Every finding on record at Metropolis Rehab & HCC

Based on interview and record review the facility failed to ensure residents were free from misappropriation of resident funds for 1 (R6) of 3 residents reviewed for theft in a sample of 22. This failure resulted in R6 experiencing feelings of stress, vulnerability, worry, and disappointment/feeling taken advantage of. This Past Non-Compliance occurred between 6/21/26 and 6/26/26. The Findings Include: 1. R6's Resident Face Sheet documents that R6 was admitted to the facility on [DATE] with diagnosis that include cerebral infarction, chronic obstructive pulmonary disease, major depressive disorder, anxiety, and polyneuropathy. R6's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview Mental Status score of 15, indicating R6 is cognitively intact. R6's current Care Plan documents a Focus area of R6 requested a lock box for her personal belongings. She has requested that box and both keys be kept with Social Services Director (date initiated 6/25/25). The Goal lists R6's lock box will remain locked and in a safe location by next review date. (Initiated 06/25/2025, Revision on 04/27/2026, Target Date 09/28/2026). Corresponding Interventions include: Lock box #13 (date initiated 6/25/25); 6/21/26 R6 had card used by staff (date initiated 6/26/26); education provided on lockbox use (date initiated 6/26/26); investigation ongoing (date initiated 6/26/26) and trauma assessment completed no changes (date initiated 6/26/26). box will remain locked and in a safe place location by the next review date with a review date of 4/27/26. Interventions include, 6/21/26 R6 had a card used by staff, education provided on lockbox use, investigation on going and trauma assessment completed no changed all with a initiation date of 6/26/26. A facility Initial Investigation Report dated 6/21/26 documented on 6/21/26, (V32/Family Member) reported that CNA (Certified Nursing Assistant) had obtained a credit card in (R6's) name and was using it for both the resident and her. Under Immediate Action Taken by the Center, the report documents V20 (CNA) was suspended pending the outcome of the investigation, nurse completed head-to-toe assessment, physician was notified, family was aware, and local police and Ombudsman was notified. Under Disposition, it documents an investigation was initiated and final report will follow. The facility's final investigation report (also dated 6/21/26) documented that on 6/21/26, V32 (Family Member) reported V20 (CNA) had obtained a credit card in R6's name and was using the credit card for herself and R6. The employee was not currently working when the allegation was made but was contacted via phone to notify her of the investigation, obtain a statement, and notify suspension pending the outcome of the investigation but the employee did not answer the phone. (Local City) Police Department, MD (Medical Doctor), and the Ombudsman were notified. R6 and V32 were notified via phone of the investigation and next steps. V18 (Regional Director of Operations/RDO) received a phone call on 6/21/26 from V32 reporting that he was told V20 was in the facility. V3 (Previous Interim Administrator) came onsite, and the (Local City) Police Department was immediately notified and dispatched to the facility. Upon arrival, V20 had left the facility, and the (Local City) Police Department gathered the information related to the allegation. R6 and V32 confirmed that the card had been returned and was in their possession. Through review of medical benefits, it was identified that R6 had (name of medical plan) through 5/31/26, then changed medical plans to (name of plan), effective 6/1/26. (Name of medical plan) was contacted and it was identified that they provided R6 with a Benefits Prepaid Card with a balance of $260 showing on 6/1/26, per the statement. With R6's approval all personal information was updated and the card was cancelled, with a new card being issued in 7-10 days. Access was gained with R6's assistance and approval to the account to obtain a statement of the charges made to the account, which included the deposit of $260.00 on 6/1/26. Charges to a grocery store for $81.57 and $97.76 were shown on 6/11/26 and 6/15/26. The following charges were also noted to an online retail big-box store on 6/18/26: charge of $52.47, charge of $62.23, charge of $14.83, charge of $0.76; and on 6/19/26 a charge of $33.47. The final investigation report further documents V20 was interviewed via phone on 6/23/26 by V18 (RDO) and V10 (Regional Nurse) V20 reported that she had been making purchases with R6's card for the past month. V20 reported being in R6's room one evening when she noticed R6 had mail, V20 provided her with the envelopes, and R6 commented that oh now I have grocery money. V20 stated R6 gave her the green (prepaid benefits card) and verbally gave V20 a list of items she wanted purchased. V20 reported she used the card three times and then was questioned about the total of seven charges on the account activity. V20 explained that the multiple charges were a result of her using the (name of big box store) app and when she would add additional items to an existing order, then there would be an additional charge to the account. V20 denied making any charges at (name of grocery store). V20 admitted to some of the items that were purchased on the orders were her personal belongings mixed in R6's order. When questioned about providing receipts for the purchases, V20 declined providing receipts but stated that she would show R6 her (name of big box store) app with the purchases. V20 denied any knowledge of a white credit card that was in question. V20 denied any knowledge of the locations of R6's ID (identification) or SS (social security) card. V20 denied attempting to charge a hotel room on the card and stated that her friend paid for a hotel room for her. V20 denied attempting to purchase gasoline on the card and stated, you can't make purchases like that with this type of card. V20 reported that she previously purchased items for R6 out of her own pocket. V18 requested that V20 provide receipts for the purchases that had been made and V20 stated she didn't have receipts but would text screenshots of the purchases which were received. R6 was interviewed on 6/24/26 by V18 (RDO) in her room. R6 reported that V20 is the only person that has used her card and that she never gave her a list but instead V20 would just show up with stuff for R6. R6 stated that she had asked V20 to pick up Pepsi, Dr. Pepper, and Mt. Dew. R6 reported that she had asked V20 to help set up the card and R6 told V20 to keep the card to pick up items for her. R6 requested V20 return the card, and V20 told her that the card was at V20's house. R6 stated V20 asked if she could buy stuff with the card and R6 told her, Just a little bit. R6 denied V20 ever taking any cash from her. R6 denied having any other credit cards. The screenshots received from V20 on the purchases were reviewed with R6. A few items were verified by R6 but most of the purchases R6 declined receiving or having knowledge of the purchases. Local City Police Department came to the facility on 6/24/26 to review the documentation collected on the investigation and conducted a follow up interview for their records. Local City Police Department voiced that their investigation was ongoing and that they would be in contact with V20 to conduct an interview with V20, attempt to obtain video footage at (name of grocery store), where V20 denied making any purchases and further investigate the phone number that was originally provided to (name of medical plan) for the account.V43 (CNA) reported that she worked 6/20/26 - 6/21/26 on the 10p-6a shift. While assisting R6, she commented that a staff member had brought her soda but no food. V43 asked who the staff member was and R6 said that it was V20. R6 then reported that she had asked for the card back and V20 told her that it was in her car. V43 stated that she went to the nurse's station and told V20 that she needed to return the card to R6 and V20 responded that it was at her house. V13 (Licensed Practical Nurse/LPN) was present and stated that this needed to be reported and contacted the Administrator. V13 reported that V20 was at the desk when V43 walked up and asked V20 if she had brought R6's card back to her and V20 responded that she didn't have the card. Following additional discussion between the two, V20 walked away. V13 reported she immediately contacted the Administrator. Additional staff members were interviewed and denied any knowledge of the incident. Residents were interviewed and denied any issues with any items missing or knowledge of the incident. Based on the outcome of the investigation, the IDT (interdisciplinary team) has determined that V20 took R6's card and made purchases. The team determined that the allegations were substantiated. V20 has been removed from employment with the facility. All information has been provided to the local police. R6's care plan has been reviewed and updated with the following: Trauma assessment was completed and no changes were noted. R6 was provided with a locked box for securing personal items. R6 has been educated to keep personal items secured, contact family to pick up items to secure at home and to notify the Administrator immediately if items are missing or staff request to use items. The facility is initiating a Past Non-Compliance (PNC) related to the outcome of the investigation. The facility will continue to monitor for any signs or symptoms with R6 related to this incident. V32 agreed to notify the facility if any future issues are noted. On 7/21/26 at 10:16 AM, R6 stated that she had loaned her card out to V20 (Certified Nurse Assistant/CNA) to purchase her some snacks and drinks, and V20 never returned the card. R6 stated when she mentioned it to V32 (Family Member), he investigated it and realized it was being used at several locations and V20 was likely using it for herself because R6 was not getting items delivered or given to her from V20. R6 further stated she repeatedly asked V20 for the card to be returned only to be given excuses from V20, like she left it at home and would bring it back next time. R6 stated at this time that she had feeling of disappointment and sadness once she realized that V20 had taken advantage of her card. R6 thought she could trust her to get her grocery items and not steal her money. On 7/22/26 at 1:00 PM, V1 (Administrator) stated that the investigation of misappropriation of resident funds started immediately after it was reported on 6/21/26. All appropriate parties were notified and V20 was suspended pending investigation and V20 was terminated due to the outcome of the investigation. Surveyor attempted to contact V20 (CNA) for an interview on the following dates and times with no answer. (insert dates & times of calls) Messages were left with no return phone calls. On 7/30/26, at 2:30 PM, V43 (CNA) confirmed R6 had reported to her that V20 had taken her debit card after she had given it to her to purchase snacks and drinks. V43 stated R6 reported that despite asking for the debit card back several times, it was never returned. V43 further stated R6 was upset while discussing the missing debit card, R6 told her that she was angry with herself for trusting V20 and ended up getting taken advantage of. The facility Abuse, Prevention and Prohibition Policy dated November 2025 documents Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility prohibits mistreatment, neglect, or abuse of residents. Prior to the survey date, the facility implemented the following actions to correct the deficient practice:1. A Quality Assurance and Performance Improvement meeting was held on 6/25/26. In attendance - V2 (Payroll Clerk), V3 (Previous Interim Administrator), V10 (Regional Nurse), V15 (Housekeeping Manager), V18 (Regional Director of Operations/RDO), V41 (Admissions Director), and V42 (Activities Director).2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents have the potential to be affected that had a credit/bank card in their possession. No additional concerns were identified.3. Measures put into place/systematic changes to ensure the deficient practice does not recur: V3 provided in-service to all staff on the abuse policy and procedure. Completed on 6/26/26. V20 was terminated from employment on 6/26/26.4. Plan to monitor performance to ensure solutions are sustained: Audits on staff understanding of abuse prevention policy, type of abuse and reporting. Resident cash or card on hand, lock box availability, and resident concerns with lost items for 60 days.

