mentioned something like, seems a long time since you had a penis. V1 stated that during his interview with R1, he asked the resident how she was doing and R1 responded that she was okay. He asked R1 if she was injured in any way, R1 responded, no. He asked R1 what year it is, and the resident responded, 2000. He asked R1, Did anything happened to you? and the resident responded, No and then R1 handed him the remote and said, I'm hungry. According to V1, based on his conversation with R1, the resident was not able to say that she was sexually abused by anyone at the facility. V1 was asked the reason why the facility did not substantiate R2's sexual abuse allegations towards V4, since R2 is cognitively intact and had been consistent with expressing her sexual assault allegations on multiple interviews held by and/or made in the presence of the facility staff. V1 stated that R2 had a change in her mental status recently according to her physician. V1 added that when the facility interviewed the staff, no one heard or witnessed the sexual assault, and when other residents were interviewed, no one reported being sexually assaulted at the facility by any staff member, therefore the facility was not able to substantiate R2's allegation of sexual abuse and her (R2) allegation that her roommate (R1) was also sexually abused. On February 11, 2025 at 5:20 PM, V1 (Administrator) and V3 (acting Director of Nursing) confirmed that V4 was the only tall black man working at the second floor as a housekeeper on January 25, 2025. V1 was asked if he was notified by V3 and V14 (Nursing consultant) over the phone on January 30, 2025 about R1's allegation made in the presence of V3 and the surveyor, that she was inappropriately touched on her vaginal area by a black male and R1 commenting, he needs to be put away. V1 responded that he does not remember being informed about it. V1 and V3 were notified of R2's interview that day, after confirmation with V8 (Detective) with regards to the resident's allegation that on January 25, 2025, the tall black housekeeper had sucked her nipple in addition to what she (R2) had alleged during the interview on January 30, 2025 at 2:08 PM with V3. V1 and V3 were informed that according to V8, V4 admitted to V8 that he had physical contact with R2 because he wiped the food spill on R2's gown by the chest area on January 25, 2025 while he was inside the resident's room, cleaning. The facility submitted an addendum to their final report to the State Agency on February 12, 2025, 2025 at 2:15 PM. The addendum documented that on February 11, 2025, the facility re-interviewed R2 who stated that, she woke up to find the employee's mouth on her breast and screamed for him to stop. The addendum documented that R1 was re-interviewed to inquire about any inappropriate behavior from the former employee and R1 was unable to recall/provide details or information of any incident. The addendum showed that on February 12, 2025, the facility contacted the local police to confirm the new information provided by the surveyor on February 11, 2025. The local Police informed V1 (Administrator) that the former employee admitted to wiping food off of [R2's] shirt, then resident said, not to touch her like that and former employee left the room. Local police stated they could not share what [R2] said. Local police confirmed investigation is still pending. The same addendum showed, Housekeepers should not have physical contact with residents. With this new information the facility now sustains resident [R2's] allegation that she was touched inappropriately by the former employee. The facility's abuse policy and procedure dated November 15, 2022 showed, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The policy also showed that sexual abuse is non-consensual contact of any type with a resident. The Immediate Jeopardy began on January 25, 2025. The facility presented a removal plan to remove the immediacy on February 18, 2025 at 12:46 PM. The survey team reviewed the removal plan and was unable to accept the plan to remove the immediacy. The removal plan was returned to the facility for revisions. The facility presented a revised removal plan to remove the immediacy on February 18, 2025 at 2:09 PM. The survey team reviewed the removal plan and was unable to accept the plan to re [TRUNCATED]

Based on interviews and record review, the facility failed to thoroughly investigate the allegation of sexual abuse made by R1 and R2. R1 and R2 had consistently expressed being sexually assaulted by a housekeeper (V4) and the facility failed to investigate allegations after obtaining additional information, initially not substantiating R1 and R2's allegations of sexual abuse on January 25, 2025. These failures have the potential to affect all 237 residents who reside at the facility. The findings include: The facility's daily census on January 30, 2025, showed that there were 237 residents in the facility. R2 had multiple diagnoses including chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, thrombocytopenia and need for assistance with personal care, based on the face sheet. R2's admission MDS (minimum data set) dated November 21, 2024, showed that the resident was cognitively intact (BIMS (Brief Interview for Mental Status) of 15) and required maximum to total assistance from the staff with all her ADLs (activities of daily living). R2's progress notes dated January 25, 2025 at 3:10 PM created by V5 (LPN/Licensed Practical Nurse) showed in-part, Resident reported alleged inappropriate touching by staff, prompting immediate head-toe assessment, which showed no new bruising, and resident denied pain, or distress. [Physician] immediately notified and ordered to send her to ER (emergency room ) for evaluation, but resident refused to go to ER. Provided education resident continues to refuse to go. POA (Power of Attorney) made aware. R2's electronic records including, progress notes and care plans showed no documentation that the resident had behavior of falsely accusing staff and/or residents of any abuse or inappropriate behavior towards her or other residents. On January 30, 2025, at 2:08 PM, R2 was in bed, alert and oriented. In the presence of V3 (Acting Director of Nursing), R2 stated that on Saturday (January 25, 2025) a tall, black man wearing a mask, fondled her breast and placed his hand inside her disposable brief and touched her vaginal area. The same tall, black man told her (R2), It's been a long time since you had a penis. R2 stated that she asked the man to stop what he was doing. R2 added that after the sexual assault, the man told her, I will see you later. According to R2, the sexual assault happened after breakfast, and she believes that the tall black man who sexually assaulted her was a housekeeper because he had a mop or a broom with him. During the same interview, R2 stated that after her sexual assault, she heard her roommate (R1) saying, that hurts. R2 stated that she was unable to see what was going on with R1 because the curtain between them was drawn. R2 believes that the same tall black man was inside R1's room. R2 stated that she did not call for help and/or immediately report the sexual assault because she was in shock of what had happened to her. According to R2, she only reported the incident to her (family member) and her (family member) called the nurse. R2 stated that after her (family member) informed the nurse of the incident, multiple facility staff and police had talked to her, then she reported her sexual assault and what she had heard from her roommate (R1). On February 11, 2025, at 10:52 AM, R2 was again interviewed about the events of January 25, 2025. R2 was unable to recall the specific time but believed it was after breakfast and again stated that V4 had fondled her breast while his other hand was inside her disposable brief, touching her vaginal area. R2 repeated the statement that the man commented, It's been a long time since you had a penis. R2 stated that she told the man to stop and to go away and the man told her, I will see you later. R2 stated that after leaving her side of the room, she saw the tall black man went to her roommate's (R1) side of the room. R2 stated that the curtain between her and R1 was drawn, and she could not see what was going on in R1's room, but she heard R1 said, Ouch, it hurts then she saw the tall black man leave their room. R2 stated that she was in shock, and she just wanted the man to leave her alone. R2 stated, that she cried the next day because she cannot believe what happened. R2 added, even up to now, I would start crying when I remember it. According to R2 she was traumatized. R2's late entry progress notes dated January 30, 2025 at 3:13 PM, created by V11 (Licensed Clinical Psychologists) showed in-part under summary and treatment, Resident was referred secondary to allegations of being sexually assaulted by a janitorial staff member. Resident open and willing to address her emotions. Reported an increase of racing thoughts at night, feels uneasy at times, also reported feelings of anger secondary to incident. R2's late entry progress notes dated February 4, 2025 at 1:22 PM, created by V11 (Licensed Clinical Psychologist) showed in-part, Resident continued to discuss and work through negative emotions secondary to incident that occurred a few weeks ago. She shared that the thoughts have affected her ability to sleep some nights. She also expressed feeling angry at times. The progress notes documented under statements that pertain to treatment goals showed, The other day I couldn't sleep because it kept going on in my mind. How do you expect me to feel? one day I'm ok and the next day I'm not. On February 19, 2025 at 11:39 AM, V11 stated that she first saw R2 on January 30, 2025 because the resident was referred by the facility. Stated that during her talk to R2, the resident told her that that a male housekeeping staff had touched her breast and had his hand inside her brief. V11 stated that during this initial meeting with R2, the resident had verbalized increased of racing thoughts at night, feeling uneasy and angry due to being touched without her consent by the housekeeper. According to V11, she made a follow up visit to R2 on February 4, 2025. V11 stated that during this visit, R2 expressed having difficulty sleeping at some nights and feeling angry at times because of being inappropriately touched by the housekeeper. R1 had multiple diagnosis including, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, flaccid hemiplegia affecting left non-dominant side, vascular dementia without behavioral disturbance and severe morbid obesity due to excess calories, based on the face sheet. R1's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition (BIMS of 7) and required total assistance from the staff with most of her ADLs. R1's progress notes dated January 25, 2025 at 9:08 PM created by V5 (LPN) showed, [Physician] called back and was notified that alleged staff was touching resident inappropriately. [Physician] stated to let nursing supervisor know and follow protocol. R1's progress notes dated January 26, 2025 at 9:47 AM, created by V9 (Physician) as a late entry showed that the resident was seen because of an unusual incident at the facility were in R1's roommate (R2) alleged that a housekeeper had inappropriately touched her (R2). R1's electronic records including, progress notes and care plans showed no documentation that the resident had behavior of falsely accusing staff and/or residents of any abuse or inappropriate behavior towards her or other residents. On January 30, 2025 at 1:57 PM, R1 was in bed, alert and was able to respond verbally to simple questions and at times responds using gestures. In the presence of V3 (Acting Director of Nursing), R1 was asked if anyone had inappropriately touched her at the facility. R1 stated, he put his finger and using her right hand pointed at her disposable brief. R1 was asked if the person placed his finger inside her disposable brief and R1 nodded. R1 was asked if the person touched her vaginal area, and the resident nodded. R1 stated, he needs to be put away. R1 was asked to describe who had inappropriately touched her vaginal area and the resident stated, African American. R1 was not able to give further description, and she was not able to give the date and time of the incident. R1 was interviewed again on February 11, 2025 and once again verbally responded to the questions and used gestures. R1 confirmed the information obtained in the earlier interview of January 30, 2025. On February 3, 2025 at 2:13 PM, V8 (Detective) stated that the local police department had received the allegation of sexual abuse on January 25, 2025 and a police officer had made the report. V8 stated that on January 27, 2025 he went to the facility to speak to R2. During his conversation with R2, the resident informed him that a black man, wearing a mask fondled her breast and placed his hand inside her brief and touched her vagina. R2 described the man as the worker that comes to clean her room. V8 stated that a photo lineup was established but R2 was not able to identify the person that touched her because of the mask. According to V8, during his interview with R2, the resident also told him that she heard her roommate (R1) saying, don't touch me but she cannot see what was going on in her roommate's area because the curtain was drawn. V8 stated that he talked to R1 (roommate) and the resident had informed him that her private area was touched by someone that worked there, but no other information was given by R1. V8 stated that the facility identified the male housekeeper working on January 25, 2025 at R1 and R2's unit, to be V4 (Housekeeper). V8 stated that he spoke to V4 on January 27, 2025. He was told by V4 that he was inside R2's room in the morning (he does not remember the exact time) of January 25, 2025 to clean the room. V8 added that V4 told V8 that R2's gown had spills and V4 used a towel to clean the food spills by the chest area and during that time, R2 told V4 to stop and not to touch her. V8 stated that V4 was inside R2 and R1's room on January 25, 2025 and admitted that he had physical contact with R2. V8 added that V4 was a housekeeper and should have not touched R2. V8 was not able to share any additional information since the case was under investigation. According to V8, he had the video footage that the facility gave him but had not looked at the said video footage yet. V8 stated that his investigation of the case is still on going and that there is no final determination yet. According to V8, The good thing is that he (V4) acknowledged that he was inside their room. As a housekeeper he should not touch a patient. V8 added that there is no projected date when he can complete the investigation. On February 11, 2025, at 1:42 PM, V8 (Detective) stated that when he talked to V4 (housekeeper), V4 acknowledged that he was inside R1 and R2's room on January 25, 2025 to clean. V4 also admitted that he used a towel to clean the spill on R2's gown by the chest area, on January 25, 2025. According to V8, V4 admitted to having physical contact with R2, which should not have occurred because V4 was a housekeeper and not a nursing staff. During the same interview, V8 was asked if R2 had mentioned to him on January 27, 2025 when he talked to the resident about her allegation that the housekeeper had sucked her nipple and that the housekeeper told her, It's been a long time since you had a penis. V8 stated that R2 had told him about it. V8 stated that when he started to ask V4 about R2's allegation of being touched in her vaginal area, V4 requested to have an attorney and V4 was not questioned further about R1 and R2's case. According to V8 he had not shared any information to the facility about R1 and R2's case because the investigation was still an ongoing/open case. Review of the facility's final report to the State Agency made on January 30, 2025 at 5:52 PM, regarding R2's allegation of abuse on January 25, 2025 showed, Resident (R2) alleged to her family that a male staff member wearing a blue shirt touched her inappropriately. She also stated he spoke to her inappropriately. [R2] later stated, that her roommate [R1] had also been touched and spoken to inappropriately. [R2] would not have been able to determine this as the curtains between the beds were drawn. The residents were