Based on interview and record review, the facility failed to safely transport a resident in a wheelchair for 1 (R12) of 3 residents reviewed for accidents in the sample of 22. This failure resulted in R12 falling out of the wheelchair and acquiring a laceration to her forehead resulting in 2 sutures being placed.This past noncompliance occurred between 5/31/2025 and 6/9/2025.Findings included:R12's admission Record documented an admission date of 9/9/2024 with diagnoses including Alzheimer's disease, unspecified, dysphagia, oropharyngeal phase, diseases of lips, muscle weakness, unspecified osteoarthritis, unspecified site, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits.R12's Minimum Data Set (MDS) dated [DATE] documented under C0100: Should Brief Interview for Mental Status (BIMS) be conducted with 0 indicating R12 is never/rarely understood. This same document under Section GG- Functional Abilities documented R12 has dependent on all care and mobility. Dependent meaning - helper does all of the effort. Resident does none of the effort to complete the activity Or, the assistance of 2 or more helpers is required for the resident to complete the activity. This section also documents that R12 uses a manual wheelchair for mobility and was dependent for wheelchair mobility.R12's most recent Care Plan documents a Focus area of R12 being at risk for falls with an initiation date of 9/10/24. Documented interventions include: Ensure foot pedals are on wheelchair when propelling resident with an initiation date of 5/31/25. The same Care Plan also documents a Focus area of R12 has limited physical mobility with an initiation date of 9/10/24 and includes the intervention of R12 uses a wheelchair for locomotion with an initiation date of 9/10/24.On 7/23/2026 at 1:02 PM, V38 (License Practical Nurse/LPN) stated she had been working last year on 5/31/2025 when R12 had fallen from her wheelchair. V38 stated R12 had been assisted back to her room by V58 (CNA) while in her wheelchair. V38 stated V58 had removed R12's footrest while in the dining room and did not apply the footrest back prior to assisting R12 to her room. V38 stated R12 did fall forward out of her wheelchair and received a laceration to her forehead. V38 stated R12 was sent to the local emergency room where she received sutures.On 8/5/2026 at 9:31 AM, V39 (family member) stated he was notified on 5/31/2025 by V38 (LPN) that V58 (Certified Nurse Assistant/CNA) had been assisting R12 in her wheelchair from the dining room without her foot pedals in place. V39 stated R12 put her feet down causing her to fall face forward in the floor causing a laceration to her forehead. V39 stated R12 had been sent to the local emergency room where she received a couple of sutures. V39 stated V58 did come to him to apologize and asked for forgiveness.On 8/5/2026 at 11:38 AM, V48 (Director of Rehabilitation/DOR) stated R12 had been assisted in her wheelchair without her foot pedals in place on 5/31/2025 by V58 (CNA). V48 stated R12 did place her feet on the ground causing her to fall forward out of the wheelchair into the floor where she received a laceration. V48 stated, in her opinion, if a resident cannot hold their feet up while being assisted then foot pedals should be in place. V48 stated V58 should have placed R12's foot pedals on her wheelchair prior to assisting her down the hallway.On 8/5/2026 at 12:35 PM, V22 (Previous Director of Nursing/DON) stated R12 did have a fall from her wheelchair on 5/31/2025. V22 stated R12 had been assisted in her wheelchair without her foot pedals in place by V58 (CNA) when R12 put her feet down causing her to fall forward, landing in the floor, and received a laceration to her forehead. V22 stated R12 had been sent to the local hospital where she received some sutures to the laceration then returned to the facility.R12's Progress Note dated 5/31/2025 at 1:05 PM by V38 (LPN) documented this nurse was called to the hallway by V58 (CNA) related to a fall from wheelchair (w/c). R12 noted to be lying on left side, rolled slightly onto her face, bleeding noted to left forehead area. Pressure dressing applied to head injury, when area assessed there is bruising to left forehead with a pinhole opening with bleeding. Resident denies pain, says she's okay when asked. Area to head assessed, pressure dressing applied, range of motion within normal limits for resident.EMS (Emergency Medical Service) called for transport to local emergency room for evaluation.R12's Progress Note dated 5/31/2025 at 7:15 PM by V57 (Registered Nurse) documented R12 arrived back at facility from local emergency room. Hematoma/bruise to left forehead sealed with 2 sutures hemostatic pressure dressing to stay in place for 3 days . new orders periorbital hematomas to bilateral eyes black to purple in color. Bruising to left hand purple in color.R12's local emergency room Note dated 5/31/2025 under Patient Visit Information: closed head injury, falls, and traumatic hematoma of forehead. This same document under Activity Restrictions or Additional Instructions: Two sutures were placed and need to be removed in 5-6 days.The facility's Final Investigation dated 5/31/2025 documented R12 fell at 1:30 PM. Earlier in the shift V58 (CNA) removed R12's footrest from her wheelchair. after lunch as V58 was assisting R12 from the dining room area to her room, R12 put her feet down on the ground and fell forward out of her wheelchair. R12 was assessed and found to have a laceration to the left side of her forehead and was take to the local emergency room where she received two sutures.On 8/5/26 at 10:24 AM and 12:34 PM attempts were made to contact V58 (CNA) by phone without success.The facility policy titled Skilled Fall Policy (dated 5/2025) under the section Policy documents The community shall ensure that the Fall Program is maintained to reduce the occurrence of falls, reduce risk of injury, and promote independence and safety. Each resident residing at this facility will be provided services and care that ensures that the resident's environment remains as free from accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents.Prior to the survey date, the facility took the following actions to correct the non-compliance:All C.N.A. staff were educated by the V22 (Previous Director of Nursing /DON)/Regional Nurse Consultant (RNC) that all residents that require a wheelchair should have wheelchair legs attached to the wheelchair while being pushed around the facility. All full and part time nursing staff were educated by the DON/RNC on the fall program and the prevention of falls prior to working their next shift. All PRN (as needed) and Agency staff will be educated prior to working a shift at our facility. All CNA staff were educated to ensure that all residents have leg rest when being pushed around in their wheelchairs. An Audit of all Fall Risk Assessments were completed to ensure 100% compliance. Review of the Fall Risk Assessment Audit was completed to ensure the residents that were a high risk had the appropriate Leaf. Completed on 6/9/25.All residents have the potential to be affected by the alleged deficient practice.An Audit of all Fall Risk Assessments and Wheelchair footrest were completed to ensure 100% compliance. Completed 6/9/25.QAPI (Quality Assurance and Performance Improvement) meeting with the Medical Director was held on 6/9/25.DON or Designee will do random checks 3 times per week for 2 weeks to ensure leg rest was attached prior to being pushed.DON or Designee will do random checks of fall interventions to ensure they are in place and being used effectively.DON or Designee will review each fall for 2 weeks to ensure the program was completed successfully and an intervention is put into place to prevent future falls.

Based on interview and record review the facility failed to notify the physician and resident representative of a change in condition for 1 (R12) of 3 residents reviewed for change in condition in a sample of 22.Findings included:R12's admission Record documented an admission date of 9/9/2024 with diagnoses including Alzheimer's disease, unspecified, dysphagia, oropharyngeal phase, diseases of lips, muscle weakness, unspecified osteoarthritis, unspecified site, personal history of Transient Ischemic Attack (TIA), and cerebral infarction without residual deficits. The same admission Record documents that V39 (Family Member) is the responsible party for R12. R12's Minimum Data Set (MDS) dated [DATE] documented under C0100: Should Brief Interview for Mental Status (BIMS) be conducted with 0 indicating R12 is never/rarely understood. This same document under Section GG- Functional Abilities documented R12 is dependent on all care and mobility. Dependent meaning - helper does all of the effort. Resident does none of the effort to complete the activity Or, the assistance of 2 or more helpers is required for the resident to complete the activity.On 7/22/2026 at 9:30 AM, V30 (Licensed Practical Nurse/LPN) stated she was the nurse working on 7/20/2026 when R12 had complained of pain to her left leg. V30 stated she came into work around noon on 7/20/2026 and was notified by a V38 (LPN) that R12 had some face grimacing and said ouch when moving her left leg. V30 stated she was told by V27 (CNA) that R12 had been making facial grimacing the day prior and notified V17 (LPN). V30 stated there had been no documentation in R12's EHR of this notification.On 7/22/2026 at 9:49 AM, V27 (CNA) stated last Wednesday (7/15/2026) she and V37 had been working the 300 hall. V27 stated when she and V37 went into R12's room she had already been dressed without shoes on and lying in bed. V27 stated she went to put on R12's left shoe and R12 said ouch! V27 stated R12 did have some facial grimacing at that time as well. V27 stated they did transfer R12 by mechanical lift to her wheelchair. V27 stated, once R12 was in her chair she noticed R12 could not straighten out her left leg or touch the pedal with her foot. V27 stated she assisted R12 out to the nurse's station and notified V17 (LPN) that R12 was having some pain and reported to her about R12's left leg. V27 stated V17 told her that R12 had pain medication due so she would give her the medication. V27 stated she does not know what V17 did after that. V27 (CNA) stated she did work on 7/19/2026 with V37 (CNA) on the 300 hall. V27 stated she reported multiple times to V17 that R12 had some facial grimacing and appeared to be in pain when her left leg was touched. V27 stated she did not report this information to any other nurse or V2 (Director of Nursing/DON). V27 stated nothing was done for R12 until V39 (Family) was here on 7/20/2026. On 7/22/2026 at 1:20 PM, V37 stated she did work last Wednesday (7/15/26) with V27 on the 300 hall. V37 stated when she and V27 went into R12's room she had already been dressed without shoes on and lying in bed. V37 stated she went to put on R12's left shoe and R12 said ouch. V37 stated R12 did have some facial grimacing at that time as well. V37 stated they did transfer R12 by mechanical lift to her wheelchair. V37 stated once R12 was in her chair, V27 noticed R12 could not straighten out her left leg or touch the pedal with her foot. V37 stated V27 assisted R12 out to the nurse's station and notified V17 (LPN) that R12 was having some pain and reported to her about R12's left leg. V37 stated V17 told her that R12 had pain medication due so she would give her the medication. V37 stated she does not know what V17 did after that V37(CNA) stated she did work this weekend with V27 and reported multiple times to V17 that R12 had some facial grimacing and appeared to be in pain when her left leg was touched. V37 stated she did not report this information to any other nurse or V2 (DON). V37 stated R12 did get transferred to the hospital on 7/20/2026 with a fracture on her left leg.On 7/23/2026 at 8:51 AM, V17 (LPN) stated she did work this past weekend (7/18/2026-7/19/2026) with V27 and V37 on the 300 hall. V17 stated the weekend was horribly busy. V17 stated, V27 and V37 both came to report the morning of 7/19/26, R12 had facial grimacing and appeared to have some pain in her left leg. V17 stated, she did tell V27 and V37 that R12 had some acetaminophen ordered that she would give her during her morning medication administration. V17 stated, she is not sure what time she assessed R12, but she did not think R12 grimaced enough to show she was in pain. V17 stated there is no documentation of her assessment, change in status, or acetaminophen being given.On 7/23/2026 at 2:55 PM, V1 (Administrator) stated V17 had been notified by V27 and V37 on 7/19/2026 that R12 had expressed pain when her left leg was lifted and not able to straighten it. V1 stated V17 did not document an assessment, change of status, medication administration, etc. for R12 on 7/19/2026. V1 stated his expectations are all staff follow professional standards of practice, follow policy and procedure of change in status, and physician orders.On 8/5/2026 at 9:31 AM, V39 (Family) stated he came to visit R12 on 7/20/2026. V39 stated he was in the dining room with R12 during lunch time and when he went to put her left foot back on her foot pedal R12 had severe pain with shaking all over and could not place her foot on the pedal. V39 stated he had been told by V27 (CNA) and V37 (CNA) on 7/20/2026 that they did report to V17 (LPN) on 7/15/2026 that R12 showed facial grimacing and said ouch when they attempted to put her shoes on her that morning and again on 7/19/2026 R12 was continuing to have the same facial grimacing. V39 stated there was no documentation in R12's electronic health record when he asked about this.R12's Progress Note dated 7/20/2026 at 2:07 PM by V30 (LPN) documented R12 is experiencing a change in condition.The change in condition the resident is currently experiencing is Pain in the LLE (left lower extremity) with movement. V35 (Physician) and I did an examination of the LLE, with her husband at bedside. No apparent signs of a blood clot such as warmth, redness, or streaks but R12 does grimace when lifting up the left leg.R12's Emergency Department Encounter note dated 7/20/2026 at 8:40 PM documented under history of present illness.resident is bedbound and found to have a left femur fracture in the nursing home today. This same document under radiology documented imaging of femur 2 View Left with result date: 7/20/2026. Examination: imaging femur 2 view left- 7/20/2026 9:24 PM. History: Fracture. Findings: 2 view exam of the left femur demonstrates a transverse fracture involving the distal femoral shaft above the condyles and just above the patient's distal femoral prosthesis for her knee arthroplasty. There are displacement and angulation of the fracture with anterior angulation at the fracture site. No additional fractures are present. Impression: Displaced and angulated fracture of the distal femoral shaft just above the prosthesis. The patient has undergone previous total knee arthroplasty.R12's Medication Administration Record dated July 1st, 20206-July 31st, 2026, documented an order for Acetaminophen Oral Tablet Give 325 mg by mouth every 8 hours as needed for mild pain/fever with a start date of 07/20/2025 with no documentation of R12 receiving pain medication on 7/19/2026.There was no documentation provided by facility during this investigation of V17 (LPN) completing a change in status assessment, contacting family or medical provider, or pain medication given to R12 on 7/19/2026 when V17 became aware of R12's complaints of pain.The facility's Significant Condition Change and Notification (12/2024) documented under Purpose: To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below:.abnormal, unusual or new complaints of pain. This same document under Procedure: When any of the above situations exists, the licensed nurse will contact the resident's representative, and their medical practitioner. Prior to calling the medical practitioner the nurse will complete the Situation, Background, Assessment, and Recommendation (SBAR) assessment.

Based on interview and record review the facility failed to follow physician orders by ensuring tubular support bandages were applied and removed as ordered for 1 (R12) of 3 residents reviewed for quality of care in a sample of 22.Findings include:R12's admission Record documented an admission date of 9/9/2024 with diagnoses including Alzheimer's disease, unspecified, dysphagia, oropharyngeal phase, diseases of lips, muscle weakness, unspecified osteoarthritis, unspecified site, personal history of Transient Ischemic Attack (TIA), and cerebral infarction without residual deficits.R12's Minimum Data Set (MDS) dated [DATE] documented under C0100: Should Brief Interview for Mental Status (BIMS) be conducted with 0 indicating R12 is never/rarely understood. This same document under Section GG- Functional Abilities documented R12 is dependent on all care and mobility. Dependent meaning - helper does all of the effort. Resident does none of the effort to complete the activity Or, the assistance of 2 or more helpers is required for the resident to complete the activity.R12's Physician Order Summary Report with a print date of 8/5/26 documents the following active order with an order date of 4/20/26: Bilateral lower legs: Apply Tubigrip size E to bilateral lower legs daily, apply in AM, remove at bedtime.R12's Progress Note dated 3/3/2026 at 1:49 PM by V38 (Licensed Practical Nurse/LPN) documented 2 (Certified Nurse Assistant/CNA's) had notified her this morning that R12's tubular support bandages had rolled down at an angle to bilateral lower legs and when she straightened them out, she noticed redness where the socks were rolled. When the same CNA's laid R12 down after lunch, R12 had reddened area to her let upper/inner calf measuring 3 inches and 1 inch area to her right upper/inner calf.On 8/5/2026 at 9:31 AM, V39 (Family) stated R12 had been wearing tubular compression stockings that are cut to length. V39 stated R12 was supposed to wear the stockings when she was up out of bed and to be taken off when in bed at night. V39 stated he had been notified on 3/3/2025 by V38 (LPN) R12's compression stockings were rolled down from the top below the knee. V39 stated, V38 explained there had been red marks noted to both calves on R12 where the compression stockings had been rolled down and tight. V39 stated it was his understanding that the facility's investigation showed R12 had worn her compression stockings all night and were not removed.On 8/5/2026 at 10:52 AM, V38 (LPN) stated V27 (CNA) and V37 (CNA) had come to her on 3/3/2026 with concerns of R12's compression stockings and redness. V38 stated she did evaluate R12 at that time and found her compression stocking not in proper placement and adjusted the compression stockings. V38 stated the compression stockings had rolled down to her calves at an angle and above her toes. V38 stated the rolling of the stocking caused them to be tighter around the calves causing redness. V38 stated she completed a skin assessment, and an investigation was started by V22 (Previous DON). V38 stated the investigation findings had been R12's compression stocking had been left on overnight.On 8/5/2026 at 11:05 AM, V27 (CNA) stated she did work the morning of 3/3/2026 with V37 (CNA). V27 stated when she and V37 went to get R12 up for the day she noticed her compression stockings were rolled down from the top and she had some redness to both calve areas. V27 stated she and V37 notified V38 and she came to assess R12 and fixed her compression stockings. V27 stated after lunch when they were lying R12 down in bed, she noticed the red areas seemed bigger and she notified V38. V27 stated there was an investigation completed by V22 and the findings were that R12's stockings had been left on overnight.On 8/5/2026 at 12:35 PM, V22 (Previous DON) stated R12 did have some red areas noted to both calve areas on 3/3/2026. V22 stated she completed an investigation to determine what caused the areas. V22 stated her findings where R12's compression stockings had not been removed prior to bed.R12's Progress Note dated 3/3/2026 at 1:52 PM by V38 documented Skin Issue: 1: New skin Issue. Location: Front left lateral lower leg. Issue type: Other skin issue. Other skin issue description: redness Wound acquired in-house. Exact date: 03/03/2026. Skin Issue: 2: New skin Issue. Location: Front right lateral lower leg. Issue type: Other skin issue. Other skin issue description: redness Progress: New: new wound. Wound acquired in-house. Exact date: 03/03/2026.R12's Progress Note dated 3/4/2026 at 10:57 AM by V22 (Previous Director of Nursing/DON) documented upon conclusion of investigation it was determined that the tubular support bandages had been left on overnight.R12's Treatment Administration Record dated March 1st, 2026, through March 31st, 2026, documented an order for double layer tubular compression stocking from toe to just above knee on in am and off at bedtime every day and night shift for edema. On in day . night shift removes at night with a start date of 07/20/2025.