both assessed with no skin alterations, visible injuries, pain, and both remained at their baseline for cognition. Resident [R2] initially refused to go to the hospital and later went to appointment for medical treatment and currently being treated for UTI (urinary tract infection) with IV (intravenous) (antibiotic). [R1's] (family member) arrived and requested to have [R1] sent to ER (emergency room ) for (evaluation). Resident [R1] (primary care physician) and hospital evaluation with no findings. The same final report showed, Interviews with staff and residents could not substantiate abuse. The facility presented the statement of V4 obtained by V1 (administrator) via phone made on January 25, 2025 (no time was documented), as part of the facility investigation. V4's statement showed that V4 worked at the facility on January 25, 2025, during the morning shift as a housekeeper. V4 acknowledged that he swept and mopped inside R1 and R2's room. The statement documented in-part, While in there I did speak with the ladies by saying good morning while they were eating breakfast. After cleaning the room, I took the garbage out. I never spoke to the residents inappropriately or touched them inappropriately. After my workday I clocked out and left the building. The housekeeping schedule for January 25, 2025, showed that V4 was assigned to multiple rooms at the second-floor east hallway, including the rooms of R1 and R2. V4's January 2025 time sheet showed that he clocked in on January 25, 2025, at 6:38 AM and clocked out the same day at 3:06 PM. Further review of V4's January 2025 time sheet showed no other activity past January 25, 2025. The facility presented documentation from Human Resources that on January 30, 2025, V6 (Housekeeping Supervisor) received a text message from V4 that he was resigning and will not be returning at the facility. On January 30, 2025, at 4:03 PM, V5 (Licensed Practical Nurse) stated that she was R1 and R2's nurse on January 25, 2025 during the morning (6:00 AM - 2:00 PM) and afternoon shifts (2:00 PM - 10:00 PM). V5 stated that on January 25, 2025 at around 3:00 PM, she received a call from V10 (R2's family) telling her to check on R2 because the resident was scared because a black guy was in her room. She told V10 that she was just inside R2's room, and the resident did not say anything to her. After hanging up the phone with V10 she went to talk to R2. While V10 was listening on R2's phone, the resident informed her that a tall black guy touched her breast and placed his hand inside her brief and told her that she hasn't had a penis for a long time. V5 stated that after hearing R2's allegation she immediately informed V12 (Nursing supervisor) and then called V1 (Administrator) on his cellular phone to report the allegation. According to V5, since she also worked during the morning shift, she was aware that there was only one black male staff in the unit, and it was the housekeeper (V4). According to V5, he had seen V4 cleaning resident rooms. V5 stated that R2 did not report to her any abuse allegation during the morning shift and that she only learned about the allegation after R2's family (V10) called her to check on the resident. V5 stated that when she received the report from R2, V4 was no longer in the building. V5 stated that after she reported to V1 she went back to R2 to assess the resident. R2 informed her that she was touched on her breast and on her private area by a black guy holding a mop. R2 had no bruising, no bleeding and no visible injury and/or complaint of pain. According to R2, she was touched on her vaginal area and no object was inserted. According to V5, R2 did not say anything to her after the sexual assault because she was scared and that the tall black guy told her (R2) that he will be back. V5 stated that V12 notified R2's physician about the allegation and the physician ordered for R2 to be sent to the hospital for evaluation. V5 added that R2 refused and that V1 (Administrator) also offered to send R2 to the hospital, but R2 refused. V5 added that after she completed assessing R2, the resident told her to check on her roommate (R1). R2 told her, Just check on her (R1). V5 stated that she assessed R1 with V12 (Nursing Supervisor). According to V5, R1 was hard of hearing. She asked R1 in the presence of V12, if she saw a black guy in her room and R1 nodded indicating yes. She asked R1 if he was touched by the black guy that she saw in her room and R1 nodded indicating yes. She asked R1, where she was touched and R1 pointed to her private area below her waist. V5 stated that she is a regular second floor nurse and had been assigned to R1 and R2. V5 stated that R1 is oriented x 1 (to person) and R2 is cognitively intact, good historian and reliable. According to V5, R1 and R2 had never made any false allegations towards any staff or other residents in the past. On February 18, 2025 at 9:42 AM, V5 confirmed the accuracy of the interview made to her by the surveyor on January 30, 2025 at 4:03 PM. V5 was asked if she informed V1 (Administrator) of the information she received from R1 during the resident's assessment and interview on January 30, 2025 after the resident's roommate (R2) told her to check on R1. According to V5 she did not inform V1 because I assumed that (V12/Nursing Supervisor) informed (V1), because she (V12) was present during the assessment. V5 added that after she and V12 assessed and interviewed R1 on January 25, 2025, both V1 and V12 went to R1 and interviewed the resident. On February 18, 2025 at 10:15 AM, V1 (Administrator) was asked if V5 (Licensed Practical Nurse) and/or V12 (Nursing Supervisor) had informed him about any information they obtained from R1 on January 30, 2025 during their interview and assessment of the resident. According to V1, he was not informed by either V5 or V12. On February 11, 2025, from 1:55 PM through 3:05 PM, the video footage for the second-floor east hallway and dining room for January 25, 2025 was observed with V3 (acting Director of Nursing). V3 explained that he had reviewed the footage on February 4 and 5, 2025 and that the video footage time was indicating daylight saving time and that one hour should be deducted from the posted time on the video to determine the actual time. To be able to watch the video clearly and identify the staff, the video footage must be zoomed in. On January 25, 2025 at 12:10 PM (actual time), a tall black man wearing a blue shirt, parked the housekeeping cart outside of R1 and R2's room (east hallway) and went inside the said room carrying a mop. V3 identified the tall black man as V4 (housekeeper). At 12:11 PM, V7 (CNA/Certified Nursing Assistant) went inside R1 and R2's room. From 12:11 PM through 12:30 PM, both V4 and V7 were observed going in and out of R1 and R2's room. At 12:30:26 PM, V4 went out of R1 and R2's room without the mop that he brought in the room (at 12:10 PM), he then moved the housekeeping cart away from R1 and R2's room. At 12:30:49 PM, V7 came out of R1 and R2's room with a food tray. At 1:28 PM, V4 was cleaning tables inside the unit dining room. At 1:30:20 PM, V4 went out of the unit dining room towards the east hallway without taking his housekeeping cart. While walking along the east hallway, V4 pulled out something from his back pocket which V3 believed was a towel or rug and on the same back pocket a small rectangular item was left hanging which according to V3 looks like a mask. At 1:30:44 PM, V4 went inside R1 and R2's room. According to V3, he had reviewed the same video footage and confirmed that prior to V4 entering R1 and R2's room at 1:30:44 PM, no other staff had entered the said room. At 1:37:08 PM, V4 went out of R1 and R2's room and was observed walking back and forth in the east hallway. V3 stated that V4 was inside R1 and R2's room for approximately seven minutes without staff present and without his housekeeping cart outside of the room for easy access to the cleaning supplies. At 2:30:26 PM, the housekeeping cart was observed along the east hallway, V4 came out of another resident's room, placed a broom and a dustpan in the housekeeping cart, then went inside R1 and R2's room without any visible cleaning supplies. At 2:31:40 PM, V4 went out of R1 and R2's room without any visible items or cleaning supplies at hand. At 2:32 PM, V4 went inside R1 and R2's room and at 2:32:01 PM, went back out and proceeded to go inside another resident's room at the east hallway. At 2:33:37 PM, V4 again went inside R1 and R2's room and at 2:34:20 PM, V4 came out of the room with a garbage bag and talked to a staff identified by V3 as V13 (CNA). According to V3, he asked V13 what they were talking about and V13 stated that according to V4, R2 wanted to be boosted up in bed. At 2:35:12 PM, V4 again went inside R1 and R2's room and came out at 2:37:09 PM carrying a mop (which he brought in the room at 12:10 PM and was only taken out). During the review of the video footage, V3 stated that he was wondering why V4 kept on going in and out of R1 and R2's room, after he was inside the same room from 12:10 PM through 12:30 PM cleaning while V7 (CNA) was inside the room. V3 added that he wanted to ask V4 what he was doing, going in and out of R1 and R2's room after 12:30 PM and what he was doing inside the room for at least seven minutes (from 1:30:44 PM through 1:37:08 PM). V3 stated that he attempted to call V4 on February 7, 2025, but he did not answer. On February 11, 2025, at 4:24 PM, V3 (acting Director of Nursing) stated that he had been working at the facility for two years. V3 stated that there was no documentation, and he was not aware of any history of false allegations from R1 and R2 towards any staff or other residents. According to V3 he only started to review the video footage for the second-floor east hallway for January 25, 2025 on February 4, 2025 until February 5, 2025 after being asked by the surveyor on February 3, 3025, if he had seen the footage. V3 stated that V1 (Administrator) had conducted the sexual abuse investigation of R2, including R1. V3 stated that he had assisted with the interviews with the nurses and the CNAs (Certified Nursing Assistants). According to V3, he had not spoken to R1 and R2 during the investigation and stated that it was his first time hearing the allegation from R1 and R2 when he was with the surveyor on January 30, 2025. V3 stated that after hearing R1 and R2's sexual assault allegation on January 30, 2025 (with the surveyor), he immediately informed their nursing consultant (V14) who was in the building. Stated that he and V14 then informed V1 (Administrator) of what R1 and R2 told the surveyor. V3 stated that over the phone, he informed V1 that R1 had pointed at her private area when R1 was asked, if anyone had touched her inappropriately. V3 also told V1 that R1 made a comment that the person needs to be punished or put away. V3 added that he also informed V1 that according to R2 a tall, black man wearing a mask which she (R2) identified as a housekeeper had touched her breast and had placed his hand inside her brief and touched her private area. V3 stated, as far as I know, this is the same information that [V1] got from [R2]. On February 11, 2025 at 4:40 PM, V1 (Administrator) stated that he was not aware of R1 and R2 making any false allegations towards any staff or residents in the past. V1 stated that during the investigation process before February 4, 2025 (cannot give the date) he watched the video footage of the second floor east hallway for January 25, 2025 and I could not make anything out, to believe that anything had transpired. V1 stated that the sexual assault allegation was reported to the police, and it was up to the resident to press a case. According to V1, V8 (Detective) came to the facility to talk to the residents but he (V8) did not tell him anything about what the resident said during his interview. V8 however told him that he showed pictures to R2, but the resident cannot identify anybody. V1 stated that he gave V8, V4's information because he fit the description of what R2 had said. V1 stated that during his interview of R2, the resident said that a black male with a broom or a mop came over and touched the top of her gown and had his hand inside her brief. According to V1, he asked R2 if the black male went under her hospital gown and she said, no. V1 added that during his interview with R2, the resident said that the black male mentioned something like, seems a long time since you had a penis. V1 stated that during his interview with R1, he asked the resident how she was doing and R1 responded that she was okay. He asked R1 if she was injured in any way, R1 responded, no. He asked R1 what year it is, and the resident responded, 2000. He asked R1, Did anything happened to you? and the resident responded, No and then R1 handed him the remote and said, I'm hungry. According to V1, based on his conversation with R1, the resident was not able to say that she was sexually abused by anyone at the facility. V1 was asked the reason why the facility did not substantiate R2's sexual abuse allegations towards V4, since R2 is cognitively intact and had been consistent with expressing her sexual assault allegations on multiple interviews held by and/or made in the presence of the facility staff. V1 stated that R2 had a change in her mental status recently according to her physician. V1 added that when the facility interviewed the staff, no one heard or witnessed the sexual assault, and when other residents were interviewed, no one reported being sexually assaulted at the facility by any staff member, therefore the facility was not able to substantiate R2's allegation of sexual abuse and her (R2) allegation that her roommate (R1) was also sexually abused. On February 11, 2025 at 5:20 PM, V1 (Administrator) and V3 (acting Director of Nursing) confirmed that V4 was the only tall black man working at the second floor as a housekeeper on January 25, 2025. V1 was asked if he was notified by V3 and V14 (Nursing consultant) over the phone on January 30, 2025 about R1's allegation made in the presence of V3 and the surveyor, that she was inappropriately touched on her vaginal area by a black male and R1 commenting, he needs to be put away. V1 responded that he does not remember being informed about it. V1 and V3 were notified of R2's interview that day, after confirmation with V8 (Detective) with regards to the resident's allegation that on January 25, 2025, the tall black housekeeper had sucked her nipple in addition to what she (R2) had alleged during the interview on January 30, 2025 at 2:08 PM with V3. V1 and V3 were informed that according to V8, V4 admitted to V8 that he had physical contact with R2 because he wiped the food spill on R2's gown by the chest area on January 25, 2025 while he was inside the resident's room, cleaning. The facility submitted an addendum to their final report to the State Agency on February 12, 2025, 2025 at 2:15 PM. The addendum documented that on February 11, 2025, the facility re-interviewed R2 who stated that, she woke up to find the employee's mouth on her breast and screamed for him to stop. The addendum documented that R1 was re-interviewed to inquire about any inappropriate behavior from the former employee and R1 was unable to recall/provide details or information of any incident. The addendum showed that on February 12, 2025, the facility contacted the local police to confirm the new information provided by the surveyor on February 11, 2025. The local Police informed V1 (Administrator) that the former employee admitted to wiping food off of [R2's] shirt, then resident said, not to touch her like that and former employee left the room. Local police stated they could not share what [R2] said. Local police confirmed investigation is still pending. The same addendum showed, Housekeepers should not have physical contact with residents. With this new information the facility now sustains resident [R2's] allegation that she was touched inappropriately by the former employee. The facility's abuse policy and procedure dated November 15, 2022 showed, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The policy also showed that sexual abuse is non-consensual contact of any type with a resident. The facility's abuse investigation and reporting policy dated July 2017 showed in-part, All reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management.