Based on interview and record review, the facility failed to ensure medications were available and administered as ordered by the provider for 1 (R22) of 4 residents reviewed for pharmacy services in a sample of 22.Findings include: R22's admission Record documented an initial admission date of 12/09/2021with diagnoses including Chronic Obstructive Pulmonary Disease, unspecified dementia, unspecified severity, with agitation, pain in left ankle and joints of left foot, muscle weakness (generalized) and dysphagia, oral phase.R22's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 03 meaning R22 has severe cognitive impairment.R22's Care Plan documents a Focus area of R22 is at risk for pain related to osteoarthritis with and initiation date of 12/3/25. Documented interventions include: Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.R22's Order Summary Report documented an order for Tramadol HCL tablet 50 Milligrams (MG) by mouth every 8 hours for moderate to serve pain with a start date of 7/21/2026.On 7/22/2026 at 2:05 PM, V30 (Licensed Practical Nurse/LPN) stated R22's Tramadol 50 MG every 8 hours for pain had not come in at this time. V30 stated she contacted the facility pharmacy and found out that V34's (Nurse Practitioner/NP) Tramadol prescription had not gone through to the pharmacy on 7/21/2026. V30 stated R22's prescription was refaxed to the pharmacy with her medication coming in this evening. V30 stated Tramadol is available in the emergency kit, but she is not aware how to access the emergency kit at this time.On 7/22/2026 at 2:10 PM, V21 (Director of Nursing/DON) stated she had been notified this morning by V30 that R22 had not received her Tramadol 50 MG every 8hours for moderate to severe pain. V21 stated she contacted the facility pharmacy to follow up on R22's medication. V21 stated she was told by the pharmacy that V34's order was not received by the pharmacy. V21 stated the pharmacy explained to her that with controlled medications, the provider will have to fax over a prescription for it to be accepted. V21 stated she was not aware of this requirement either but did notify V34 of the correct practice.On 7/22/2026 at 1:29 PM, V1 (Administrator) stated his expectations are resident's medications are received by the facility and administered in a timely manner.On 7/23/2026 at 9:25 AM, V34 (NP) stated during her visit with R22 on 7/21/2026 at 8:00 AM, R22 complained of moderate to severe pain all over and to the left ankle that acetaminophen was not relieving. V34 stated she ordered Tramadol 50 MG by mouth every 8 hours for moderate to severe pain. V34 stated she had been contacted on 7/22/2026 by V21 (DON) that my order for Tramadol 50 MG did not get sent to the pharmacy on the previous day. V34 stated Tramadol is a medication that would be accessible in an emergency kit. V34 stated she is new to the facility and their system. V34 stated her expectations are the facility have resident medications available and administered in a timely manner.R22's Medication Administration Record dated 7/1/2026 to 7/31/2026 documented Tramadol HCL tablet 50 Milligrams (MG) by mouth every 8 hours for moderate to serve pain with a start date of 7/21/2026 and first dose received on 7/22/2026 at 3:00 PM and administered by V30 (LPN).

A. Based on observation, interview, and record review the facility failed to ensure residents were free from neglect for 1 (R1) of 5 residents reviewed for abuse in a sample of 15. This failure resulted in a protracted period of time with unmanaged pain with R1 calling 911 a total of 5 times requesting an ambulance due to new onset severe pain to R1's right hip that had a nondisplaced right femur fracture found 6 days prior. The calls took place over a period of 2 hours and 3 minutes, during this time the nurse caring for R1 was called by the police dispatcher and said R1 was confused, had an affinity for pain medication, and there was no reason for R1 to be transferred to the hospital. The facility then failed to immediately administer Cardio-Pulmonary Resuscitation (CPR) and administer Narcan when R1 was found unresponsive after R1 returned from the hospital where R1 received injectable Dilaudid potentially contributing to R1 expiring. The Immediate Jeopardy began on [DATE] at approximately 8:41 AM when R1 called 911 requesting an ambulance to transport him to the hospital due to severe new onset hip pain. V45 (Administrator), V42 (Regional Director of Operations), V18 (Regional Clinical Director), and V46 (Regional [NAME] President of Operations) were notified of the Immediate Jeopardy on [DATE] at 2:53 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.B. Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for 1 (R4) of 5 residents reviewed for abuse in a sample of 15. Findings include:A.R1's admission Record documented an admission date of [DATE] with diagnoses including fracture of unspecified part of neck to right femur, periprosthetic fracture around internal prosthetic right hip joint, pain in right hip, chronic pain syndrome, and reduced mobility. According to R1's [DATE] ambulance report R1 expired in the Emergency Department of the local hospital on [DATE] (3 days after admission).R1's Minimum Data Set, dated [DATE] documents a Brief Interview on Mental Status (BIMS) assessment score of 0, indicating severe cognitive impairment.R1's Care Plan Report documented a [DATE] focus of the resident has pain with [DATE] interventions of monitor/record/report to Nurse resident complaints of pain or requests for pain treatment.R1 Physician Order Summary Report documents R1 had an order for Acetaminophen Tablet 325 MG (milligrams) give 650 mg by mouth every six hours as needed for pain or elevated temperature not to exceed 40000 mg per day. Start date [DATE]. This report also includes an order for Hydrocodone-Acetaminophen tablet 7.5-325MG give 1 tablet by mouth every 4 ours as needed for pain for 3 days. Do not exceed 3 GM (grams) acetaminophen from all sources in 24 hours. Start date [DATE] and end date [DATE].R1's hospital record documented an admission date of [DATE] with a discharge date of [DATE] documented in part . Patient's Chief Complaint: Transferred to our hospital for right femoral fracture. being admitted to our hospital for the management of right femoral fracture. As reported, patient was moving a plant and then he lost his balance and fell landing on his right side. Patient initially presented to (another hospital), with initial workup done in the ED showing a right femoral periprostatic fracture. R1's Progress Notes dated [DATE] documented in part, at 00:10 (12:10AM) resident arrived to facility via stretcher with Regional Ambulance service from an out of state hospital. He is admitted to facility for rehab therapy for a right femoral fracture after a fall at home. He is alert and oriented x 4. Pleasant and cooperative with staff.On [DATE] at 8:33 PM, V44 (Licensed Practical Nurse/ LPN) said she was the nurse caring for R1 on the night of [DATE]. V44 said R1 was alert and oriented to person, place, and time. V44 said R1 was very upset and aggressive when asking for pain medication due to hip pain. V44 said after she administered R1's pain medication R1 went back to his room and went to sleep. V44 said R1 had not displayed any aggressive behaviors relating to pain prior to this incident to her knowledge. V44 said she did not think R1 was exhibiting narcotic pain medication seeking behaviours. V44 said R1 had not requested to be sent to the hospital during her shift.On [DATE] at 10:03 AM, V53 (Certified Nursing Assistant/ CNA) said she was the CNA caring for R1 on the night shift on [DATE]. V53 said R1 did not seem confused. V53 said that was the first time V53 had met R1 and was not sure how cognitive R1 was at baseline but during her shift R1 appeared to be alert and oriented.On [DATE] at 1:28 PM, V8 (CNA) said she was the CNA caring for R1 on [DATE] during dayshift. V8 said she was not sure of R1's cognitive status at baseline because that was the first time she met R1 but R1 did not seem confused. V8 said R1 told her he was in excruciating pain because the night before he had hit his leg on something and had an increase in pain. V8 said R1 requested pain medication several times and was requesting to be sent to the hospital. V8 said she reported to V5 (Licensed Practical Nurse/ LPN) was requesting pain medication due to an increase in pain and requesting to be sent to the hospital.A recording from a 911 call from R1 on [DATE] at 8:41 AM was reviewed. In the call R1 requested an ambulance to transport him to the hospital due to tremendous pain to his right hip and that R1 was in great pain.A recording from a 911 call from R1 on [DATE] at 9:06 AM was reviewed. In the call R1 requested an ambulance to transport him to the hospital because he was in tremendous pain and that R1 just needed some help.A recording from V65 (Police Dispatcher) to V5 (Licensed Practical Nurse/ LPN), the nurse caring for R1, on [DATE] at 9:08 AM was reviewed. In the call the dispatcher told V5 R1 had called 911 twice requesting an ambulance due to pain. V5 told the dispatcher, (R1) is just going to keep calling you. I don't know what to do. And We have an affinity for pain medication. V5 explained to the dispatcher R1's pain medication was as needed not scheduled and (R1) doesn't get it a quickly as (R1) would like to. V5 then stated, In my professional opinion, (R1) does not need to be seen by an ER (Emergency Room) like he doesn't need emergency care. The dispatcher then asked, (R1) just wants more pain medication? and V5 responded, Yes. V5 then said (R1's) not all the way there, indicating R1 was confused. V5 then went on to say, I don't want to say disregard this but this is kind of normal for (R1).A recording from a 911 call from R1 on [DATE] at 9:32AM was reviewed. In the call R1 requested an ambulance to transport him to the hospital. In the call R1 stated, over the night I have damaged my hip again. The dispatcher said she had spoken with V5 about R1's pain medication and it was not time for R1 to receive pain medication. The dispatcher then said the nurse has to call them before an ambulance could be sent.A recording from a 911 call from R1 on [DATE] at 10:41AM was reviewed. In the call R1 requested an ambulance to transport him to the hospital. R1 said he needed to be transferred to the emergency room to get an X-Ray. The dispatcher then said yes, but your nurse has to order that. We can't just send something over there without the nurse telling us. So, you have to talk to the nurse first. R1 then asked the dispatcher if he called the hospital R1 had been admitted to the facility from and asked them to send an ambulance would they send one up here? and the dispatcher said they would not. Not without your nurse ordering it. R1 responded, what if I just tell them anything. I just need an ambulance. The dispatcher responded Well, you're going to have to tell them you are in a nursing home and what room you're in and they're going to call your nurse like I did. R1 then asks the dispatcher if she had found out what room R1 was in and the dispatcher said she did not. R1 then tells the dispatcher, the pain pills are having a little effect and I have been panting for 2 hours.A recording from a 911 call from R1 on [DATE] at 10:44AM was reviewed. In the call R1 asked the dispatcher what they are going to do. R1 said someone said to just keep calling 911 and the dispatcher responds Well, if you keep calling 911 you are going to get a fine for it. R1 then says No, I don't want to do that. The dispatcher said Well, this is like abuse of 911 because you have to talk to your nurse. This is probably your sixth or seventh time calling. R1 then says, I know. I know. I know. And I hate this but I'm going to do what I need to do to not get in trouble. The dispatcher then says, Right, yeah, you have to talk to your nurse and tell the nurse to call us if they want to send an ambulance. I can't send one without them saying so.A recording from a 911 call from V5 on [DATE] at 10:59 AM was reviewed. In the call V5 stated, I have a resident that is adamant about being sent to the ER. He swears his hip is broken. He has called several times and now he has called the police. The dispatcher (V65) said I think I know who you are talking about. I think he has called here like 7 times. V5 then says, I just got off the phone with the police and they said well can't you just take his phone and I was like no. The dispatcher (V65) then tells V5 an ambulance will be sent to the facility to transport R1 to the hospital. R1's [DATE] at 11:30 AM Progress Note documented in part . C/O (Complains Of) severe pain in right hip. Pain medicine administered at 5am and 9am. Stated pain medicine did not help. Pt (patient) behavior demanding, belligerent. Insisting to go to (Name of Out of State Hospital) ED regarding hip pain. Resident would not comply with alternative treatment options. Multiple calls made to police department and 911. Called police department 9 times. Spoke with (V61 R1's Significant Other) about what was happening. Explained that resident had received pain medication, and that patient was being belligerent, calling the authorities multiple times, demanding to go (Name of Local Hospital) swing bed or (Name of Out of State Hospital) ED. (V61) communicated understanding of the issue and stated she would contact residents next of kin. Spoke with (V62 Police Officer) regarding the multiple calls made to the police dept. (Local Police Department) (V62) stated that understanding of abuse of emergency line needs to be communicated to resident. (V62) said that he would contact (V61) to also update her on what was going on. Telephone number provided by nurse. Abuse Coordinator (V1 Former Administrator) contacted by nurse to explain what was happening. Explained that resident was being sent to the ED due to being belligerent toward staff, and demanding to be taken to (Name of Out of State Hospital) ER or (Name of Local Hospital) swing bed. Resident was taken to (Name of Hospital) ER by EMS (Emergency Medical Services) staff at 11:25 AM.R1's [DATE] Emergency Department Encounter documented in part . presents to the emergency department for persistent right hip pain related to a known right hip fracture sustained after a fall. Initial hip fx (fracture) fixed at (Name of Hospital) in [DATE]. Treatment non op (non-operational) when admitted [DATE]. Last night he was in a wheelchair and bumped into a door and a few other walls, worsening his hip pain. Pain remains localized to the lateral aspect of the right hip. Home pain control has consisted of acetaminophen. He requests additional pain medication today. Mental status: he is alert and oriented to person, place, and time.12:36 PM hydromorphone (Dilaudid) injection 1 mg intramuscular.A message was left requesting a call back from V66 (emergency room Physician) 3 times with no returned contact.R1's [DATE]-[DATE] Medication Administration Record (MAR) documented an order for Hydrocodone-Acetaminophen Tablet 7.5-325 MG Give 1 tablet by mouth every 4 hours as needed for pain for 3 Days, Do not exceed 3 GM acetaminophen from all sources in 24 hours with a start date of [DATE]. The following doses where given with the correlating pain scale assessments: [DATE] at 10:25 PM pain scale 5, [DATE] at 5:19 AM pain scale 5, 9:21 AM pain scale 6, 8:25 PM pain scale 3, [DATE] at 11:59 PM pain scale 7, [DATE] at 4:51 AM pain scale 6. R1's MAR documents an order for Acetaminophen Tablet 325 MG (milligrams) give 650 mg by mouth every six hours as needed for pain or elevated temperature not to exceed 40000 mg per day. Start date [DATE]. R1 received 1 dose on [DATE] at 8:20 AM pain scale 8. According the pain scale chart listed on R1's Physician Order Summary: 0-1 No Pain; 2-3 Mild Pain; 4-5 Moderate Pain; 6-7 Severe Pain; 8-9 Very Severe Pain; 10 Worst Possible Pain.R1's [DATE] Hydrocodone-Acetaminophen 7.5-325 mg Controlled Substances Proof of Use form documented the medication was given but was not documented on the MAR with no accompanying pain scale assessment on the following dates: [DATE] at 2:54 PM, [DATE] at 8:00 AM, 3:00 PM, and 9:00 PM, [DATE] at 9:45 AM.R1's [DATE] at 5:31 PM Progress Note documented in part . Returned from ED (Emergency Department) at 1345 (1:45 PM). Received Dilaudid pain medication at 12:36 (PM). No current c/o (complaint of) pain. In bed resting with eyes closed.On [DATE] at 2:32 PM, V5 (LPN) said she was the nurse caring for R1 on [DATE]. V5 stated everything was normal, R1 had received pain medication around 5:00 AM then V5 administered pain medication to R1 around 9:00 AM. V5 said R1 requested to be sent to a local hospital for swing bed services and V5 told R1 that a referral would have to be sent to the local hospital prior to R1 being sent. V5 said R1 then requested to be sent to the hospital R1 had been at prior to being admitted . V5 said she told R1 there wasn't much they could do for him at the ER. V5 said, R1 kept calling 911 so I finally sent him out to the hospital R1 was at prior to his admission to the facility. V5 said, R1 was just a crotchety old man who would scream and yell for his pain meds. V5 said R1 told V5 his hip was hurting and V5 said she told R1, I knew it was hurting but it wasn't broken it was just fractured, and I finally just said OK I'll send you out. When V5 was asked why she did not contact a physician, V5 stated she called the on call nurse (V63/LPN/Wound Nurse) and the administrator to let them know what was going on and did not call a physician. V5 said when R1 returned to the facility from the hospital, where R1 had received a dose of Dilaudid (Hydromorphone), R1 was still screaming and disturbing other residents. V5 said she did not monitor R1 any closer after he returned from the hospital because he wasn't any different and there was no need to. V5 said later during her shift V8 (CNA) came out of R1's room and asked if R1 was a full code and said she did not think R1 was breathing. V5 said she went to R1's room and found R1 to be unresponsive. V5 said R1 looked normal, (R1) was sitting in his wheelchair slack [NAME] with his head back. V5 said she went back to the nurse's station and knocked on the glass doors to get V4 from outside and told V4 to go start CPR on R1 so she could call EMS (Emergency Medical Services). V5 said she then called 911 and she believes EMS arrived 5 or 6 minutes later. V5 said EMS gave R1 Narcan when they arrived to the facility. V5 said she did not administer Narcan to R1 when he was found unresponsive because V5 did not think R1 was experiencing an opioid overdose. On [DATE] at 2:45 PM, V5 said she was not sure if the facility had an AED (Automated External Defibrillator) and was not sure where the facility kept the crash cart or where an AMBU (Artificial Manual Breathing Unit) bag could be found.On [DATE] at 1:28 PM, V8 (Certified Nursing Assistant/ CNA) said on [DATE] around 1:45 PM R1 returned to the facility from the hospital where R1 had received pain medication (Dilaudid/ hydromorphone). V8 stated around 5:15PM R1 rang his call light and when V8 entered R1's room R1 was vomiting into the trash can. V8 said R1 asked V8 to assist R1 to his wheelchair to go to the bathroom to get cleaned up because R1 had a bowel movement in his incontinence brief. V8 said she asked if R1 needed any further assistance and R1 said no. V8 said she left R1's room and informed V5 (Licensed Practical Nurse/ LPN) that R1 was vomiting then started passing evening meal trays. V8 said she checked on R1 approximately 10 to 15 minutes later and found R1 sitting in his wheelchair in his room by the bathroom door. V8 said when she spoke to R1 he did not respond. V8 said that is when she noticed R1 was not breathing. V8 said R1 did not have any discoloration at that time and was warm to the touch. V8 said she immediately went to inform V5 that R1 was unresponsive and asked what R1's code status was. V8 said V5 checked R1's code status and said R1 was a full code, then V5 walked down to R1's room, looked at R1, then walked back up the hall to the nurse's station. V8 said V5 did not appear to be in a hurry. V8 said V5 then got the attention of V4 (LPN), the oncoming nurse that was standing outside of the facility by glass doors next to the nurse's station and sent V4 down to R1's room to start CPR. V8 said she and V4 placed R1 on the floor and V8 went to get the crash cart. V8 said V10 (CNA) and V6 (CNA) were coming down the hall with the crash cart to R1's room to assist with CPR. V8 stated CPR was not started for a while and I would estimate maybe 5 to10 minutes before CPR was started after I found (R1) unresponsive. On [DATE] at 2:55 PM, V4 (LPN) said she was an agency nurse and [DATE] was the first time she came to the facility. V4 said she arrived at the facility at 5:30 PM and went to the hall she was assigned to. V4 said she had walked outside of the facility to make a phone call when V5 banged on the glass doors motioning for her to come inside. V4 said she was told to go to R1's room and V4 walked to R1's room. V4 said when she entered R1's room R1 was sitting in his wheelchair facing the wall unresponsive. V4 said V8 told her R1 was a full code and they needed to start CPR. V4 said she and V8 placed R1 in the floor and V4 started doing chest compressions. V4 said after she entered R1's room it was maybe 5 minutes after starting CPR when EMS arrived.On [DATE] at 2:45 PM, V10 (CNA) said she went to V5 to ask for pain medication for another resident and heard V5 say there was a resident that needed CPR to be started so V10 ran down the hall to get V6 (CNA) and the crash cart. V10 said after retrieving the crash cart she entered the hallway R1's room was located on and saw V8 and V4 standing outside R1's room's doorway. V10 said V6 went into R1's room and started compressions while V10 found the AMBU bag. V10 said she handed the AMBU bag to V4 to start giving breaths to R1. V10 said the AMBU bag was not hooked up to oxygen and V10 was not sure if the crash cart had an oxygen tank on it.On [DATE] at 2:24 PM, V6 (CNA) said on [DATE] she was passing the evening meal trays when V10 came running down the hall and told her a resident (R1) needed CPR. V6 stated then she and V10 went to get the crash cart. V6 said when she and V10 arrived in the hallway of R1's room she saw V4 and V8 standing outside the door to R1's room. V6 said R1 was lying on a sheet on the floor in his room and CPR had not been started. V6 said she went into R1's room and started doing chest compressions. V6 said while she was doing chest compressions V4 was using the AMBU bag to give R1 breaths. V6 said V7 (LPN) came into R1's room and took over chest compressions while V4 continued using the AMBU bag. V6 said she was upset V5 had not called a code on the facility intercom and was also upset no one had started CPR until she arrived to R1's room.R1's [DATE] progress note documented in part . At approximately 1715 (5:15 PM) CNA (V8) assisted resident to the bathroom. CNA left room to provide privacy. Approximately 10 minutes later CNA returned to room and found resident in wheelchair unresponsive to stimuli. Nursing staff (V5) came to observe resident finding him unresponsive. Staff nurse called 911 and instructed additional nurse staff to begin CPR. EMS (Emergency Medical Services) arrived at approximately 1740 (5:40 PM) and took over CPR administration. Narcan was administered by EMS with no response. Resident was taken to (Local Hospital) at 1757 (5:57 PM). (V25 R1's Power of Attorney/ POA) was notified of what had occurred and where resident had been taken. On call nurse notified. Attempted to call (V3 Physician) no answer.R1's [DATE] ambulance report documented EMS (Emergency Medical Services) were called at 5:48 PM, arrived at patient at 5:54 PM, and left the facility with R1 at 6:05 PM and documented in part .Upon EMS arrival, we found a patient lying supine on the floor of his room. CPR in progress by fire department and nursing home staff. CPR was halted and pulse check was recorded. No pulse at this time. CPR was continued. Staff states that patient was given Dilaudid at 12:30 PM at (Local Hospital) prior to returning at the nursing home.Staff states that when patient had gotten back from the hospital, patient was in good spirits and was not complaining of much pain on that right side. 2 mg of Narcan was administered intranasally while inside the facility with no relief of patient's unresponsiveness. CPR continued until arrival at ED. Patient care was turned over to (Local Hospital) ER staff. Resuscitation attempt continued while in the ED. Left patient in care or ER nursing staff. This report further documents R1 expired int the ED.R1's Electronic Medical Record (EMR) documented a IDPH (Illinois Department of Public Health) Practitioner Order for Life-Sustaining Treatment (POLST) Form signed by R1 on [DATE] with an X denoting Attempt Resuscitation/ CPR and an X denoting Full Treatment: Primary goal of sustaining life by medically indicated means. This document was scanned into R1's EMR on [DATE].R1's EMR also documented a POLST form signed by R1 on [DATE] with an X denoting No CPR: Do Not Attempt Resuscitation and an X denoting Comfort-Focused Treatment: Primary goal is maximizing comfort through symptoms management. Allow natural death. This document was signed by the medical director on [DATE] and was scanned into R1's EMR on [DATE].R1's Care Plan Report documented [DATE] focus of Advanced Directive/ End of Life Care Plan Resident is not at or approaching end of life at this time with a [DATE] intervention Code Status: DNR (in chart)On [DATE] at 10:07 AM, V2 (Director of Nursing/ DON) said R1's POLST form was signed by V3 on [DATE] and was emailed to the facility on [DATE]. V2 said due to [DATE] being a Saturday the staff with access to that email account were not in the facility to upload the new POLST form into R1's EMR. V2 said when R1 was found unresponsive on [DATE] staff would have seen R1 was a full code and should have started CPR immediately.On [DATE] at 12:34 PM, V3 (Medical Director) said he expected CPR to be started if someone was found to be unresponsive, not breathing, and having no pulse within a minute if they were a full code. V3 said if R1 was found unresponsive and was warm it was possible R1's life could have been saved if CPR had been started immediately. V3 said he would expect any resident with an order for a narcotic medication to have an order for Narcan. V3 said any resident found unresponsive who was receiving a narcotic medication should be given Narcan that is common sense. V3 said if a resident had a change in their pain level he would expect a medical provider to be notified for pain control.On [DATE] at 1:15 PM, V51 (LPN) was asked if a resident did not have an active order for Narcan could the nurse manually override in the emergency medication stock system to receive the medication and V51 said yes and demonstrated how the process was completed. V51 said their emergency medication stock system contained injectable and nasal spray Narcan.According to the Mayo Clinic at https://www.mayoclinic.org/drugs-supplements/hydromorphone-injection-route/description/drg-20074244. Hydromorphone (injectable route) medication information documented in part .Symptoms of an overdose include: extreme dizziness or weakness, slow heartbeat or breathing, seizures, trouble breathing, and cold, clammy skin. In case of an overdose, call your doctor right away. Tell your doctor right away if you notice these symptoms. Your doctor may also give naloxone or nalmefene to treat an overdose. Check with your doctor or nurse immediately if any of the following side effects occur: stomach pain. vomiting.On [DATE] at 2:09 PM, V2 (Director of Nursing) said Narcan was part of the order set when entering a medication into the EMR. V2 demonstrated entering a narcotic medication into a residents EMR and how the Narcan order would populate but had to be selected by the nurse entering the medication. V2 said if the Narcan was also selected an order would be sent to V3 (Medical Director) to be signed and sent to the pharmacy. V2 said V5 had access to the emergency stock medication system and had personally shown V5 how to pull medications for residents.On [DATE] at 2:39 PM, the facility's crash cart kept between 200 and 300 hall did not have an AMBU bag present. V51 was asked if a resident needed CPR to be started where an AMBU bag could be found and V51 said honestly I would have no idea. Maybe the oxygen room. V51 went to the oxygen room and no AMBU bag could be found. V51 said she would have to ask where AMBU bags were stored in the facility. V51 said she was told AMBU bags could be found in a supply closet on 300 hall. V51 said the crash carts were supposed to be checked daily on night shift. At this time the crash cart had a check list titled Split Hall Emergency Cart that documented on [DATE] an AMBU-bag with mask was present.The facility's 11/2025 Abuse, Prevention and Prohibition Policy documented in part . Each Resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even to those residents in a coma, can cause physical harm, pain, or mental anguish. Definitions: Deprivation of Goods and Services by Staff. Abuse also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff have the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s). Neglect. means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.The facility's 3/2025 Cardiopulmonary Resuscitation Policy documented in part . Cardiac arrest is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness). The goal of early delivery of CPR is to try to maintain life until emergency response team arrives to deliver Advanced Life Support (ALS). 1. If a resident is found unresponsive and not breathing normally, a clinical staff member will verify code status using the medical record. 2. If the resident is a full code, per the medical record, a staff member that is certified in CPR will initiate CPR until emergency response team arrives.The facility's 12/2024 Advanced Directive Policy documented in part .2. Information about whether or not the resident has executed an advanced directive shall be placed in the medical record. 4. The plan of care for each resident will be consistent with his or her documented treatment preferences and/ or advance directive. 