Based on observation, interview and record review, the facility failed to ensure that a safety measure was implemented by not providing adequate assistance for a resident requiring total assistance with two-person assist during transfer using mechanical transfer lift device. Based on observation, interview and record review the facility failed to follow R1's physician orders and treatment plan. That requires R1 to be transferred using the mechanical lift and two-person transfer. This failure resulted in R1 sustaining an acute displaced comminuted fracture of the left tibia. This applies to 1 of 3 residents (R1) reviewed for transfers with use of mechanical transfer lift device. The findings include: The EMR (Electronic Medical Record) shows that R1, an [AGE] year-old, was admitted to the facility on [DATE]. The POS (Physician Order Sheet) for the month of January 2023 shows R1's diagnoses includes but not limited to anxiety disorder, major depressive disorder, cerebral infarction, paraplegia, TIA (transient ischemic attack), atrial fibrillation, seizure, lymphedema, venous insufficiency, peripheral vascular disease, encephalitis, history of bilateral knee replacement ([AGE] years ago.) The POS also shows Special Instructions for ***** TRANSFER CODE: Mechanical Full body lift with TOTAL 2-Person Assist). The most recent MDS (Minimum Data Set) dated 12/29/2022 shows R1's BIMS (Brief Interview Mental Status) score was 14/15, cognitively intact in cognition. R1 was also assessed for 0 hallucination, 0 for behavior, though some rejection of care that occurs occasionally. R1's assessment for Functional Status shows a score of 3/3 for bed mobility (extensive assistance/2-person physical assist); 4/3 for transfer (total assistance with 2 plus person physical assist); 3/3 for dressing (extensive with two-person assist). The Functional Limitation in Range of Motion shows R1 has impairment on one side of the body for the upper extremity (shoulder, elbow, wrist and hand) and impairment to both sides to the lower extremities (hip, knee, ankle and foot). The current care plan with a date initiated on 12/29/2022 shows that R1 has a functional and self-care deficit in performing ADLs (Activities of Daily Living) due to impaired mobility, physical limitations, decreased in strength, endurance, balance, tolerance and coordination related to seizure, paraplegia, and anxiety disorder. The care plan shows that R1 requires two-person assistance in bathing, including transfer in and out of shower room. R1 also requires extensive assist with two-persons assistance for mobility and repositioning in bed. R1 was also assessed needing extensive assist of two-person in dressing, toilet use. The care plan also shows that R1 requires total assist of two-person in transfer using the full body lift device. The progress notes dated 1/9/2023 shows that R1 was on antibiotic treatment for UTI (urinary tract infection). R1 also was tested positive for Covid infection on 12/30/2022. The progress notes dated 1/12/2023 shows that R1 was seen by a nurse practitioner. The notes shows that R1's general appearance was appropriate, grooming and hygiene is fair, speech was of impaired rate, impaired rhythm, low volume, and normal prosody with mild latency of response, the mood was described as constricted mood and congruent affect, thought processes showed normal associations/impaired processes/abstractions, thought content shows R1 did not endorse suicidal ideation, homicidal ideation, violent ideation, auditory/visual hallucinations, or delusions, insight/judgment are fair, was alert and oriented times/x 2-3, mild deficits in short and long-term memory, mildly impaired attention, mildly impaired concentration. The facility's incident report with initial date report of 1/18/2023 and final report of 1/25/2023 shows that R1 complained of pain to LLE (left lower extremity), some swelling and bluish discoloration on 1/16/2023. Medical Doctor/MD was notified, an x-ray was done, and result obtained on 1/17/2023 with result of questionable hairline fracture of the tibia (shin). It was recommended that R1 be sent to the hospital for further evaluation. On 1/17/2023, R1 was sent to the hospital. R1's hospital x-ray of the lower extremities shows an acute displaced comminuted intraarticular fracture of the proximal left tibia. Review further of the facility's investigation shows the following: Date of incident: 1/14/2023 Interview of (R1) dated 1/16/2023 by V2 (Director of Nursing) shows: CNA (Certified Nurse Assistant) fell on top of me when assisting me to bed. You know I tripped when I was walking, then I slid out of chair, he carried me and placed me in the bed, then fell on top of me. During this interview by V2, R1 denied pain, have non-pitting edema to bilateral lower extremities, left shin area discoloration. Interview of V7 (CNA from staffing agency) by V2 on 1/16/2023: I was assigned to (R1) on 1/14/2023 from 6:00 A.M. through 10:00 P.M. (double shifts). When I assisted (R1) to bed, she complained of lower extremity pain. I used a full Hoyer lift (mechanical transfer lift device) to transfer her. The female CNA from staffing agency had assisted me during (R1's) transfer. Interview of V9 (LPN/License Practical Nurse) by V2 on 1/16/2023: I was assigned to (R1) on 1/14/2023 from 6:00 A.M. through 10:00 P.M. (double shifts). (V7) came to inform me that (R1) complained of lower extremity pain. I immediately went into see (R1) who seemed to be confused and stated that she was assisted to sit on toilet, then he carried me in to bed and fell on top of me. I performed an assessment to (R1), noted bilateral lower extremity edema. On 1/27/2023 at 11:19 A.M., V2 stated that on 1/14/2022 after dinner, R1 had complained of left leg pain after being transferred by V7. V2 added that R1 is bedbound and seldom gets out of bed. V2 also stated that due to current UTI, R1 is with bout of confusion. V2 stated that V7 informed her V8 (the only female CNA from staffing agency on 1/14/2023 evening shift) had helped during transfer of R1 to bed using the transfer lift device. V2 stated that upon interview with V8 on 1/16/2023, V8 stated that she never assisted V7 or other CNA using the total lift transfer device. V2 stated that V7 transferred R1 to bed on 1/14/2023 after dinner by himself, then after transfer, R1 complained of left leg pain. V2 added that R1 was assisted only by one staff which was V7 for transfer using the transfer device and that R1 required two-person assist. V2 also added that V7 stated that there was no fall incident. V2 concluded that she cannot substantiate if R1 fell but can assure that only one person versus two had transferred R1 to bed using the total lift device. V2 stated that R1 was transferred to the hospital and was admitted on [DATE]. V2 added that R1 had returned to the facility on [DATE]. V2 added that while R1 was at the hospital, R1 had suffered a hypotensive episode, increased confusion related to encephalopathy. V2 stated that R1's POA (Power of Attorney) had decided no aggressive treatment and R1 was placed on hospice care. On 1/27-28/2023 at different times, the following staff that took care of R1 from 1/14/2023-1/17/2023 were interviewed: 1/27/2023 at 2:04 P.M., V7(CNA-Certified Nurse Aide) stated that after dinner at 8:00 P.M. on 1/14/2023, he transferred R1 to bed via the total lift transfer device. V7 stated that a female CNA from agency working on the same floor where he was assigned, second floor) had helped him during R1's transfer. V7 stated that there was no fall incident, but R1 had complained of left leg pain and that she immediately informed V9 (R1's nurse). 1/27/2023 at 2:50 P.M., V8 (the only female CNA from agency working on the second floor on 1/14/2023) stated that V7 never asked her to help transfer R1. V8 stated that she was on the opposite side of the hallway and had not helped any CNA with transfer lift device the evening of 1/14/2023. 1/28/2023 at 11:00 A.M., V9 (LPN-Nurse) stated that V7 (CNA) came to informed her on 1/14/2023 at around 8:00 P.M. that R1 complained of left leg pain after being R1 was transferred by V7. V9 added that she immediately assessed R1 and noted bilateral lower extremities edema which was an on and off issue with R1 due to lymphadenopathy. V9 also added that she provided R1 with Tylenol with good result. V9 also added that she also took care of R1 on 1/15/2023 (AM and PM/double shifts) and on 1/17/2023, morning shift, when R1 was sent to the hospital for further evaluation. V9 added that R1 had not complained of pain after that, some minimal swelling. However, on 1/17/2023, there was a marked bruise noted already on R1's left leg, just slightly below the knee. 1/27/2023 at 2:35 P.M., V10 (LPN for R1 during the night shift 10:00 P.M. through 6:00 A.M. on 1/14/15 and 16,2023. V10 stated that R1 slept well at night and no complaints of pain. V10 also added that she did not receive a report from her CNA's if R1 had bruises so there was no need for V10 to check R1's skin since she was asleep most of the nights. On 1/27/2023 at 2:30 P.M., V14 (RN/Registered Nurse) stated that she received a report from V12 that R1 has a bruise and some swelling to the left leg and an x-ray is pending. V14 stated that R1 was monitored and complaint of no pain. The above staff have all stated that R1 was usually in bed and had stayed in bed during the time they took care of her from 1/14/2023-1/17/2023. The hospital record documented by the orthopedic consultation report dated 1/18/2023 shows an [AGE] year-old in hospital due to left knee pain. She is non-ambulatory, with history of herpetic encephalitis. She does not move her legs; she has been in this state for about [AGE] years. Per family, someone tried to lift her and fell on to her, at the (nursing facility) and after that she was found to have pain. She came to ER and found to have a proximal tibia fracture. She has history of left partial knee replacement estimated at about [AGE] years ago. She goes from bed to reclining chair via a Hoyer lift. The x-ray result done at the hospital dated 1/17/2023 shows acute displaced comminuted fracture of the left tibia (shin). On 1/27/2023 at 11:00 A.M., R1 was observed lying in bed. R1 stated a male CNA fell on top of me assisting me to bed, the Hoyer lift tripped and fell on me also the CNA. It happened near that door (R1 was pointing at her entrance door to her room adjacent to the bathroom door). With R1's permission, and together with V2, R1's lower extremities were checked. R1's left leg has a faded bruise surrounding the left leg. There was also a darker bruise that surrounds the left leg proximal to the left knee. On 1/27/2023 at 3:00 P.M., V18 (Director of Therapy Department/Occupational Therapist) stated that two-person physical assist is a must when transferring a resident using a mechanical transfer lift device. On 1/27/2023 at 2:45 P.M., V19 (R1's Attending Physician) stated that she followed R1's care at the hospital related to the fracture and encephalopathy. V19 stated that R1's comminuted fracture was acute, meaning it occurred very recently, and that kind of fracture was caused from an impact and it just did not happen spontaneously. The facility's policy with last reviewed date of 11/2021 regarding Resident Transfer Protocol shows this policy is to attempt to protect both its residents and employees from injury in the course of transferring residents 1. All residents will be assigned a transfer technique that identifies the kind of transfer that is appropriate for their individual needs according to following; -independent; one person transfer; Sit to stand Lift requires two-person assist; Total Mechanical Lift requires two-person assists .

Based on observation, interview, and record review, the facility failed to monitor and supervise residents to prevent injury. This failure affects 2 of 3 residents (R1, R2,) reviewed for resident injury in a sample of 3, and caused injury to 1 of 3 residents, R1, reviewed for resident injury. Findings include: 1. R1 is an [AGE] year-old female admitted on [DATE] with admitting diagnoses including Dementia, fall, and a history of traumatic fracture. R1 was not in the facility during this survey. On 5/31/22 at 11:45 AM, V5 (Wound Care Nurse) stated, On 5/27/22 early morning at around 6:00 AM, I provided left heel wound care to R1 and noticed R1's left lower leg flaccid and crepitus (crunching sound or sensation). I notified [V10] (Nurse Practitioner-NP) that R1'S foot is flaccid and has crepitus. She ordered an X-ray, and the floor nurse followed upon that. Record review on facility-provided radiology result dated 5/29/22 indicates an acute to subacute fracture of the left distal tibia and fibula. Record review on hospital left leg X-ray result dated 5/29/22 document an acute displaced fracture of left tibia and fibula. On 5/31/22 at 11:45 AM, V2 (Director of Nursing) stated, V3 (R1's Attending Physician/MD) and V10 (NP) assessed R1 on 5/27/22. R1 was bedridden and won't be able to walk around. This is not a fall. We don't know exactly what caused her injury. On 6/1/22 at 10:30 AM, V10 (NP) stated, R1's X-ray for the left lower leg showed an acute displaced fracture of her left tibia/fibula fracture. There might be some incident causing acute displaced fracture for both the tibia and fibula- some kind of external force from a fall or blow can cause that injury. Trapping the resident's leg with the bedframe/side rail when they turned and repositioned R1 can also cause that injury. There is no reported fall or trauma, and we don't know exactly what caused that injury. On 6/1/22 at 11:45 AM, V3 (R1's Physician) stated, On Friday (5/27/22), I went to assess R1, and there was nothing visible to tell fracture. But I could tell something was going on from her left leg crepitus. So, I ordered an X-ray, and it showed a left tibia/fibula fracture. I don't know what happened or caused her leg fracture. I don't know her leg stuck somewhere .or any trauma happened. 2. Record review of a reportable incident dated 1/28/22 documented R2 fell , resulting in a right hip fracture. Record review on fall risk assessment dated [DATE] documented that R2 was at moderate risk for fall. Record review on another reportable incident indicated that R2 fell again on 3/18/22, causing a left femur fracture. Fall risk assessment dated [DATE] documented that R2 was at high risk for falls. Record review on R2's fall care plan interventions includes ensuring the call light is within reach and encouraging to use it for assistance as needed. The fall interventions also include providing a bed pad alarm when in bed and continuing with a clip alarm. On 5/31/22 at 10:40 AM, R2 was on her bed with a call light push button hanging behind the headboard. In response to the surveyor's question (in the presence of R2's nurse V13), How do you use the call light to call for assistance? R2 stated, I don't know .I am looking for it .I can't see it. V13 stated, The call light should be reachable to R2. On 5/31/22 at 10:45 AM, observed no bed alarm padding or bed alarm activated for R2 while R2 was in bed. Observed a chair alarm set hanging from bedframe with string not clipped to resident gown (not activated). V13 stated, R2 is at high risk for falls. The alarm should be activated to monitor/supervise R2. The facility presented the Call Light Answering Policy (undated) document: When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. Record review on Fall and Fall Risk Management policy revised in March 2018 document: The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling.

Based on observation, interview, and record review, the facility failed to ensure safe practices for turning a resident in bed, and failed to ensure a resident with a fall risk was monitored. This failure resulted in a resident falling out of bed during care and sustaining an acute significant temporal lobe brain hematoma, a subdural hematoma, maxillary sinus fracture, and a facial laceration requiring 10 stitches. This applies to 2 of three residents (R1 and R4) reviewed for falls. The findings include: 1. According to the Electronic Health Record (EHR), R1 had [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], showed R1 needed extensive assistance of two people for bed mobility which includes how a resident moves to and from a lying position, turns side to side, and positions body while in bed; transfers; bathing; and toilet use. R1 needed extensive assistance of one person for dressing and personal hygiene. The MDS showed R1 had impairment on one side of the body of both the upper and lower extremities. R1 used a wheelchair for mobility and had an indwelling urinary catheter. The MDS showed R1 weighed 282 pounds and was five feet eight inches tall. R1 had a Brief Interview for Mental Status (BIMS) of 15 /15 possible points, indicating (R1's) cognition was intact. The MDS showed R1 had an indwelling urinary catheter and was always incontinent of bowel. A care plan showed R1 was at risk for falls related to heart failure, [MEDICAL CONDITIONS], and [MEDICAL CONDITION] arthritis. R1 had a care plan created on 03/18/2019, and cancelled on 05/29/2019, showing R1 needed extensive assistance of two people for toileting, transfers, and bed mobility due to weakness, limited mobility, decrease strength and endurance, poor safety judgment related to [MEDICAL CONDITION] and [MEDICAL CONDITION] following cerebral infarction, and obesity. On 06/05/2019, between 2:08 PM and 2:36 PM, V6, Certified Nursing Assistant (CNA), said as per R1's usual routine, every morning around 11:00 AM, V6 was getting everything to get R1 ready to get up for the day. V6 was standing on R1's right side and turned R1 onto R1's left side to clean off R1's back. V6 said V6 wasn't giving R1 a complete bath, but R1 liked having R1's back cleaned off in the morning. V6 said R1's left side was R1's weak side, and V6 would only roll R1 to the left side, or R1 wouldn't be able to grab onto the bed rail with R1's left arm if R1 was turned onto the right side. V6 said if V6 needed to remove R1's incontinence brief, V6 would pull it out from behind and underneath R1. V6 stated when V6 turned R1, R1's left leg went off the bed, and the weight of R1's leg going over carried R1 the rest of the way over the bed. V6 said R1 was a big guy, probably weighing over 300 pounds. V6 said R1 was close to the left side of the regular size (not a bariatric or wide bed) air mattress bed when R1 was turned. V6 said R1 had partial side rails near the head of the bed used for positioning. According to V6, it happened suddenly, and V6 couldn't recall if R1 had grabbed onto the side rail with R1's right hand. V6 said R1 was alert and oriented 60 to 70 percent of the time, with mild confusion,was pleasant, and R1 could use the call light when R1 needed assistance, which R1 always used. V6 said R1 needed two-people for transfers using the sit to stand mechanical lift, and also needed two people for toilet use when getting R1's incontinence brief changed while lying in bed. V6 thought R1 was just a one person assist for bed mobility because R1 could grab the side rails to assist. V6 stated, however, R1 needed assistance with turning in bed because R1 was unable to turn on R1's own, and was unable to grasp anything with R1's left arm. V6 said when R1 fell , R1 landed on R1's face and that R1's whole body landed on the floor, hitting the floor at the same time. V6 said R1 must have hit the base of a gastrostomy tube feeding pole when R1 fell also. V6 called the nurse (V7, Licensed Practical Nurse, LPN) from the doorway and when V7 came in, V6 and V7 saw bleeding from R1's face. V7 called the supervisor. V6, V7, and the supervisor turned R1 to R1's back; the nurses did first aid to stop the bleeding, then V6 and V7 transferred R1 to bed using the total body mechanical lift. When the wound nurse left the room, V6 stayed in the room until the ambulance arrived, but V6 was unsure how long it took for the ambulance. V6 said R1 seemed disoriented and didn't really know what happened, although R1 did recognize who V6 was. R1 would say some things that made sense, and some things didn't make sense, which was not normal for R1, which the nurses were aware of. On 06/05/2019 at 3:34 PM, V7, LPN, said according to the CNA (V6), V6 was trying to clean R1 up. R1 was on R1's weaker side, and then R1 fell out of the bed. When V7 entered the room, R1 was lying on the left side of the bed on the floor; R1 was lying on R1's left side, not completely face down. R1 was bleeding from R1's head, and there was a laceration on the left side of the forehead above the eyebrow area. V7 said V7 did not know how big it was, it wasn't measured as they were focused on cleaning up the wound and controlling the bleeding. R1 fell sometime before lunch, and was unsure who rolled R1 to R1's back and got R1 to bed. V7 said R1 needed to be sent to the hospital because of the laceration and the bleeding. V7 said a private ambulance company was called instead of 911 because R1 was alert and oriented, talking, the bleeding had stopped, and since it wasn't life threatening, no respiratory issues, and (R1's) vital signs were stable. V7 could not recall how long it took before the ambulance arrived. On 06/10/2019 at 4:50 PM V9, Medical Doctor (MD), Hospital Emergency physician, said (R1) was seen in the emergency room , then transferred to another hospital for the neurosurgery consult. V9 said R1 had an acute significant traumatic brain hematoma which was caused from the fall at the nursing home. He stated, All of our head bleeds with a potential to become severe and possibly need surgery we have to send out to be monitored closely as only time will tell if the hematoma will worsen. We never know if it is going to get bigger, so R1 was transferred to an Intensive Care Unit setting. V9 said since R1 was on Apixaban (a blood thinner), they would have had to hold giving it to R1 to not be the cause of worsening the brain bleed. V9 said of course holding the blood thinner would put him at a higher risk for developing blood clots, stroke, and embolism. All of the things it was given to prevent in his diagnoses, but since R1 did have a brain bleed, they wouldn't have wanted the brain bleed to get worse. The hospital records, Radiology studies, Computed [NAME]ography (CT) scan, dated 05/14/19 at 3:05 PM, showed R1 had an acute 1.6 centimeter (cm) by 1.0 cm left temporal lobe hematoma with surrounding [MEDICAL CONDITION], a 0.5 cm thickness subdural hematoma along the left aspect of the falx, nondisplaced fractures of the anterior and posterolateral walls of the left maxillary sinus with hemorrhagic fluid level, left periorbital and premalar soft tissue hematoma with swelling, and a small amount of right mastoid fluid present. The emergency room record dated 05/14/19, showed R1 had a five centimeter laceration to the left upper eyelid which was closed with 10 sutures, as well as a 0.5 cm skin tear to the left nasal bridge, and a quarter size abrasion to the left anterior leg. R1 had left infraorbital [MEDICAL CONDITION] and ecchymosis with mild tenderness, and mild left temporomandibular joint (TMJ) tenderness. The second hospital record, a CT scan, dated 05/14/19 at 10:58 PM, showed R1 had a partial increase in the parenchymal hemorrhage within the anterior left temporal lobe measuring approximately 2.3 by 1.5 cm. A third CT scan dated 05/15/19 at 3:23 PM, showed the anterior left temporal lobe hemorrhage measured 2.4 by 1.6 cm, and the anterior subdural hematoma measured six to seven millimeters (mm). The hospital records showed R1 was in the hospital for one week. The discharge summary showed R1's Apixaban (blood thinner) was recommended to be held for one month, after which a repeat CT scan and follow-up with neurosurgery should be done to determine restarting the blood thinner. On 06/10/2019 at 1:13 PM, V8, Physical Therapist, Acting Therapy Manager, stated R1's most recent Physical Therapy evaluation dated 05/01/19, bed mobility assessment, showed during therapy R1 needed maximum assistance of one person for rolling side to side. V8 said, we enter a residents transfer code status in the EHR, and whatever was entered for the person we expect them to follow that. V8 said R1's transfer assistance was entered as a two person assist. V8 said we don't put in for bed mobility because if the resident needed two person assistance for transfers from the nursing staff, then the resident would probably need two person assistance for bed mobility as well, for safety reasons. V8 said, The correct procedure for rolling a person from side to side in bed, as an example, if we are rolling them to their left side, have the resident bend the right leg so they can push against the mattress to facilitate turning to the left and use their right hand to reach to the left handrail. If they still need assistance we would give them some assistance toward the hip or trunk. V8 said, Maximum assistance would mean (V8) had to do maximal assistance for (R1) including helping (R1) to bend the knee, assist by bringing (R1's) right arm to reach the left side bedrail, and assisting by placing (V8's) hands on (R1's) trunk and hip. The person should be standing on the side that the person was turning toward to prevent them from turning too far and potentially falling off the bed. V8 said the bedrail was mostly used for support for the resident to grab, not to stop them from falling. The Physical Therapy Plan of Care dated 05/01/2019, showed R1 needed maximum assistance (76 to 99 percent) for rolling side to side. The Occupational Therapy Plan of Care dated 05/01/2019, showed R1's left upper extremity gross motor and fine motor skills were severely impaired. R1 required dependent 100 percent assistance for be to wheelchair transfers. On 06/06/2019 at 3:40 PM, V3, Director of Nursing (DON), stated R1 was extensive assistance of one person for hygiene and the CNA wasn't giving R1 a bath; (V6) was just giving (R1) some hygiene on his back. V3 said yes, the CNA did have to turn R1 to the side to clean R1's back. V3 said R1 needed two people