9. The Interdisciplinary Team will review at regular intervals with the resident his or her advance [sic] directives to ensure that such directives are still the wishes of the resident. Staff will assist the resident or representative to make changes to advanced directives in accordance with state law. Changes and/or revocations will be added to the clinical record. The Care plan will be updated to reflect the change.The facility's 2/2025 Pain Management policy documented in part . If is the policy of this facility to respect and support the resident's tight to optimal pain assessment and management. Each and every resident has a right to the assessment and management of pain. Effective pain management can remove the adverse psychological and physiological effects of unrelieved pain. Optimal management of the resident experiencing pain enhances the healing and promotes both physical and psychological wellness. It is the responsibility of all clinical staff to assess and periodically reassess the resident pain and relief from pain. strategies for pain management include but are not limited to: Assessing potential for pain, recognizing onset, present sand duration of pain and assessing characteristics of pain. Addressing/ treating underlying causes of pain to extent possible.The facility's 12/2024 Significant Condition Change and Notification policy documented in part . Purpose: To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below:. A significant change in the resident's physical, mental or psychosocial status. (See below for examples). Abnormal, unusual or new complaints of pain. When the above situations exists, the licensed nurse will contact the resident's representations and their medical provider. The medical practitioner will be contacted immediately for any emergencies regardless of the time of day. If the medical practitioner cannot immediately be reached in an emergency, the facility medical director will be called. If that medical practitioner cannot be reached, the director of nursing or the charge nurse can make arrangements for transportation to the emergency department. All significant changes will be recorded. in the resident record.The facility's Opioid Overdose policy documented in part . Opioid overdose occurs when a person takes a larger dosage of opioids than their body can handle, and breathing slows or stops as a result eventually leading to brain damage or death. Signs of Opioid Overdose: Unresponsiveness to voice or touch. Loss of consciousness. Slow, shallow, irregular or stopped breathing. Limp, lifeless body or movement. Vomiting. It is out policy for licensed staff to monitor for signs of opioid overdose and to administer naloxone to individuals experiencing an opioid overdose at the earlier opportunity to minimize chance of death. 3. Identify and confirm signs of potential opioid overdose. 4. Attempt to wake or rouse the resident. Perform sternal rub if no response to voice or shaking. 5. Assess the resident's breathing. 6. If unresponsive and not breathing, then call 9-1-1. 7. Obtain Naloxone from the E-kit, crash cart or designated accessible location. Ensure that it is not expired, is unused and is free from tampering or defects. 8. Maintain universal precautions and administer naloxone as follows. 9. Initiate CPR after administration of Naloxone. 10. If there is no response to the first dose of Naloxone after 2-3 minutes, then staff shall administer a second dose of Naloxone and continue with CPR while awaiting EMS.The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy:The incident occurred on [DATE] and the investigation was completed on [DATE].On [DATE], V54 (LPN Infection Control Nurse/ ICN) completed re-education for nurse involved (V5 LPN) regarding emer

Based on interview and record review the facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) timely for 1 (R1) of 4 residents reviewed for death in a sample of 15. This failure resulted in a delay in providing immediate emergency basic life support including CPR after finding R1 in his wheelchair with no pulse and no respirations. After CPR was initiated, R1 was transferred via ambulance to the local hospital and pronounced dead. The Immediate Jeopardy began on [DATE] at approximately 5:30 PM when R1 was found unresponsive in his room. V45 (Administrator), V42 (Regional Director of Operations), V18 (Regional Clinical Director), and V46 (Regional [NAME] President of Operations) were notified of the Immediate Jeopardy on [DATE] at 2:53 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include:R1's admission Record documented an admission date of [DATE] with diagnoses including fracture of unspecified part of neck to right femur, periprosthetic fracture around internal prosthetic right hip joint, pain in right hip, chronic pain syndrome, and reduced mobility. R1's Minimum Data Set, dated [DATE] documented a Brief Interview on Mental Status (BIMS) assessment score of 0, indicating severe cognitive impairment.On [DATE] at 1:28 PM, V8 (Certified Nursing Assistant/ CNA) said on [DATE] around 1:45 PM R1 returned to the facility from the hospital where R1 had received pain medication (Dilaudid/ hydromorphone). V8 stated around 5:15PM R1 rang his call light and when V8 entered R1's room R1 was vomiting into the trash can. V8 said R1 asked V8 to assist R1 to his wheelchair to go to the bathroom to get cleaned up because R1 had a bowel movement in his incontinence brief. V8 said she asked if R1 needed any further assistance and R1 said no. V8 said she left R1's room and informed V5 (Licensed Practical Nurse/ LPN) that R1 was vomiting then started passing evening meal trays. V8 said she checked on R1 approximately 10 to 15 minutes later and found R1 sitting in his wheelchair in his room by the bathroom door. V8 said when she spoke to R1 he did not respond. V8 said that is when she noticed R1 was not breathing. V8 said R1 did not have any discoloration at that time and was warm to the touch. V8 said she immediately went to inform V5 that R1 was unresponsive and asked what R1's code status was. V8 said V5 checked R1's code status and said R1 was a full code, then V5 walked down to R1's room, looked at R1, then walked back up the hall to the nurse's station. V8 said V5 did not appear to be in a hurry. V8 said V5 then got the attention of V4 (LPN), the oncoming nurse that was standing outside of the facility by glass doors next to the nurse's station and sent V4 down to R1's room to start CPR. V8 said she and V4 placed R1 on the floor and V8 went to get the crash cart. V8 said V10 (CNA) and V6 (CNA) were coming down the hall with the crash cart to R1's room to assist with CPR. V8 stated CPR was not started for a while and I would estimate maybe 5 to10 minutes before CPR was started after I found (R1) unresponsive. On [DATE] at 2:32 PM, V5 (LPN) said V8 came out of R1's room and asked if R1 was a full code and said she did not think R1 was breathing. V5 said she went to R1's room and found R1 to be unresponsive. V5 said R1 looked normal, (R1) was sitting in his wheelchair slack [NAME] with his head back. V5 said she went back to the nurse's station and knocked on the glass doors to get V4 from outside and told V4 to go start CPR on R1 so she could call EMS (Emergency Medical Services). V5 said she then called 911 and she believes EMS arrived 5 or 6 minutes later.On [DATE] at 2:45 PM, V5 said she was not sure if the facility had an AED (Automated External Defibrillator) and was not sure where the facility kept the crash cart or where an AMBU (Artificial Manual Breathing Unit) bag could be found.On [DATE] at 2:55 PM, V4 (LPN) said she was an agency nurse and [DATE] was the first time she came to the facility. V4 said she arrived at the facility at 5:30 PM and went to the hall she was assigned to. V4 said she had walked outside of the facility to make a phone call when V5 banged on the glass doors motioning for her to come inside. V4 said she was told to go to R1's room and V4 walked to R1's room. V4 said when she entered R1's room R1 was sitting in his wheelchair facing the wall unresponsive. V4 said V8 told her R1 was a full code and they needed to start CPR. V4 said she and V8 placed R1 in the floor and V4 started doing chest compressions. V4 said after she entered R1's room it was maybe 5 minutes after starting CPR when EMS arrived.On [DATE] at 2:45 PM, V10 (CNA) said on [DATE] she went to V5 to ask for pain medication for another resident and heard V5 say there was a resident that needed CPR to be started so V10 ran down the hall to get V6 (CNA) and the crash cart. V10 said after retrieving the crash cart she entered the hallway R1's room was located on and saw V8 and V4 standing outside R1's room's doorway. V10 said V6 went into R1's room and started compressions while V10 found the AMBU bag. V10 said she handed the AMBU bag to V4 to start giving breaths to R1. V10 said the AMBU bag was not hooked up to oxygen and V10 was not sure if the crash cart had an oxygen tank on it.On [DATE] at 2:24 PM, V6 (CNA) said on [DATE] she was passing the evening meal trays when V10 came running down the hall and told her a resident (R1) needed CPR and V6 and V10 went to get the crash cart. V6 said when V6 and V10 arrived in the hallway of R1's room she saw V4 and V8 standing outside the door to R1's room. V6 said R1 was lying on a sheet on the floor in his room and CPR had not been started. V6 said she went into R1's room and started doing chest compressions. V6 said while V6 was doing chest compressions V4 was using the AMBU bag to give R1 breaths. V6 said V7 (LPN) came into R1's room and took over chest compressions while V4 continued using the AMBU bag. V6 said she was upset V5 had not called a code on the facility intercom and was also upset no one had started CPR until she arrived to R1's room.On [DATE] at 12:34 PM, V3 (Medical Director) said he expected CPR to be started if someone was found to be unresponsive, not breathing, and having no pulse within a minute. V3 said if R1 was found unresponsive and was warm it was possible R1's life could have been saved if CPR had been started immediately.R1's Electronic Medical Record (EMR) documented a IDPH (Illinois Department of Public Health) Practitioner Order for Life-Sustaining Treatment (POLST) Form signed by R1 on [DATE] with an X denoting Attempt Resuscitation/ CPR and an X denoting Full Treatment: Primary goal of sustaining life by medically indicated means. This document was scanned into R1's EMR on [DATE].R1's EMR also documented a POLST form signed by R1 on [DATE] with an X denoting No CPR: Do Not Attempt Resuscitation and an X denoting Comfort-Focused Treatment: Primary goal is maximizing comfort through symptoms management. Allow natural death. This document was signed by the medical director on [DATE] and was scanned into R1's EMR on [DATE].On [DATE] at 10:07 AM, V2 (Director of Nursing/ DON) said R1's POLST form was signed by V3 on [DATE] and was emailed to the facility on [DATE]. V2 said due to [DATE] being a Saturday the staff with access to that email account were not in the facility to upload the new POLST form into R1's EMR. V2 said when R1 was found unresponsive on [DATE] staff would have seen R1 was a full code and should have started CPR immediately.R1's [DATE] progress note documented in part . At approximately 1715 (5:15 PM) CNA (V8) assisted resident to the bathroom. CNA left room to provide privacy. Approximately 10 minutes later CNA returned to room and found resident in wheelchair unresponsive to stimuli. Nursing staff (V5) came to observe resident finding him unresponsive. Staff nurse called 911 and instructed additional nurse staff to begin CPR. EMS (Emergency Medical Services) arrived at approximately 1740 (5:40 PM) and took over CPR administration. Narcan was administered by EMS with no response. Resident was taken to (Local Hospital) at 1757 (5:57 PM). (V25, R1's Power of Attorney/ POA) was notified of what had occurred and where resident had been taken. On call nurse notified. Attempted to call (V3 Physician) no answer.R1's [DATE] ambulance report documented EMS (Emergency Medical Services) was called at 5:48 PM, arrived at patient at 5:54 PM, and left the facility with R1 at 6:05 PM and documented in part .Upon EMS arrival, we found a patient lying supine on the floor of his room. CPR in progress by fire department and nursing home staff. CPR was halted and pulse check was recorded. No pulse at this time. CPR was continued. CPR continued until arrival at ED.The facility's 3/2025 Cardiopulmonary Resuscitation Policy documented in part . Cardiac arrest is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness). The goal of early delivery of CPR is to try to maintain life until emergency response team arrives to deliver Advanced Life Support (ALS). 1. If a resident is found unresponsive and not breathing normally, a clinical staff member will verify code status using the medical record. 2. If the resident is a full code, per the medical record, a staff member that is certified in CPR will initiate CPR until emergency response team arrives.The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy:The incident occurred on [DATE] and the investigation was completed on [DATE].On [DATE], V54 (LPN Infection Control Nurse/ICN) completed re-education for nurse involved (V5 LPN) regarding emergency response procedures and the requirement to initiate CPR without delay for residents who are full code. On [DATE], V18 (Regional Clinical Director) completed counseling with nurse V5 (LPN) regarding the incident. All licensed nurses and applicable staff were re-educated on the facility's CPR policy, emergency response procedures, and resident code status verification on [DATE] by V42 (Regional Director of Operations), V54 (LPN ICN), V55 (Registered Nurse/RN, Assistant Director of Nursing).Mock code drills will be conducted on all shifts to reinforce expectations for immediate CPR initiation. On [DATE] V54 (LPN ICN), and V55 (RN Assistant Director of Nursing) completed an audit of all resident code status. The audit revealed that two residents that did not have their code status listed in the banner. The first resident's banner was updated to reflect code status. An order was in place; the care plan indicates the current code status. The second resident's banner was updated to reflect code status. An order is in place; the care plan indicates the current code status. Updated on [DATE]. The DON or designee will conduct and document mock code drills monthly or as needed for 3 months.The DON or designee will conduct random audits of staff understanding of the CPR policy, emergency response procedure and resident code status verification 5 times a week for 60 days. The audits will include direct staff interviews, review of the resident code status identification process, and validation of staff knowledge regarding immediate response expectations when a resident is found unresponsive. Any staff member identified as having knowledge deficits will receive immediate re-education and follow-up validation of competency. The DON or designee will review new admission code status and/or changes in code status during QA clinical meeting and ensure resident's clinical records have order and polst scanned into resident's clinical record.Findings will be reported through the QAPI process with additional education provided as indicated.Staff will initiate CPR immediately when indicated and according to resident wishes and facility policy, ensuring timely emergency response and resident safety. Immediacy removal date [DATE].