for bed mobility and R1 was on a low air loss mattress. The MDS shows personal hygiene includes: combing hair, brushing teeth, shaving, washing and drying of the face and hands, and it excludes baths and showers. The MDS for Bed mobility was how a resident moves to and from lying position, turns side to side, and positions their body while in bed. The American Congress of Rehabilitation Medicine Caregiver Guide and Instructions for Safe Bed Mobility dated (YEAR), included bed mobility refers to activities such as scooting in bed, rolling (turning from lying on one's back to side-lying), side-lying to sitting, and sitting to lying down. It also includes scooting to sit on the edge of the bed when preparing to stand or transfer. The instructions include to decide which side of the bed the patient should get out from based on their strength, and position yourself to that side of the bed. The patient should always roll toward you not away from you. Patient safety included to assist the patient on their weaker side and if you are ever unsure, get needed help. 2. According to the Electronic Health Record (EHR), R4 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], showed R4 needed extensive assistance of one person for bed mobility, transfers, dressing, and toilet use. The MDS showed R4 was not steady, and only able to stabilize with staff assistance for moving from seated to standing position, walking, and turning. R4 had a Brief Interview for Mental Status (BIMS) of 0 out of 15 possible points, indicating (R4's) cognition was severely impaired. A care plan dated 05/24/19, showed R4 was at high risk for falls related to a right pelvic fracture, impaired mobility, impaired balance, poor safety awareness, and impulsive behavior. Interventions dated 05/23/19, included to continue with chair and bed pad alarm to alert staff that resident is transferring self without assistance, closely monitor resident due to recent fall related injury, be sure call light is within reach, continue to attempt to encourage resident to stay in common area, continue to do frequent alternating rounds between CNA and nurse every two hours and as needed. Continue to do frequent alternating rounds when resident is in bed, keep bed in low position at night. A Fall Risk assessment dated [DATE], showed R4 was at a high fall risk with multiple falls in the last six months. The facility's Accident and Incident Log showed R4 had a recent fall on 05/21/19. On 06/04/2019 at 4:29 PM, R4's bedroom door was completely closed. Upon entering the room R4 was awake, non-verbal, lying in bed, with the top cover bed sheets on the floor on the right side of the bed. The bed was elevated with the top of the mattress approximately 28 inches from the floor. R4 was leaning to right side, with R4's head off the right side of the mattress. R4 was alternating between attempting to remove R4's soiled incontinence brief, which was unsecured by pulling up on the front of the brief, and reaching toward the floor for the bed sheets with R4's left hand. A bed alarm pad was noted at left edge of the mattress with the cord laying on floor not connected to the alarm box hanging on the side rail. The call light cord was on the floor. The Director of Nursing (V3) was notified, and when we went back to room less than 90 seconds later, R4 had the bedsheet from the floor in R4's hand and draped over the right side rail. V5, LPN, showed R4's bed alarm pad was bunched up to the left side of the mattress, behind R4's back. R4 was not laying on the bed pad alarm. V3, DON, said R4's bed was in the lowest locked position, however V3 was able to lower the bed approximately 3 more inches before the bed frame was resting on garbage disposal can at head of bed. On 06/04/2019 at 5:00 PM, V5 said V5 had last checked on R4 around 2:30 PM (two hours prior to the observation at 4:29 PM). V10, CNA, said V10 last checked on R4 at 2:00 PM (two and a half hours prior to the observation at 4:29 PM) because R4's alarm was sounding. V10 said V10 had to reposition R4 in bed because the bed alarm pad was bunched up to R4's side. V11, CNA, and V10 were using a total body mechanical lift to get R4 from the bed to a wheelchair. The lower extremity right side of lift sling was hooked on the purple colored loop by V11. The lower extremity left side of the lift sling was hooked on the pink colored loop by V10. After prompting by this writer, V10 said the sling loops should be on the same colored loop. On 06/05/2019 at 4:28 PM, V12, LPN, said R4's fall prevention interventions for close supervision was when R4 was up in the wheelchair. V12 said when R4 was in bed, R4 needed an every two hour check and change, and R4's room was close to the nurse's station. V12 said the every two hour check and change was for all the residents. V12 said R4 didn't need more frequent checks than everyone else. On 06/06/2019 at 2:57 PM, V13, LPN, said when there was an intervention to closely monitor a resident it would be to check the resident more frequently than regular protocol. V13 was the facility's regular protocol for regular monitoring was every two hours, alternating between the CNA and the Nurses, so that each resident would be checked every hour to know where they were and what they were doing. V13 said V13 was unsure how R4's fall care plan intervention of frequent alternating rounds every 2 hours would be any different than monitoring for any other resident. On 06/06/2019 at 3:40 PM, V3, DON, said Closely monitor resident on the care plan means the same intervention for every resident. The residents should be checked on every hour; the CNA checks on the residents every two hours, and the nurse does a check on the residents every two hours on the alternating hours. At 4:45 PM, V3 said if a resident should be closely monitored for falls, they should not have their bedroom door closed all the way. The facility's Fall Policy dated 11/10/2012, shows, It is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies, and facilities as safe environment as possible.

Based on interview and record review the facility failed to provide assistive device to a resident during ambulation and transfer to promote resident safety.This applies to 1 of 3 residents (R8) reviewed for falls with injury in the sample of 14. This failure resulted in R8 falling during staff assisted transfer. R8 was sent to the hospital and was diagnosed with [REDACTED]. The findings include: R8 has multiple [DIAGNOSES REDACTED]. R8 also has a [DIAGNOSES REDACTED]. R8's significant change MDS (minimum Data Set) dated July 5, 2017 showed that the resident is cognitively intact and would require extensive assistance with one person assist for most of her ADL's (activities of daily living) including transfers, ambulation and toilet use. The MDS also showed that for mobility devices, R8 uses a walker or a wheelchair. A memo regarding R8's significant change of condition was reviewed. This memo showed that R8 is scheduled for a significant change of condition on July 5, 2017 due to the decline in ambulation, transfer, bed mobility and toileting from limited assistance to extensive assistance. R8's last documented weight on September 2, 2017 was 246 pounds based on the resident's weights and vitals summary. R8's preliminary report of incident/accident submitted to the State agency on September 29, 2017, showed that on September 29, 2017 at 5:00 AM the resident had a fall incident. The report showed, Staff reported that they were assisting resident to the restroom as per the usual routine, per staff when resident was in the restroom R8 let go of staff hand and attempted to reach for the grab bar in the restroom. CNA (Certified Nursing Assistant) instructed resident not to reach for the bar as R8 was not close enough and in the process, resident lost R8's balance and incidentally fell on to the floor landing on R8's buttock. Staff nurse indicated as she walked into the resident's restroom to assess, resident was sitting on the floor in front of R8's toilet with both R8's legs extended in front of R8, R8 was facing the door. Resident was alert and responsive at the time of assessment. On October 2, 2017 at 2:36 PM, E14 (CNA) stated that E14 was the staff assigned to take care of R8 on September 28, 2017 during the 10 PM through 6 AM shift. Per E14, E14 is the regular CNA assigned to take care of R8. E14 stated that on September 29, 2017 at around 5:00 AM, R8 used R8's call light and asked to be assisted to the bathroom. Per E14, E14 assisted R8 to walk from R8's bed to the bathroom without any assistive device. According to E14, E14 stayed on R8's right side and had R8 hold on to E14 left hand while walking towards the bathroom. When they reached the inside of the bathroom near the bathroom door, R8 let go of E14's hand to reach for the grab bar (inside the bathroom) but, R8 was still too far from being able to reach it, and that is when R8 fell on R8's right knee. According to E14, while R8 was on R8's right knee, the resident was told not to move while E14 called for help but, R8 moved anyway. R8 moved on R8's left side and rolled over to a sitting position, all the while complaining of pain on the right knee. When E15 (nurse) responded to E14's call for help, the nurse assessed the resident and R8 was transferred from the floor to the wheelchair manually using a big sheet with assistance from 4 to 5 staff. On October 17, 2017 at 12:04 PM, E15 (nurse) stated that on September 29, 2017 around 5:00 AM, E14 (CNA) called E15 for help because R8 was on the bathroom floor. Per E15 when E15 reached R8's bathroom, the resident was lying on R8's right side on the floor with R8's legs extended towards the door, R8 was attempting to get up on R8's own saying, I'm okay, I'm okay, get me up! E15 stated that E15 assessed R8 and noted that the resident was able to move all extremities without pain or limitation. Per E15, E15 and E14 assisted R8 to sit up on the bathroom floor and called for more staff to assist with R8's transfer. E15 stated that 3 more male staff, including a nursing supervisor came and manually transferred R8 from the floor to the wheelchair using a blanket, while 2 more staff on standby assistance to make sure that the resident was safely transferred. When R8 was on the wheelchair (per resident's request) another assessment was made by E15. R8 was able to move both lower and upper extremities without problem. R8 kept on saying, I'm okay! According to E15 during this assessment E15 noticed a bump on R8's right forehead (without bruising). Per E15, R8 remained to have an abscess on R8's right knee and right leg area which was being treated with oral antibiotics. E15 stated that after the assessment E15 called R8's physician and the covering nurse practitioner answered. The nurse practitioner was informed of the fall incident and the bump on R8's forehead. The nurse practitioner gave an order to send R8 to the hospital for evaluation and treatment because R8 was on blood thinner. During the same interview, E15 stated that E15 is the regular nurse on the unit during the 10 PM through 6 AM shift. Per E15, E15 asked E14 about the incident and was surprised to learn E14 walked R8 from the bed to the bathroom without any device. According to E15, R8 needed a wheelchair to be pushed close to the toilet then, transfer R8 from the wheelchair to the toilet using a gait belt for safety, since the resident is a one person assist. R8's POS (physician order [REDACTED]. Review of the facility transfer protocol last revised on June 10, 2011 showed in-part, 3. The transfer technique that is appropriate for each resident will be listed on the Special Care Needs Sheet and posted on the inside door of the resident's wardrobe and 4. No resident is to be transferred without first verifying the transfer technique assigned to that resident to know what type of transfer is required by that resident on that day. Review of R8's transfer code sheet showed that the resident is a one person transfer. The same transfer code sheet showed, Always use a gait belt for resident transfers with the exception of mechanical lift transfers. On October 2, 2017 at 3:14 PM, E2 (Director of nursing) stated that when residents are being ambulated and/or transferred, the staff are expected to use a gait belt for the safety of the resident. Per E2, prior to R8's fall incident, R8's care need card was available for the staff to check before providing care to the resident. R8's care need card was placed inside the resident's back door closet. According to E2, the care need card tells the staff, what the resident need and what type of assistance is required for the resident. During the same interview, E2 stated that R8 needed the gait belt for transfers and ambulation. R8's emergency room records dated September 29, 2017 showed Chief Complaint : was transferring from wheelchair to toilet, fell and hit right side of head on bar and landed on right leg. No L(NAME) (loss of consciousness). C/O (complaint of) pain to right leg. Right leg noted shorter than left. The emergency room history of present illness showed that R8 had a small hematoma to the right forehead, with significant right lower extremity leg pain at the hip and at the knee. It was also documented, The patient is morbidly obese and non-ambulatory. R8's hospital records showed an H & P (history and physical) dated September 29, 2017 stating that R8 was admitted from the emergency room due to a fall at the nursing facility. The patient fell on her right knee. The patient has moderate to severe amount of pain in the right knee with significant deformity. Pain worsens with movement and relieved by the rest. The same H & P showed a CT (Computerized Tomography was done and the results showed that, The right lower extremity shows periprosthetic fracture of the distal femur with deformity is comminuted. R8's hospital records showed that a CT scan of the resident's head was done on September 29, 2017. The result showed, Right frontal lateral subcutaneous soft tissue swelling and edema. Further review of R8's hospital records showed that an x-ray of R8's right 5th finger was obtained on September 30, 2017 due to swelling and deformity. The x-ray result showed that the fifth proximal interphalangeal joints were dislocated. R8's hospital records showed that the resident was transferred to another hospital on September 30, 2017 for further treatment for [REDACTED].