Based on interview and record review the facility failed to seek timely medical treatment and complete physician ordered laboratory testing for 1 (R13) of 5 residents reviewed for quality of care in a sample of 15. This failure resulted in R13 experiencing respiratory distress with Acute Hypoxic Respiratory Failure with oxygen saturations at 60-70%. Findings include:R13's admission Record documented an admission date of 4/10/26 with diagnoses including anemia, hypertension, and atrial fibrillation. R13 5/15/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 6, indicating R13 was severely cognitively impaired.R13's 5/27/26 at 3:02 AM Progress Note documented in part . Primary Chief Complaint: Altered Mental Status. Overnight the patient has become more agitated, argumentative and not behaving like himself. His oxygen saturation are dropping down to the low 90s and 89% this morning. Otherwise vitals are stable. He does have a bit of a cough and there's reports some wheezing and rhonchi type lung sounds. Orders:. Stat (at once/immediately) cbc (complete blood count), bmp (basic metabolic panel), procal (procalcitonin), bnp (b-type natriuretic peptide) due to AMS (Altered Mental Status).R13's Order Summary Report documented a 5/27/26 order for CBC, BMP, Procal, and BNP stat.R13's 5/1/26-5/31/26 Medication Administration Record documented a 5/27/26 order for CBC, BMP, Procal, and BNP stat but the box denoting the labs were completed was blank.On 6/12/26 at 11:24 AM, V2 (Director of Nursing/ DON) said the nurse had been aware of R13's lab orders and put them into R13's Electronic Medical Record (EMR). V2 said when the nursing staff tried to draw R13's blood they could not find a vein. V2 said this task had been passed on to the next shift but was not sure if any staff had followed up on it. V2 said she would call the lab and see if the labs had been completed.During the course of this investigation, the facility was not able to produce evidence that R13's 5/27/26 ordered CBC, BMP, Procal, and BNP were completed. R13's 6/5/26 at 12:28 PM Progress Note documented in part . MD (Medical Doctor) notified by DON (Director of Nursing) of decline in respiratory status and transport to ER (Emergency Room).R13's 6/5/26 at 12:45 PM Progress Note documented in part .Resident has had congestion throughout the day that has progressively became worse. O2 (Oxygen) has been on continuously 4L/M/NC (4 liters per minute per nasal cannula). Respiratory RN (Registered Nurse) assessed resident and O2 sats are now 74% and respiratory status continues to decline. DON ad [sic] Respiratory RN notified this nurse to send resident to ER.R13's 6/5/26 at 12:55 PM Progress Note documented in part .Spouse/ POA (Power of Attorney) notified of decline in respiratory condition and need to send to ER for eval (evaluation).R13's 6/5/26 at 1:00 PM Progress Note documented in part .EMS (Emergency Medical Services) notified of need for transport to ER. (32 minutes after the order to send R13 to the hospital for further treatment was obtained.)R13's 6/5/26 ambulance report documented EMS were notified at 1:06 PM that R13 needed transferred to the hospital, arrived at facility at 1:15 PM, and left the facility with R13 at 1:25 PM. (57 minutes after the order to send R13 to the hospital had been obtained.)On 6/24/26 at 10:52 AM, V68 (Licensed Practical Nurse/ LPN) said she was the nurse caring for R13 on 6/5/26 from 6:00 AM -6:00 PM. V68 said she was sitting at the nurses' station when V2 (Director of Nursing/ DON) and V69 (Registered Nurse) told her R13 needed sent to the hospital. V68 said V2 and V69 were taking care of R13 at this time and V68 did not see R13 until R13 was leaving. V68 said she was just documenting and doing what V2 and V69 told her to do. V68 said she was not familiar with how to contact a doctor because the facility had changed to telehealth healthcare provider system and was not familiar with it. V68 said it was about an hour between the onset and when R13 was transferred to the hospital.On 6/11/26 at 12:34 PM, V3 (Medical Director) said he expected staff to follow physician orders and labs should be completed as ordered. V3 said he expected staff would call for an ambulance immediately after obtaining the order and getting approval from the resident's family.R13's 6/5/26 Emergency Department Encounter documented in part . presents to the emergency department with CC (Chief Complaint) of respiratory distress. Noted to be saturating in the 60s to 70s upon arrival, low 80s on nonrebreather. Did not tolerate CPAP (Continuous Positive Air Pressure) in the truck. He has no history of COPD (Chronic Obstructive Pulmonary Disease), heart failure, CAD (Coronary Artery Disease), etc. He reports that he has been ill for the last 3 to 4 weeks but it got worse over the last couple days. He has audible rales. Reassessment. Transition from nonrebreather to BiPAP (Bilever Positive Airway Pressure) with significant improvement in respiratory status. Chest x-ray shows bilateral pneumonia versus pulmonary edema. He has an elevated BNP as well as an elevated white count so treatment with antibiotics and Lasix. Also given DuoNeb and steroids. unable to give additional fluids due to existing volume overload. Discussed findings with family and patient, admitted to ICU. Finial Impression. 1. Acute hypoxic respiratory failure. 2. Pneumonia of both lower lobes due to infection organism. 3. Acute pulmonary edema. R13's hospital record documented a 6/9/26 note documenting in part .Hospital Course: (R13) was admitted 6/5 with respiratory distress. He had an infiltrate and elevated BNP. He was started on BIPAP and monitored in ICU (Intensive Care Unit). He was able to transition to nasal cannula and then moved to PCU (Progressive Care Unit). He had fairly rapid improvement in his respiratory status. On the morning of 6/8 he was back to baseline and stable for transfer back to SNF (Skilled Nursing Facility). R13 was discharged from the hospital back to the facility on 6/9/26.

Based on interview and record review the facility failed to provide adequate pain control for 1 (R1) of 3 residents reviewed for pain control out of a sample of 15. This failure resulted in R1 being in excruciating pain for 2 hours and 3 minutes and calling 911 a total of 5 times requesting an ambulance.Findings include:R1's admission Record documented an admission date of 5/20/26 with diagnoses including fracture of unspecified part of neck to right femur, periprosthetic fracture around internal prosthetic right hip joint, pain in right hip, chronic pain syndrome, and reduced mobility. R1's Minimum Data Set, dated [DATE] documents a Brief Interview on Mental Status (BIMS) assessment score of 0, indicating severe cognitive impairment.R1's Care Plan Report documented a 5/20/26 focus of the resident has pain with 5/20/26 interventions of monitor/record/report to Nurse resident complaints of pain or requests for pain treatment.R1 Physician Order Summary Report documents R1 had an order for Acetaminophen Tablet 325 MG (milligrams) give 650 mg by mouth every six hours as needed for pain or elevated temperature not to exceed 40000 mg per day. Start date 5/20/26. This report also includes an order for Hydrocodone-Acetaminophen tablet 7.5-325MG give 1 tablet by mouth every 4 ours as needed for pain for 3 days. Do not exceed 3 GM (grams) acetaminophen from all sources in 24 hours. Start date 5/20/26 and end date 5/23/26. R1's hospital record documented an admission date of 5/17/23 with a discharge date of 5/19/26 documented in part . Patient's Chief Complaint: Transferred to our hospital for right femoral fracture. being admitted to our hospital for the management of right femoral fracture. As reported, patient was moving a plant and then he lost his balance and fell landing on his right side. Patient initially presented to (another hospital), with initial workup done in the ED showing a right femoral periprostatic fracture. R1's Progress Notes dated 5/20/26 documented in part, at 00:10 (12:10AM) resident arrived to facility via stretcher with Regional Ambulance service from an out of state hospital. He is admitted to facility for rehab therapy for a right femoral fracture after a fall at home. He is alert and oriented x 4. Pleasant and cooperative with staff. On 6/23/26 at 8:33 PM, V44 (Licensed Practical Nurse/ LPN) said she was the nurse caring for R1 on the night of 5/22/26. V44 said R1 was alert and oriented to person, place, and time. V44 said R1 was very upset and aggressive when asking for pain medication due to hip pain. V44 said after she administered R1's pain medication R1 went back to his room and went to sleep. V44 said R1 had not displayed any aggressive behaviors relating to pain prior to this incident to her knowledge. V44 said she did not think R1 was exhibiting narcotic pain medication seeking behaviors. V44 said R1 had not requested to be sent to the hospital during her shift. On 6/23/26 at 10:03 AM, V53 (Certified Nursing Assistant/ CNA) said she was the CNA caring for R1 on the night shift on 5/22/26. V53 said R1 did not seem confused. V53 said that was the first time V53 had met R1 and was not sure how cognitive R1 was at baseline but during her shift R1 appeared to be alert and oriented. On 6/23/26 at 1:28 PM, V8 (CNA) said she was the CNA caring for R1 on 5/23/26 during dayshift . V8 said she was not sure of R1's cognitive status at baseline because that was the first time she met R1 but R1 did not seem confused. V8 said R1 told her he was in excruciating pain because the night before he had hit his leg on something and had an increase in pain. V8 said R1 requested pain medication several times and was requesting to be sent to the hospital. V8 said she reported to V5 (Licensed Practical Nurse/ LPN) was requesting pain medication due to an increase in pain and requesting to be sent to the hospital. A recording from a 911 call from R1 on 5/23/26 at 8:41 AM was reviewed. In the call R1 requested an ambulance to transport him to the hospital due to tremendous pain to his right hip and that R1 was in great pain. A recording from a 911 call from R1 on 5/23/26 at 9:06 AM was reviewed. In the call R1 requested an ambulance to transport him to the hospital because he was in tremendous pain and that R1 just needed some help. A recording from V65 (Police Dispatcher) to V5 (Licensed Practical Nurse/ LPN), the nurse caring for R1, on 5/23/26 at 9:08 AM was reviewed. In the call the dispatcher told V5 R1 had called 911 twice requesting an ambulance due to pain. V5 told the dispatcher, (R1) is just going to keep calling you. I don't know what to do. And We have an affinity for pain medication. V5 explained to the dispatcher R1's pain medication was as needed not scheduled and (R1) doesn't get it a quickly as (R1) would like to. V5 then stated, In my professional opinion, (R1) does not need to be seen by an ER (Emergency Room) like he doesn't need emergency care. The dispatcher then asked, (R1) just wants more pain medication? and V5 responded, Yes. V5 then said (R1's) not all the way there, indicating R1 was confused. V5 then went on to say, I don't want to say disregard this but this is kind of normal for (R1). A recording from a 911 call from R1 on 5/23/26 at 9:32AM was reviewed. In the call R1 requested an ambulance to transport him to the hospital. In the call R1 stated, over the night I have damaged my hip again. The dispatcher said she had spoken with V5 about R1's pain medication and it was not time for R1 to receive pain medication. The dispatcher then said the nurse has to call them before an ambulance could be sent. A recording from a 911 call from R1 on 5/23/26 at 10:41AM was reviewed. In the call R1 requested an ambulance to transport him to the hospital. R1 said he needed to be transferred to the emergency room to get an X-Ray. The dispatcher then said yes, but your nurse has to order that. We can't just send something over there without the nurse telling us. So, you have to talk to the nurse first. R1 then asked the dispatcher if he called the hospital R1 had been admitted to the facility from and asked them to send an ambulance would they send one up here? and the dispatcher said they would not. Not without your nurse ordering it. R1 responded, what if I just tell them anything. I just need an ambulance. The dispatcher responded Well, you're going to have to tell them you are in a nursing home and what room you're in and they're going to call your nurse like I did. R1 then asks the dispatcher if she had found out what room R1 was in and the dispatcher said she did not. R1 then tells the dispatcher, the pain pills are having a little effect and I have been panting for 2 hours. A recording from a 911 call from R1 on 5/23/26 at 10:44AM was reviewed. In the call R1 asked the dispatcher what they are going to do. R1 said someone said to just keep calling 911 and the dispatcher responds Well, if you keep calling 911 you are going to get a fine for it. R1 then says No, I don't want to do that. The dispatcher said Well, this is like abuse of 911 because you have to talk to your nurse. This is probably your sixth or seventh time calling. R1 then says, I know. I know. I know. And I hate this but I'm going to do what I need to do to not get in trouble. The dispatcher then says, Right, yeah, you have to talk to your nurse and tell the nurse to call us if they want to send an ambulance. I can't send one without them saying so.A recording from a 911 call from V5 on 5/23/26 at 10:59 AM was reviewed. In the call V5 stated, I have a resident that is adamant about being sent to the ER. He swears his hip is broken. He has called several times and now he has called the police. The dispatcher (V65) said I think I know who you are talking about. I think he has called here like 7 times. V5 then says, I just got off the phone with the police and they said well can't you just take his phone and I was like no. The dispatcher (V65) then tells V5 an ambulance will be sent to the facility to transport R1 to the hospital. R1's 5/23/26 at 11:30 AM Progress Note documented in part . C/O (Complains Of) severe pain in right hip. Pain medicine administered at 5am and 9am. Stated pain medicine did not help. Pt (patient) behavior demanding, belligerent. Insisting to go to (Name of Out of State Hospital) ED regarding hip pain. Resident would not comply with alternative treatment options. Multiple calls made to police department and 911. Called police department 9 times. Spoke with (V61 R1's Significant Other) about what was happening. Explained that resident had received pain medication, and that patient was being belligerent, calling the authorities multiple times, demanding to go (Name of Local Hospital) swing bed or (Name of Out of State Hospital) ED. (V61) communicated understanding of the issue and stated she would contact residents next of kin. Spoke with (V62 Police Officer) regarding the multiple calls made to the police dept. (Local Police Department) (V62) stated that understanding of abuse of emergency line needs to be communicated to resident. (V62) said that he would contact (V61) to also update her on what was going on. Telephone number provided by nurse. Abuse Coordinator (V1 Former Administrator) contacted by nurse to explain what was happening. Explained that resident was being sent to the ED due to being belligerent toward staff, and demanding to be taken to (Name of Out of State Hospital) ER or (Name of Local Hospital) swing bed. Resident was taken to (Name of Hospital) ER by EMS (Emergency Medical Services) staff at 11:25 AM. R1's 5/23/26 Emergency Department Encounter documented in part . presents to the emergency department for persistent right hip pain related to a known right hip fracture sustained after a fall. Initial hip fx (fracture) fixed at (Name of Hospital) in July 2025. Treatment non op (non-operational) when admitted [DATE]. Last night he was in a wheelchair and bumped into a door and a few other walls, worsening his hip pain. Pain remains localized to the lateral aspect of the right hip. Home pain control has consisted of acetaminophen. He requests additional pain medication today. Mental status: he is alert and oriented to person, place, and time.12:36 PM hydromorphone (Dilaudid) injection 1 mg intramuscular.R1's 5/1/26-5/31/26 Medication Administration Record (MAR) documented an order for Hydrocodone-Acetaminophen Tablet 7.5-325 MG Give 1 tablet by mouth every 4 hours as needed for pain for 3 Days, Do not exceed 3 GM acetaminophen from all sources in 24 hours with a start date of 5/20/26. The following doses where given with the correlating pain scale assessments: 5/20/26 at 10:25 PM pain scale 5, 5/21/26 at 5:19 AM pain scale 5, 9:21 AM pain scale 6, 8:25 PM pain scale 3, 5/22/26 at 11:59 PM pain scale 7, 5/23/26 at 4:51 AM pain scale 6. R1's MAR documents an order for Acetaminophen Tablet 325 MG (milligrams) give 650 mg by mouth every six hours as needed for pain or elevated temperature not to exceed 40000 mg per day. Start date 5/20/26. R1 received 1 dose on 5/20/26 at 8:20 AM pain scale 8. According the pain scale chart listed on R1's Physician Order Summary: 0-1 No Pain; 2-3 Mild Pain; 4-5 Moderate Pain; 6-7 Severe Pain; 8-9 Very Severe Pain; 10 Worst Possible Pain.R1's 5/20/26 Hydrocodone-Acetaminophen 7.5-325 mg Controlled Substances Proof of Use form documented the medication was given but was not documented on the MAR with no accompanying pain scale assessment on the following dates: 5/21/26 at 2:54 PM, 5/22/26 at 8:00 AM, 3:00 PM, and 9:00 PM, 5/23/26 at 9:45 AM. R1's 5/23/26 at 5:31 PM Progress Note documented in part . Returned from ED (Emergency Department) at 1345 (1:45 PM). Received Dilaudid pain medication at 12:36 (PM). No current c/o (complaint of) pain. In bed resting with eyes closed. On 6/23/26 at 2:32 PM, V5 (LPN) said she was the nurse caring for R1 on 5/23/26. V5 stated everything was normal, R1 had received pain medication around 5:00 AM then V5 administered pain medication to R1 around 9:00 AM. V5 said R1 requested to be sent to a local hospital for swing bed services and V5 told R1 that a referral would have to be sent to the local hospital prior to R1 being sent. V5 said R1 then requested to be sent to the hospital R1 had been at prior to being admitted . V5 said she told R1 there wasn't much they could do for him at the ER. V5 said, R1 kept calling 911 so I finally sent him out to the hospital R1 was at prior to his admission to the facility. V5 said, R1 was just a crotchety old man who would scream and yell for his pain meds. V5 said R1 told V5 his hip was hurting and V5 said she told R1, I knew it was hurting but it wasn't broken it was just fractured, and I finally just said OK I'll send you out. When V5 was asked why she did not contact a physician, V5 stated she called the on call nurse (V63/LPN/Wound Nurse) and the administrator to let them know what was going on and did not call a physician. V5 said when R1 returned to the facility from the hospital, where R1 had received a dose of Dilaudid (Hydromorphone), R1 was still screaming and disturbing other residents.On 6/11/26 at 12:34 PM, V3 (Medical Director) said if a resident had a change in their pain level he would expect a medical provider to be notified for pain control.The facility's 2/2025 Pain Management policy documented in part . If is the policy of this facility to respect and support the resident's tight to optimal pain assessment and management. Each and every resident has a right to the assessment and management of pain. Effective pain management can remove the adverse psychological and physiological effects of unrelieved pain. Optimal management of the resident experiencing pain enhances the healing and promotes both physical and psychological wellness. It is the responsibility of all clinical staff to assess and periodically reassess the resident pain and relief from pain. strategies for pain management include but are not limited to: Assessing potential for pain, recognizing onset, present sand duration of pain and assessing characteristics of pain. Addressing/ treating underlying causes of pain to extent possible.

Based on interview and record review, the facility failed to ensure the Medical Director attended the scheduled Quality Assurance meetings. This failure has the potential to affect all 64 residents living in the facility. Findings include:The facility's QAPI (Quality Assurance and Performance Improvement) Meeting Sign In Sheets dated 5/29/26, March 2026, 2/18/26, 1/21/26, 11/19/25 and 8/21/26 did not document a signature from the facility's medical director affirming the medical director's attendance. The QAPI Meeting Sign In Sheet dated 12/31/25 documents in the signature [NAME] for the medical director Verbal. On 6/29/26 at 1:20 PM, V42 (Regional Director of Operations) stated she doesn't know why the medical director was not present for the scheduled QAPI meetings, but the medical director should be attending the QAPI meetings. V42 stated she doesn't know what Verbal means where the medical director's signature should be on the QAPI Meeting Sign In Sheet for 12/31/25. The facility's policy titled QAPI Policy dated August 2025 documents The QAPI Program takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality while involving all caregivers in practical and creative problem solving. A Resident Matrix dated 6/4/26 documents there are 64 residents living in the facility.

Based on interview and record review, the facility failed to ensure staff were trained on the required annual trainings. This has the potential to affect all 64 residents currently residing at the facility. Findings include: On 6/29/26 at 3:00 PM, staff trainings for V6 (Certified Nursing Aide/CNA), V40 (CNA), V47 (CNA), V12 (Licensed Practice Nurse/LPN), V23 (LPN), and V5 (LPN) were provided to this surveyor by V42 (Regional Director of Operations) and V18 (Regional Clinical Director) and were reviewed. It was noted at that time that training subjects missing for V6 included effective communication, QAPI (Quality Assurance and Performance Improvement), infection control, behavioral health, and the required in-service training for nurse aides. Training subjects missing for V40 included effective communication, resident rights and responsibilities, QAPI, infection control, compliance and ethics, behavioral health, and the required annual in-service training for nurse aides. Training subjects missing for V47 included effective communication, QAPI, infection control, compliance and ethics, behavioral health, and the required annual in-service training for nurse aides. Training subjects missing for V12 include effective communication, QAPI, infection control, and behavioral health. Training subject missing for V23 includes infection control. Training subjects missing for V5 included effective communication, QAPI, and compliance and ethics. On 7/1/26 at 11:01 AM, V18 stated they do not have a policy related to staff training requirements and all of the training documents they had for V6, V40, V47, V12, V23, and V5 had been provided. A Resident Matrix dated 6/4/26 documents there are 64 residents living in the facility.

Based on interview and record review that facility failed to ensure Uniform Practitioner Orders For Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Electronic Health Record and available for staff to access for 1 (R1) of 6 residents reviewed for advanced directives in the sample of 15.Findings include:R1's admission Record documented an admission date of [DATE] with diagnoses including fracture of unspecified part of neck to right femur, periprosthetic fracture around internal prosthetic right hip joint, pain in right hip, chronic pain syndrome, and reduced mobility. R1's Minimum Data Set, dated [DATE] documents a Brief Interview on Mental Status (BIMS) assessment documented a score of 0, indicating severe cognitive impairment.R1's Electronic Medical Record (EMR) documented a IDPH (Illinois Department of Public Health) Practitioner Order for Life-Sustaining Treatment (POLST) Form signed by R1 on [DATE] with an X denoting Attempt Resuscitation/ CPR and an X denoting Full Treatment: Primary goal of sustaining life by medically indicated means. This document was scanned into R1's EMR on [DATE].R1's EMR documented a POLST form signed by R1 on [DATE] with an X denoting No CPR: Do Not Attempt Resuscitation and an X denoting Comfort-Focused Treatment: Primary goal is maximizing comfort through symptoms management. Allow natural death. This document was signed by the medical director on [DATE] and was scanned into R1's EMR on [DATE].On [DATE] at 10:07 AM, V2 (Director of Nursing/ DON) said R1's POLST form was signed by V3 (Medical Director) on [DATE] and was emailed to the facility on [DATE]. V2 said due to [DATE] being a Saturday the staff with access to that email account were not in the facility to upload the new POLST form into R1's EMR. V2 said when R1 was found unresponsive on [DATE] staff would have seen R1 was a full code and should have started CPR immediately.The facility's 12/2024 Advanced Directive Policy documented in part .2. Information about whether or not the resident has executed an advanced directive shall be placed in the medical record. 4. The plan of care for each resident will be consistent with his or her documented treatment preferences and/ or advance directive. 9. The Interdisciplinary Team will review at regular intervals with the resident his or her advance [sic] directives to ensure that such directives are still the wishes of the resident. Staff will assist the resident or representative to make changes to advanced directives in accordance with state law. Changes and/or revocations will be added to the clinical record. The Care plan will be updated to reflect the change.