Based on observation, interview and record review the facility failed to ensure the proper equipment was used as well as the right number of staff utilized for transferring a resident (R1).This is for one of three residents (R1) reviewed for mechanical lift transfer in a sample of three. This failure resulted in R1 sustaining an irregular shaped laceration (10 cm x 4.2 cm) which required an emergency room visit sustaining 21 sutures to repair laceration. Findings include: R1 is a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Special Care Needs Sheet for R1 located inside the closet door states to utilize mechanical lift with two people for all transfers. Her Minimum (MDS) data set [DATE] indicates R1 is totally dependent and needs two person assistance to transfer. The care plan dated 12/4/2012 for R1 indicated R1 is to be transferred by mechanical lift. An incident report dated 2/4/2013 at 4:30 PM indicated R1 was transferred from the wheelchair to the bed by E3, certified nurses aid (CNA). After the transfer R1 was noted to have blood on the floor under her right foot as well as active bleeding from a wound on R1's right calf area. R1 was not able to tell staff what had happened to R1's leg. R1s visitor indicated the CNA (E3) transferred R1 without any mechanical lift by himself (per facility interview). E3 indicated he had utilized a sit / stand mechanical lift to transfer R1 per facility interview. E3 was immediately removed from the resident unit after the injury was discovered. Then E3 was suspended pending investigation on 2/24/2013 for improper transfer of R1. E3 then was terminated on 2/25/2013. On 3/7/2013 at 9:10 AM an attempt was made to call E3, CNA. The phone was temporarily disconnected per voice recording. On 3/7/2013 at 10:30AM, E9 LPN, (license practical nurse) stated on 2/24/2013 E9 was informed R1 had an injury by R1's visitor. When E9 entered R1's room R1 was sitting on the side of the bed with feet dangling over the side of the bed. E9 noted blood on the floor and on R1's right calf area. R1 had a irregular shaped wound to the right calf. E9 applied pressure to R1's wound and a pressure dressing. E9 indicated the bleeding would not stop so 911 was called. R1 was transferred on 2/24/13 at 4:30pm to the local hospital emergency department for treatment. She returned at 9:10pm with 21 sutures to her right lower calf. E9 also indicated R1 was on coumadin a blood thinner. R1 was receiving the blood thinner for atrial fib and immobility issues per E9. E9 looked around the room to see what R1 had injured her leg on seeing blood on the side rail which was lying on the floor. E9 indicated the only equipment in R1's room was her wheelchair when E9 entered the room. E9 felt the CNA did not properly transfer R1. E9 said R1 was to be transferred with a mechanical lift with the assistance of two staff. A nurses note dated 2/24/2013 at 9:00 PM indicated R1 returned to the facility with 21 sutures to the right calf area. Review of assessment by E2 on 2/25/2013 at 8:30 AM, indicates the following: R1 had bilateral lower extremity 4 plus pitting edema, bilateral foot drop and irregular shaped laceration approximated with 21 sutures, incision measures 4.2 cm by 10 cm. R1's wound was observed on 3/7/2013 at 9:00AM. R1 had 4 plus bilateral pedal edema with sutures to the irregular shaped wound on right calf. The suture line was taut with maceration to the left upper corner. The wound was pink in color. The old dressing removed by E2 had bright red blood tinged drainage noted in a small amount. On 3/6/2013 at 12:00 PM E1 (administrator) stated R1 should have been transferred with a mechanical lift by two staff. E2 (director of nursing) concurred. On 3/7/2013 at 10:10 AM, E8 Physical Therapist indicated R1 was assessed upon admission as requiring a two person mechanical lift transfer because R1 had bilateral foot drop. E8 also indicated that R1's family stated she was bed ridden at home for two years prior to admission to the nursing home. Facility Resident Transfer Protocol indicates #1) all residents will be assigned a transfer technique that identifies the residents needs: Total Mechanical Lift (2 person assist). This information will be listed on "Special Care Needs Sheet" posted inside all residents closet doors for staff to utilize. This information was posted in R1's closet.

Based on observation, interview and record review, the facility failed to follow facility's policy and plan of care for the proper use of the mechanical transfer lift device to ensure safety transfer to 2 of 3(R1 and R2) residents reviewed for high risk of falls. This failure resulted to R1 and R2 sustaining fractures precipitated by the the improper transfer. R1 and R2 had required hospitalization s due to the extent of the injuries. Findings include: 1) R1 is an [AGE] year old, with multiple [DIAGNOSES REDACTED]. R1's recent MDS (Minimum Data Set) dated 11/23/2011 indicated that R1 has short and term memory impairment . R1 has also moderately impaired cognition with poor decision making. The same MDS indicated that R1 required total dependence x 2 or more persons physical assist during transfers. R1 also has impairment for range of motion on both sides to lower extremity (hip, knee, ankle and foot). Review of " Special Care Needs" and Care Plan dated 11/23/2011 showed that R1 uses total mechanical lift with 2 persons physical assist for transfers. Review of facility's "Final Report of Incident/Accident " dated 2/16/2012 showed the following descriptions: --- On 2/8/2011, after dinner time, E3 and E4 (CNA , certified nurse assistant) transferred R1 from reclining chair to bed with a "2 man lift." E3 and E4 did not use the total mechanical lift device. --- On 2/9/2012 at approximately 7:00 A.M., "(R1) complained of left hip/ back pain with pain scale of 2/10. (R1) assessment revealed left hip and thigh were swollen, left lower extremity appeared slightly shorter than the right." ----Xray was done 2/9/2012 and showed fracture of the left femur. R1 was sent to the hospital 2/9/2012 and returned to the facility 2/11/2012 with a splint to immobilize the left lower extremity. ----Final conclusion of this investigation revealed " (R1's) left femur could have possibly taken place during the transfer on 2/8/2012 on 2-10 p.m. shift, the facts are that (R1) has order to be transferred with total mechanical lift due to his rigidity, [DIAGNOSES REDACTED], quadriplegia which placed (R1) at risk for fracture. The force from lifting and pivoting (R1) when (E3) and (E4) lifted and transferred (R1) have caused an undue pressure to (R1's) left lower extremity thus resulting in the left femur fracture." On 2/22/2012 at 1:45 P.M., E2(Director of Nursing) stated that E3 and E4 had improperly transferred R1 from a reclining chair to bed on 2/8/2012 after dinner time. E2 also stated that E3 and E4 also did not follow R1's plan of care to use total mechanical transfer lift device. E2 further added that R1 had no signs or indication that there was any injury prior to the improper transfer. E5 (CNA-certified nurse assistant) stated on 2/22/2012 at 3:15 P.M. that R1 complained of pain on the left hip on 2/9/2012 at around 7:00 A.M. E5 also added that some swelling was also noted on the left hip/thigh. On 2/22/12 at 2:00 P.M., R1 was observed in bed, awake, alert and verbally responsive. R1 was wearing a left hip/leg splint to immobilized the left lower extremity. R1 has contractures to both hands and was not able to move extremities or turn self without staff assistance. On an interview held at the time of this observation, R1 stated that he does not remember the improper transfer and was not able to give detailed information. 2) R2 is a [AGE] year old, with multiple [DIAGNOSES REDACTED]. R2's recent MDS (Minimum Data Set) dated 12/16/2011 indicated that R2 required extensive assistance x 2 or more persons physical assist during transfers. R2 also has impairment for the range of motion on one side to upper(shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle and foot). Review of " Special Care Needs" and Care Plan dated 12/16/2011 showed that R2 uses a "Sit to Stand Lift" mechanical transfer device with 2 person assist. Review of facility's incident report dated 1/1/2012 showed that R2 fell during a transfer while on a "Sit to Stand Lift." mechanical transfer device on 12/31/2011. This report also showed that R2 had "passed out" during transfer and was not able to hold on the handle bars of the transfer lift device. It was also indicated in this report that R2 was assisted by 1 person (E11- CNA, certified nurse assistant) during this incident that occurred during the improper transfer. On 2/22/2012 at 3:10 P.M., E10 (CNA) stated that R2 was found on the floor on 12/31/2011 at around 4:35 P.M. . E10 also stated that E11 only asked help when R2 had already slipped from the sling of the "Sit to Stand" transfer lift. E10 added that "(R2) passed out and was not able to hold on the handle bars, slipped from the sling , ending down to the floor." On 2/22/2012 at 3:00 P.M., E2(Director of Nursing) stated that E11 did not follow the facility's policy for the proper use of the " Sit to Stand " mechanical transfer lift device. E2 also stated that E11 also did not follow R2's plan of care for 2 person assist during transfer to ensure safety. Review of record showed that R2 sustained scratches on her back and a non displaced neck fracture of the humerus due to the improper transfer. R2 was sent to the hospital on [DATE] precipitated by the fall incident. R2 was observed on 2/23/2012 at 12:30 P.M. R2 stated " Yes, I fell when I slipped from the machine(sit to stand lift). There was only one CNA that transferred me when that happened." Review of the facility's policy for proper use of mechanical transfer lift device revealed that 2 person physical assist is required when transferring a resident.

Based on Record Review and Interview the facility failed to communicate new onset of symptoms to the physician in a timely manner for one of three residents ( R2) reviewed for new medical symptoms. This resulted in R2 experiencing discomfort for 22 hours and a delay in treatment for [REDACTED]. Findings included : R2 is a [AGE] year old resident who was admitted to the facility on 12/06/11. The face sheet documented [DIAGNOSES REDACTED]. R2's Admitting assessment dated [DATE] noted dependent [MEDICAL CONDITION] to the scrotum; the scrotum was blanchable. R2 also had right hand [MEDICAL CONDITION] and [MEDICAL CONDITION] to bilateral feet. R2's Care Plan dated 12/16/11 addressed scrotal [MEDICAL CONDITION] under skin integrity. The approaches included positioning, keep clean and dry, inspect daily, and pain management. A Physician order [REDACTED]. R2's Nursing Notes between 12/06/11 and 12/20/11 did not document any change in status of the scrotum. During this time, [MEDICATION NAME] was documented as being given for generalized pain. On 12/20/11 R2's Nursing Notes documented at 0:700am documented 3+ [MEDICAL CONDITION] to the scrotum. Z1, physician, was paged for this change in status. R2 was medicated with [MEDICATION NAME] for pain. Z1 examined R2. There was no scrotal pain, bluish discoloration, or drainage. A scrotal support and [MEDICATION NAME] were ordered at 10:30am. At 01:50pm a scant light green/yellow drainage was noted: it had a foul odor. R2 was medicated at 01:00pm with [MEDICATION NAME] for scrotal pain. No pain was present at 01:50pm. R2 voided at 07:00am and had not voided since that time. R2's status was relayed to the afternoon shift. At 04:00pm on 12/20/11 R2 was in bed. Scrotal [MEDICAL CONDITION] present with light green drainage that had a foul odor. A Bluish discoloration was noted to the scrotum. Z2, Nurse Practitioner, was notified of abdominal pain and lack of urination. An indwelling urinary catheter was ordered and inserted. 500 cubic centimeters of dark amber urine was emptied into the drainage bag. At 07:30pm [MEDICATION NAME] was again given for scrotal pain which was rated at intensity of 8 on a 10 point scale. At 05:30am on 12/21/11 the Nursing Notes document that R2 had a blood sugar of 30mg per deci-liter. [MEDICATION NAME] was given. Blood sugar remained unchanged. Z2 was updated on R2's condition and R2 was transferred to a local emergency room for Evaluation and Treatment. At that time Z2 transferred R2 because of [DIAGNOSES REDACTED], scrotal pain, discoloration, and scrotal drainage that was yellow/green and foul smelling. An ambulance report dated 12/20/11 documented that R2 was a resident who was found with a blood sugar of 30. R2's scrotum was swollen and R2 had been in a lot of pain due to this problem. He was alert and complained of scrotal pain that could not be rated. The scrotum was the size of a "grapefruit" and some discoloration and foul odor was noted. He was alert and oriented 2/3, and was slow to respond. The Emergency Report documented that R2 was admitted with massive scrotal swelling with violaceous discoloration of the left scrotal sac; exquisitely tender to palpation. He was admitted to the hospital with [REDACTED]. E4. Nurse, E5, Certified Nursing Assistant, E7, Nurse,E8, Nurse, and Z1 were interviewed privately regarding the status of R2's scrotal [MEDICAL CONDITION]. All stated there were no change in medical symptoms prior to 12/12/11. On 01/03/12 at or about 10:30am E7 stated that R2's scrotum was swollen. He paged Z1. Z1 examined R2 on 12/20/11 in the morning. At that time no scrotal discoloration , pain, or drainage were noted. At 01:50pm a small amount of yellow green drainage was noted in R2's adult incontinence brief. It was foul smelling. He did not report to the physician about the drainage because he wanted to monitor it and determine the source. In addition R2 did not urinate between 07:00am and 01:50pm. E7 added that this information was relayed to E8 at the change of shift. At 02:45pm on 01/03/12 E8 stated that Z2 was notified of R2's inability to void. An indwelling urinary catheter was inserted. There was good urine return and the abdominal pain that was present prior to the insertion of the catheter was relieved. I did give R2 [MEDICATION NAME] for scrotal pain on my shift. It relieved the scrotal pain. On 01/03/12 at 11:00am Z2 stated she was not too familiar with R2. " I had not personally examined him yet. He was on my list of residents to assess. Every thing I do, I call Z1. I did send R2 to the hospital on [DATE]. I knew he had a problem with sugar, [MEDICAL CONDITION], and blood sugar control. I was not aware of scrotal discoloration, drainage, or scrotal pain prior to his discharge to the hospital. On 01/03/11 at 11:40am Z1was interviewed. He stated,"I had examined R2 in the morning of 12/20/11. At that time he was medically stable. His scrotum was swollen.: I ordered [MEDICATION NAME] and a scrotal support. There was no scrotal drainage, pain, or discoloration at the time of my examination. I was not informed of these changes. Strangulation of blood vessels can occur suddenly and symptoms can occur with a sudden onset. R2 is at risk because of Obesity,Hypertension, Hypertension, and Diabetes Mellitus. I, or my Nurse Practitioner were not informed of R's drainage, bluish discoloration of the scrotum, or scrotal pain until his discharge. I would have sent R2 to the emergency room for evaluation and treatment at time I would've been informed of the bluish discoloration and pain.

Based on record review and interview the facility failed to: -- ensure the nursing staff notified R1's physician of her acute unrelieved pain in a timely manner; -- ensure the nursing staff followed the facility policy and procedure including notifying physician for management of pain. As result: (1) R1 on [DATE] suffered from acute onset of new pain for a prolonged period of time from 4:10 am to 1:00 pm. (2) On [DATE] at 1:00 pm when the Local Fire Department Crew arrived at the facility, the crew found R1 to be unresponsive with agonal respirations and a weak pulse. R1 became pulseless and apneic shortly after getting into the ambulance. R1 arrived at the Hospital Emergency Department with full [MEDICAL CONDITION]. R1 was pronounced dead in the emergency room . R1 was on FULL CODE status. This is for one of three residents (R1) in the sample. Findings include: R1's admission record noted she was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R1 upon admission to the facility, was receiving medications for pain, anticoagulation therapy and was on [MEDICATION NAME]. R1 upon admission to the facility had physician order [REDACTED]. On [DATE] E3 the Night Nurse documented the following in R1's Nurses Notes: At 4:10 am R1 requested a heating pad saying her left hip was hurting. At 4:15 am administered [MEDICATION NAME] ,[DATE] one tablet for throbbing pain to left hip. The pain was at 2 on a scale of 5. A score of 2 is considered as 'little pain.' At 4:30 am R1 still complained of throbbing pain and she was touching two inches above the left hip, again the pain was noted at two on a scale of five. This time the pain assessment was done with a night supervisor and R1 was touching the spot two to three inches higher than last time. A cold pack was given and the vital signs were noted to be blood pressure ,[DATE], pulse 81, respirations 20 and temperature 97.6, pulse oxygen was 98 - 99%. At 4:45 am [MEDICATION NAME] 0.5 mg was given for anxiety with 60 cc of water. At 5:55 am R1 was in pain again at one on a scale of five (one being bearable pain). At 6.05 am night shift supervisor (E8) and day shift supervisor (E8) assessed R1, applied cold pack. On [DATE], day shift Nurse (E4) noted following in the nurses notes: At 6:35 am R1 complained of left sided abdominal pain, vital signs were: blood pressure ,[DATE], pulse 80, respirations 18, temperature 98.8 F. At 8:00 am R1 complained of abdominal discomfort, vital signs were blood pressure ,[DATE], pulse 83, respirations 18, temperature 99.4 F pulse oxygen 96%. Administered [MEDICATION NAME] ,[DATE] for pain. The pain was rated at 3 on the scale of 5 (three being moderate pain). R1 has physician order [REDACTED]. E4 administered the second dose of [MEDICATION NAME] ,[DATE] one tablet within four hours, without physician being aware of it. At 10:00 am R1's daughter (Z2) approached E4 saying, "my mother is asking to go to Hospital, but I called the doctor (Z1) and he will be here at 1:00 pm. Could you give my mother a [MEDICATION NAME]?" E4 gave [MEDICATION NAME] 0.5 mg for subjective complaint of anxiety as requested by Z2. The facility did not formulate advance directives for R1 when she was admitted to the facility. The facility also did not ensure if Z2 could legally authorize health care for R1. R1 has physician order [REDACTED]. E4 administered the second dose [MEDICATION NAME] 0.5 mg within six hours, again without physician being aware of it. These medications side effect is 'it could cause sedation,' and could mimic objective symptoms of R1's physical and mental symptoms. At 11:00 am R1 had nausea, vomiting, had basin with her. There was a small amount of white secretions in it. At 12:45 pm Z2 approached E4 saying R1 complained of severe abdominal pain, but Z2 does not want her to go to Hospital, they are only going to send her back. Z2 continued to say, Z1 will be in nursing home at 1:00 pm. When E4 went to R1 to assess, E4 found R1 pale, eyes rolled back, change in mental status, speech slow and slurred and became unresponsive and only pulse and breathing. At this time E3 called 911. The local Fire Department record obtained from the hospital indicated on [DATE]: The Fire Department received call at 12:56 pm, the crew arrived at the facility at 1:00 pm. The crew found R1 to unresponsive with agonal respirations and a weak slow pulse. R1 became pulseless and apneic shortly after getting into the ambulance. The crew continued to Cardio [MEDICAL CONDITION] Resuscitation (CPR) on the way to Hospital. The Hospital record indicated R1 had no vital signs when she arrived the Emergency Department, and she was pronounced Dead in the Hospital emergency room . R1 on [DATE] from 4:10 am to 1:00 pm experienced acute change in physical and mental condition, and suffered from acute unrelieved new pain. None of the facility staff notified Z1 about R1's suffering from new on set of pain. R1 continued to exhibit pain and underwent physical and mental changes. The facility policy for pain under procedure noted: (2) pain will be assessed and managed in a timely fashion, especially if it is of recent onset. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician. Thorough communication with the physician will ensure an appropriate pain management plan. The facility did not ensure the staff followed the policy and procedure for the management of pain. On [DATE] at 10:50 pm per phone conversation, E3 indicated she thought of calling Z1, but did not call. E3 also stated she should have called Z1 and notified him when R1 continued to have pain even after receiving pain and anxiety medications. E3 said after she gave report to E4 on [DATE] the morning shift nurse, E4 told E3 she (E4) would call the doctor, but apparently E4 also did not call the doctor. On [DATE] at 11:05 pm per phone conversation, E8 the night shift supervisor stated after she evaluated R1, she got busy helping the other unit nurse to administer medications to the residents. E8 also stated she directed E3 to call the doctor. On [DATE] at 3:15 pm E7 the day shift supervisor stated she called the doctor (Z1) on [DATE] around 12:25 pm to confirm if he was going to come to the facility which he confirmed that he will be in the facility. E7 also stated she did not tell him about R1 having pain. E7 thinks E4 should have notified the doctor. On [DATE] and [DATE] in and interview E4 stated, when R1 complained of pain around her left hip, the nurses (E3 and E4) and nursing supervisors (E7 and E8) were focussing on fall, fracture or bowel obstruction in their assessment. E4 said that she should have called the doctor before administering second dose of [MEDICATION NAME] and [MEDICATION NAME]. E4 also stated Z2 was a distraction when she was taking care of R1, and she should not have listened to Z2, and she should have sent R1 to hospital. On [DATE] at 10:15 am R1's physician Z1 stated: - R1, even though had multiple health issues including status [REDACTED]. - The cause of death was internal bleeding. - The facility staff did not notify him of R1 experiencing pain for so long time on [DATE]. - Z1 only became aware of R1 experiencing pain for so long time when he walked into the facility at 1:00 pm. By then it was too late comparing to when R1 started to have abdominal pain in the middle night say 3:00 am or 4:00 am. Z1 expect the staff to notify him as and when a resident (R1) under going change in physical condition. - If he was made aware of R1's pain earlier, he would have sent R1 to hospital for fluid [MEDICATION NAME]; and her condition could have have been reversed.

Based on record review and interview the facility failed to: -- ensure the nurses followed the facility policy and procedure to conduct an accurate assessment of pain; -- develop and implement individualized interventions for the treatment of [REDACTED]. -- notify physician promptly after R1 began to experience acute unrelieved pain; and -- provide emergency room services in a timely manner for the management of R1's pain. As a result: (1) R1 on [DATE] suffered from acute on set of new pain for a prolonged period of time from 4:10 am to 1:00 pm. (2) On [DATE] at 1:00 pm when the Local Fire Department Crew arrived at the facility, the crew found R1 to be unresponsive with agonal respirations and a weak pulse. R1 became pulseless and apneic shortly after getting into the ambulance. R1 arrived Hospital Emergency Department with full [MEDICAL CONDITION]. R1 was pronounced dead in the emergency room . R1 was on FULL CODE status. This is for one of three residents (R1) in the sample. Findings include: R1's admission record noted she was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R1 upon admission to the facility, she was receiving medications for pain, anticoagulation therapy and was on [MEDICATION NAME]. R1 upon admission to the facility she had a physician order [REDACTED]. R1's [DATE] admission assessment for pain section was left blank. R1's [DATE] admission pain care plan interventions noted 'monitor pain.' This intervention is generalized and no other interventions noted in the care plan. R1's as needed Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no pain assessment for the administration of these doses of [MEDICATION NAME]. A pain questionnaire was filled in on [DATE] and [DATE] which did not indicated why, where R1 was having pain. There is no documentation to indicate the quality of pain, what makes it worse, what makes it better or whether she had such pain before. On [DATE] E3 the Night Nurse documented the following in R1's Nurses Notes: At 4:10 am R1 requested a heating pad saying her left hip was hurting. At 4:15 am administered [MEDICATION NAME] ,[DATE] one tablet for throbbing pain to left hip. The pain was at 2 on a scale of 5. A score of 2 is considered as 'little pain.' At 4:30 am R1 still complained of throbbing pain and she was touching two inches above the left hip. Again, the pain was noted at two on a scale of five. This time the pain assessment was done with night supervisor and R1 was touching the spot two to three inches higher than last time, gave cold pack and the vital signs were noted to be blood pressure ,[DATE], pulse 81, respirations 20 and temperature 97.6, pulse oxygen was 98 - 99%. At 4:45 am [MEDICATION NAME] 0.5 mg was given for anxiety with 60 cc of water. At 5:55 am R1 was in pain again at one on a scale of five (one being bearable pain). At 6.05 am night shift supervisor (E8) and day shift supervisor (E8) assessed R1, applied cold pack. On [DATE], day shift Nurse (E4) noted following in the nurses notes: At 6:35 am R1 complained of left sided abdominal pain, vital signs were: blood pressure ,[DATE], pulse 80, respirations 18, temperature 98.8 F. At 8:00 am R1 complained of abdominal discomfort, vital signs were blood pressure ,[DATE], pulse 83, respirations 18, temperature 99.4 F pulse oxygen 96%. Administered [MEDICATION NAME] ,[DATE] for pain. The pain was rated at 3 on the scale of 5 (three being moderate pain). R1 has physician order [REDACTED]. E4 administered the second dose of [MEDICATION NAME] ,[DATE] one tablet within four hours, without physician being aware of it. At 10:00 am R1's daughter (Z2) approached E4 saying, "my mother is asking to go to Hospital, but I called the doctor (Z1) and he will be here at 1:00 pm, could you give my mother a [MEDICATION NAME]." E4 gave [MEDICATION NAME] 0.5 mg for subjective complaint of anxiety as requested by Z2. The facility did not formulate advance directives for R1 when she was admitted to the facility. The facility also did not ensure if Z2 could legally authorize health care for R1. R1 has physician order [REDACTED]. E4 administered the second dose [MEDICATION NAME] 0.5 mg within six hours, again without physician being aware of it. These medications side effect is 'it could cause sedation,' and could mimic objective symptoms of R1's physical and mental symptoms. At 11:00 am R1 had nausea, vomiting, had basin with her. There was a small amount of white secretions in it. At 12:45 pm Z2 approached E4 saying R1 complained of severe abdominal pain, but Z2 does not want her to go to the hospital. They are only going to send her back. Z2 continued to say, Z1 will be in the nursing home at 1:00 pm. When E4 went to R1 to assess, E4 found R1 pale, eyes rolled back, change in mental status, speech slow and slurred and became unresponsive and only pulse and breathing. At this time E3 called 911. The local Fire Department record obtained from the Hospital indicated on [DATE]: The Fire Department received call at 12:56 pm, the crew arrived at the facility at 1:00 pm. The crew found R1 unresponsive with agonal respirations and a weak slow pulse. R1 became pulseless and apneic shortly after getting into the ambulance. The crew continued to Cardio [MEDICAL CONDITION] Resuscitation (CPR) on the way to Hospital. The Hospital record indicated R1 had no vital signs when she arrived the Emergency Department, and she was pronounced dead in the Hospital emergency room . R1 on [DATE] from 4:10 am to 1:00 pm experienced acute change in physical and mental condition, and suffered from pain. None of the facility staff notified Z1 about R1 suffering from new on set of pain and continued to exhibit pain and undergoing physical and mental changes. The facility policy for pain under procedure noted: (2) pain will be assessed and managed in a timely fashion, especially if it is of recent onset. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician. Thorough communication with the physician will ensure an appropriate pain management plan. (3) (A) pain screening. Upon admission, readmission, each Minimum Data Set assessment, change of condition or when new pain or an exacerbation of pain is suspected, the pain questionnaire will be filled out with input from the resident, family member, or responsible party. If the resident scores 5 or above on the pain questionnaire, the comprehensive pain assessment must be completed. 3 (C) the will repeat the comprehensive assessment under any of the following circumstances: (a) score of 5 of above on the pain screening, (b) a change in resident condition occurs to require pain control, (c) new pain is reported. The facility did not ensure the staff followed these policy and procedure for pain management. On [DATE] at 10:50 pm per phone conversation, E3 indicated she thought of calling Z1, but did not call. E3 also stated she should have called Z1 and notified him when R1 continued to have pain even after receiving pain and anxiety medications. E3 said after she gave report to E4 on [DATE] the morning shift nurse, E4 told E3 that she (E4) will call the doctor, but apparently E4 also did not call the doctor. On [DATE] at 11:05 pm per phone conversation, E8 the night shift supervisor stated after she evaluated R1, she got busy helping the other unit nurse to administer medications to the residents. E8 also stated she directed E3 to call the doctor. On [DATE] at 3:15 pm E7 the day shift supervisor stated she called the doctor (Z1) on [DATE] around 12:25 pm to confirm if he was going to come to the facility which he confirmed that he will be in the facility. E7 also stated she did not tell him about R1 having pain. E7 thinks E4 should have notified the doctor. On [DATE] and [DATE] in and interview E4 stated, when R1 complained of pain around her left hip, the nurses (E3 and E4) and nursing supervisors (E7 and E8) were focussing on fall, fracture or bowel obstruction in their assessment. E4 said she should have called the doctor before administering second dose of [MEDICATION NAME] and [MEDICATION NAME]. E4 also stated Z2 was a distraction when she was taking care of R1 and she should not have listened to Z2, and she should have sent R1 to hospital. On [DATE] at 10:15 am R1's physician Z1 stated: - R1, even though had multiple health issues including status [REDACTED]. - The cause of death was internal bleeding. - The facility staff did not notify him of R1 experiencing pain for so long time on [DATE]. - Z1 only became aware of R1 experiencing pain for so long time when he walked into the facility at 1:00 pm. By then it was too late comparing to when R1 started to have abdominal pain in the middle night say 3:00 am or 4:00 am. Z1 expect the staff to notify him as and when a resident (R1) under going change in physical condition. - If he was made aware of R1's pain earlier, he would have sent R1 to Hospital for fluid [MEDICATION NAME]; and her condition could have have been reversed.

Based on record review and interview the facility failed to; - promptly notify the physician and family after a [MEDICAL CONDITION] and subsequent fall that resulted in 1 resident (R3) sustaining a fracture to the right hip. - Assess and continue to monitor 1 resident (R3) after a fall which resulted in a delay of treatment for [REDACTED]. Findings Include: Documentation denotes that on 3/6/2011 at 1:45 a.m. R3 was noted to have a staff witnessed [MEDICAL CONDITION] and fell to the floor. Further documentation denoted that R3 was picked up by staff and taken back to the room. Review of the facilities incident report, nurses notes and investigation denotes inconsistent documentation of the time that the incident occurred and the time of the notification of the physician and family/responsible party. Some documents were noted to be blank containing no documented notification of the family, while others were noted with long gaps in between the time of the incident and the time that the physician and family was notified about the incident. Documentation denotes that R3 refused to eat and to get out of bed through out the entire day, which was an usual and a change in behavior for R3. Documentation denotes that R3's daughter visited at 2 p.m. and notified the nurse when R3 was moaning in pain and guarding the right hip area upon repositioning. At that time it was noted that R3 was unable to move his right hip, and that the right leg was rotated slightly outward. Review of the clinical record denotes no reassessment or reevaluation of R3's extremities for a 12 hour period by two shifts of nurses (E3 and E4), after the initial fall at 1:45 a.m. Further Documentation denotes that R3 was not reassessed until after 2:00 p.m. when R3's daughter notified the nurse. Documents denotes that the physician was called and R3 was sent to the hospital were he was diagnosed with [REDACTED]. Per interview Z1stated that she was notified that R3 had had a [MEDICAL CONDITION], but not informed that he had fallen. Z1 stated that when she arrive at the facility later that afternoon, R3 was in bed and was non-verbal which was unusual for him. Z1 further stated that R3 made no attempts to move, which was again unusual. Z1 state that R3 was in obvious pain and was guarding is right side. Z1 stated that when she looked at R3's leg/hip area she noticed that something was wrong. Z1 stated that R3 spent 9 days in the hospital, 4 days in intensive care and had a minor [MEDICAL CONDITION] after surgery for [REDACTED]. Per interview on 3/12/11, E1 (administrator) stated that it is the facilities policy to notify the physician family and administration immediately after falls and incidents with or without injury. E1 stated that after the investigation by the facility, E3 was terminated secondary to poor nursing judgement, and that E4 was suspended secondary to failure to properly assess R3's change in condition.

Based on record review and interview the facility failed to ensure the safety of one resident (R1) by using improper transfer technique for one out of 3 residents sampled for fall risk. This improper transfer resulted in R1 falling and sustaining a fracture of the right tibia and fibula. and a hospital admission. Findings include; The medical record of R1 documents a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's record contains an admission assessment dated [DATE] that states she had diminished breath sounds, right great toe amputation, that she had a gait disturbance and was chair bound/bedfast. R1's record contains a physical therapy evaluation dated 11/25/09 that states she need to use a sit to stand lifting device with the aid of two person assist to transfer from bed to chair or wheelchair. R1's record further contains nursing documentation dated 11/26/09 that states, "Resident was brought to the bathroom by CNA(certified nurse assistant), her knees buckled down. CNA unable to hold her up, so she just lowered her down to the floor." R1's record contains nursing documentation that x-rays of her hip, femur and tibia was taken on 11/27/09 at 2:00 AM and that she sustained a fracture to the tibia and fibula. R1's record contains nursing documentation that she was transported to the hospital on [DATE] and was admitted to the hospital with [REDACTED]. In an interview with E2, the CNA, she stated that she attempted to transfer R1 from the wheelchair to the bathroom toilet. E2 stated that she instructed R1 to hold onto the bathroom bar but that her knees buckled and she began falling and that E2 lowered her the rest of the way to the floor and called the nurse to get help. E2 stated that she did not know that she needed to use the sit to stand lift or that she needed a two person assistance. In an interview with E3, the physical therapist, he stated that in his evaluation he documented that R1 needed a sit to stand mechanical lift with a two person assist and that the staff was /should have been aware of this. In an interview with E5, the director of nursing, she stated that the E2 was counseled and re-instructed on safe transfers.