Based on interview and record review the facility failed to notify the physician with a change of condition for 2 of 4 (R1 and R12) residents reviewed for change of condition in the sample of 15. Findings Include: 1. R1's admission Record documented an admission date of 5/20/26 with diagnoses including fracture of unspecified part of neck to right femur, periprosthetic fracture around internal prosthetic right hip joint, pain in right hip, chronic pain syndrome, and reduced mobility. R1's Minimum Data Set, dated [DATE] documents a Brief Interview on Mental Status (BIMS) assessment documented a score of 0, indicating severe cognitive impairment. On 6/23/26 at 8:33 PM, V44 (Licensed Practical Nurse/ LPN) said she was the nurse caring for R1 on the night of 5/22/26. V44 said R1 was alert and oriented to person, place, and time. V44 said R1 was very upset and aggressive when asking for pain medication due to hip pain. V44 said after she administered R1's pain medication R1 went back to his room and went to sleep. V44 said R1 had not displayed any aggressive behaviors relating to pain prior to this incident to her knowledge. V44 said she did not think R1 was exhibiting narcotic pain medication seeking behaviors. V44 said R1 had not requested to be sent to the hospital during her shift. On 6/23/26 at 10:03 AM, V53 (Certified Nursing Assistant/ CNA) said she was the CNA caring for R1 on the night shift on 5/22/26. V53 said R1 did not seem confused. V53 said that was the first time V53 had met R1 and was not sure how cognitive R1 was at baseline but during her shift R1 appeared to be alert and oriented. On 6/23/26 at 1:28 PM, V8 (CNA) said she was the CNA caring for R1 on 5/23/26. V8 said she was not sure of R1's cognitive status at baseline because that was the first time she met R1 but R1 did not seem confused. V8 said R1 told her he was in excruciating pain because the night before he had hit his leg on something and had an increase in pain. V8 said R1 requested pain medication several times and was requesting to be sent to the hospital. On 5/23/26 at 8:41 AM, 9:06 AM, 9:32 AM, 10:41 AM, and 10:44 AM R1 called 911 asking for an ambulance to take him to the hospital due to tremendous pain in his right hip that was previously diagnosed with a femur fracture and the pain pills are having little effect. On 5/23/26 at 9:08 AM, a call from the police dispatcher (V65) to V5 (Licensed Practical Nurse/ LPN), the nurse caring for R1, was reviewed with the dispatcher telling V5 that R1 had called 911 twice requesting an ambulance due to pain and V5 told the dispatcher (R1) is just going to keep calling you. I don't know what to do. And we have an affinity for pain medication. V5 explained to the dispatcher R1's pain medication was as needed not scheduled and (R1) doesn't get it a quickly as (R1) would like to. V5 then said in my professional opinion, (R1) does not need to be seen by an ER (Emergency Room) like he doesn't need emergency care and the dispatcher said (R1) just wants more pain medication? V5 responded Yes. V5 then said (R1's) not all the way there indicating R1 was confused. V5 then went on to say I don't want to say disregard this but this is kind of normal for (R1). R1's 5/23/26 at 11:30 AM Progress Note documented in part . C/O (Complains Of) severe pain in right hip. Pain medicine administered at 5am and 9am. Stated pain medicine did not help. Pt (patient) behavior demanding, belligerent. Insisting to go to (Name of Out of State Hospital) ED regarding hip pain. Resident would not comply with alternative treatment options. Multiple calls made to police department and 911. Called police department 9 times. Spoke with (V61 R1's Significant Other) about what was happening. Explained that resident had received pain medication, and that patient was being belligerent, calling the authorities multiple times, demanding to go (Name of Local Hospital) swing bed or (Name of Out of State Hospital) ED. (R1's Significant Other) communicated understanding of the issue and stated she would contact residents next of kin. Spoke with (V62 Police Officer) regarding the multiple calls made to the police dept. (Local Police Department) (V62) stated that understanding of abuse of emergency line needs to be communicated to resident. (V62) said that he would contact (V61) to also update her on what was going on. Telephone number provided by nurse. Abuse Coordinator (V1 Former Administrator) contacted by nurse to explain what was happening. Explained that resident was being sent to the ED due to being belligerent toward staff, ad demanding to be taken to (Name of Out of State Hospital) ER or (Name of Local Hospital) swing bed. Resident was taken to (Name of Hospital) ER by EMS (Emergency Medical Services) staff at 11:25 AM. On 6/23/26 at 2:32 PM, V5 (LPN) said she was the nurse caring for R1 on 5/23/26. V5 stated everything was normal, R1 had received pain medication around 5:00 AM then V5 stated she administered pain medication to R1 around 9:00 AM. V5 said R1 requested to be sent to a local hospital for swing bed services and V5 told R1 that a referral would have to be sent to the local hospital prior to R1 being sent. V5 said R1 then requested to be sent to the hospital R1 had been at prior to being admitted . V5 said she told R1 there wasn't much they could do for him at the ER. V5 said R1 kept calling 911 so I finally sent him out to the hospital R1 was at prior to his admission to the facility. V5 said R1 was just a crotchety old man who would scream and yell for his pain meds. V5 said R1 told V5 his hip was hurting and V5 said she told R1 I knew it was hurting but it wasn't broken it was just fractured, and I finally just said OK I'll send you out. When V5 was asked why she did not contact a physician, V5 stated she called the on call nurse (V63/LPN/Wound Nurse) and the administrator to let them know what was going on and did not call a physician. R1's Electronic Medical Record (EMR) 5/23/26 Progress Notes documented no medical provider was notified of R1's increase in pain. On 6/11/26 at 12:34 PM, V3 (Medical Director) said he would expect staff to notify a medical provider if a resident had an increase in pain. The facility's 12/2024 Significant Condition Change and Notification policy documented in part . Purpose: To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below:. A significant change in the resident's physical, mental or psychosocial status. (See below for examples). Abnormal, unusual or new complaints of pain. When the above situations exists, the licensed nurse will contact the resident's representations and their medical provider. The medical practitioner will be contacted immediately for any emergencies regardless of the time of day. If the medical practitioner cannot immediately be reached in an emergency, the facility medical director will be called. If that medical practitioner cannot be reached, the director of nursing or the charge nurse can make arrangements for transportation to the emergency department. All significant changes will be recorded. in the resident record. 2. R12's admission Record with a print date of 6/24/26 documents R12 was admitted to the facility on [DATE] with diagnoses that include cerebral infarct, myasthenia gravis, muscle weakness, cognitive communication deficit, dysphagia, anemia, heart disease, cardiac pacemaker, and history of falls. R12's current Care Plan documents a Focus area of, (R12) has anemia. Date Initiated: 06/09/2026. This Focus area includes the intervention of .Monitor/document/report to MD (physician) PRN (as needed) following s/sx (signs/symptoms) of anemia: pallor, Fatigue, Dizziness, Syncope, Headache, Palpitations, Weakness, Feeling of cold, Low Hgb/hct (hemoglobin/hematocrit), SOB (shortness of breath) on exertion, Sore tongue, Chest pain, Tinnitus, Headache, Changes in cognition. Date Initiated: 03/23/2026. R12's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 06, indicating a severe cognitive deficit. R12's Progress Notes document the following. 6/6/26 3:42 AM, Resident continues on new medication Mirtazapine QHS (every night) for decreased appetite and Scopolamine Patch for nausea/increased secretions. Resident was alert and took HS medications whole with mashed watermelon which had been thickened. Resident tolerated well with no c/o (complaints of) nausea or difficulty swallowing. She is resting in bed quietly with eyes closed. Alert but drowsy at this time. Easy to wake to verbal stimuli. She denies complaints at this time. Skin to coccyx is red with a small round dark purple area in the center (less than 1 cm (centimeter) in circumference). Treatment order updated to apply zinc paste and cover with foam dressing for protection. Also noted multiple small hard red bumps to bilateral labia majora and around anus that appear to be ingrown hairs with no s/s (no signs or symptoms) of infection. She has had scant amount of urine output this shift. Urine is dark amber in color and malodorous. VSS (vital signs) BP (blood pressure) 122/80 (manual), HR (heart rate) 78, RR (respirations) 20, SPO2 94% on room air. Respirations even and unlabored. No s/s (signs/symptoms) of distress or discomfort noted. Bed in lowest position with wheels locked for safety. Call light within resident's reach. 6/6/26 11:07 AM, Res (resident) slept well last night. Awoken this am (morning) and res (resident) to eat breakfast. Res left alone then came back and was able to get res to eat half her yogurt and a small cup of water. Mouth care given due to dry lips. Continues on Scopolamine 1.5/72 hr (hour) patch noted to left ear for excess mucous/nausea x 10 days and Mirtazapine 7.5 mg (milligrams) at hs (nighttime). Skin warm and dry. Color wnl (within normal limits). Res. Speech very soft. Call light within reach. To continues (sic) current poc (plan of care). 6/6/26 3:27 PM, Resident awake and kicking legs off the side of her bed. Res said she was getting up in chair. Res very week (sic). Res drinking her cold water really well today. Res only ate 2 bites of meat and gravy and 2 bites of mashed potatoes at lunch and said she did not want anymore and began belching. Res afraid she was getting sick. Res assisted with check and change and has been wet x (times) 2 today. No family here today so far noted. Call light within reach and bed remote. TV turned on for res as well. To continue current poc. R12's progress notes do not document physician notification of the change in condition, including the dark amber malodorous urine. On 6/18/26 at 3:08 PM, V29 (CNA/Certified Nursing Assistant) stated she called V2 (Director of Nurses/DON) and reported a decline in R12's condition. V29 stated she reported R12 had a green discharge and mucus bumps on her labia. V29 stated she reported the change to V44 (Licensed Practical Nurse/LPN) who told her she thought they had already done blood work. V29 stated she felt like R12 needed to be sent to the hospital for evaluation but V2 told her she would check on it the next morning. V29 stated she didn't follow up with V2 to see if anything was done. On 6/24/26 at 5:00 PM, V44 (LPN) stated R12 had a decline in her condition, and she remembered her urine being dark and a vaginal discharge. V44 stated she didn't remember if she contacted the physician or if she passed it on to day shift to contact them. V44 stated if she had contacted the physician she would have documented it in the progress note unless it was a crazy day and she forgot to. On 6/22/26 at 3:10 PM, V2 (DON/Director of Nurses) stated V29 (CNA) called her and reported the symptoms of dark urine and discharge, and she called the facility and spoke with an unknown agency nurse. V2 stated she told them to call telehealth. V2 stated the next time she was at the facility she looked at R12's progress notes but didn't read them. V2 stated there was a note in there so she was sure they had contacted the physician. V2 stated she didn't assess R12 or follow up. V2 stated she would expect the nurse to notify the physician. On 6/22/26 at 3:16 PM, V1 (Former Administrator) stated she was unaware of the decline in R12's condition and/or that the physician wasn't notified. On 6/24/26 at 9:10 AM, V39 (Power of Attorney) stated R12 had stopped eating and she didn't want a bunch of tests done. V39 denied concerns with the care R12 received at the facility. On 7/6/26 at 10:21 AM, V18 (Regional Clinical Director) stated she had reached out to the physician office and they were unable to find any communication from the facility regarding R12's change in condition. V18 stated the physician should have been notified. The facility Significant Condition Change and Notification policy dated 12/2024 documents, Purpose: To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below.Symptoms of infectious process.other abnormal assessment findings.Procedure: When any of the above situations exists, the licensed nurse will contact the resident's representative and their medical practitioner. Prior to calling the medical practitioner the nurse will complete the SBAR assessment.The medical practitioner will be contacted immediately for any emergencies regardless of the time of day. Non-emergency notifications may be made the next morning if the situation occurs on the late evening or night shift. This applies to any day of the week including holidays. If the medical practitioner cannot immediately be reached in any emergency, the medical director will be called. If that medical practitioner cannot be reached the director of nursing or the charge nurse can make arrangements for transportation to the emergency department. Each attempt will be charged as to the time the call was made, who was spoken to, and what information was given to the medical practitioner. In a non-emergency situation, the primary medical practitioner will be called unless he/she has left an alternate name to call. If after two attempts, there is no response to calls, the medical director will be contacted.Change of condition is reviewed by DON (Director of Nurses) or designee for the continued need for additional documentation.

Based on interview and record review the facility failed to report an allegation of staff to resident abuse immediately to the administrator and to the state agency (Illinois Department of Public Health) for 1 of 6 residents (R4) reviewed for abuse and neglect in the sample of 15.Findings include:R4's admission Record documented an admission date of 3/9/26 with diagnoses including dependence on renal dialysis, muscle weakness, and need for assistance with personal care. R4's 6/8/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R4 was cognitively intact.R4's 4/8/26 at 10:24 PM Progress Note authored by V23 (Licensed Practical Nurse/ LPN) documented in part .Resident up in wheelchair propelling towards front door of facility. Facility phone rang and this nurse answered, finding that resident was on the phone with the police due to him calling 911. Nurse explained that resident was fine and in wheelchair at nurse's station. Resident had refused to go to bed earlier and now was telling police on phone to come and pick him up. This nurse called resident's significant other and explained what was going on with resident. Significant other said she was the POA (Power of Attorney) and wanted for nurse to take resident's phone until tomorrow when she gets here. Nurse asked significant other to speak with resident and maybe he would calm down. Phone given to resident for him to talk to family, but resident began cursing and yelling in phone and threw phone that nurse. Resident then grabbed items on nurse's station and started throwing items on floor and at staff. Resident assisted to his room by several staff due to resident kicking and punching. Resident face kicked CNA (Certified Nursing Assistant) but only caught CNA glasses. Resident grabbed nurse's arm and started cursing nurse, stating, you are a f*****g b***h and I will kill you. Other staff present at the time and removed resident's hand from nurse's arm.R4's 4/9/26 at 1:30 PM Progress Note documented in part .Resident has been up in w/c most of today. No behaviors or aggression noted this shift. Resident's spouse came in and brought paperwork for POA gave to Social Services to review and upload into chart. Resident's cell phone was given to spouse.The facility's investigation folder of R4's 5/15/26 incident contained an undated statement from V24 (Certified Nursing Assistant/ CNA) documenting in part . (V24) stated that she was aware of the phone being taken from (R4) the first time around the time (R4) was moved from the 400 hall (that was around 4/8/26). (V24) stated that (R4) called the police and (V23 Licensed Practical Nurse/ LPN) snatch [sic] the phone out of his hand and told him to get the hell down there. (V17) was in the building at the time. (V24) stated (V24) told (V17) and (V17) stated I know we need to have a meeting. (V24) stated that (R4) was combative with staff and had hit (V23) and (V23) forced (R4's) arms down on his lap. (V24) stated that (R4) told (V23) to stop, and (V23) told (V24) to get on my d**n hall. The last time I (V24) worked (R4) followed me around and asked for his phone. I (V24) asked (V17) about it and (V17) said absolutely not sir and then said I am not dealing with (R4). (V24) was asked if she reported this to anyone and she stated (V17). The abuse policy was discussed with (V24) and who and when alleged abuse must be reported. (V24) stated that the staff are all like family and you don't want to cause a problem.The facility's investigation folder of R4's 5/15/26 incident contained an undated statement from V23 documenting in part . 7. Have you witnessed a staff member taking (R4') cell phone? Couple of months ago but this incident May. Comments: A couple months ago (R4) was calling 911 and he was being physically abusive c (with) staff so I called (V64 R4's Significant Other) (to come sit with (R4)). (V64) said to that (R4's) phone and (V64) would be in and get it. That is all I know personally. Denied ripping from hands. Told (R4) that (V64) was going to come and get. (Education provided- res. (resident) rights).On 6/23/26 at 3:27 PM, V24 (CNA) stated R4 is loud and curses a lot. V24 stated during the incident involving V23 (LPN) R4 had just been moved from the 400 hall to the 200 hall and was confused. V24 stated R4 came to the nurse's station and was confused about where he was and asking to go home. V24 stated R4 was trying to talk to V23 and she said I'm not listening to this, go back to your room. R4 responded with listen b***h I'm going to call the police. V23 said hell no, spun R4's wheelchair around and R4 threw his feet on the ground. R4 grabbed the caboodle sitting on the nurse's station and smacked V23 (LPN) with it. V24 stated night shift was coming in and V23 said to the night shift CNA's to help her. V24 stated V23 was trying to get R4 down the hall and the night shift CNA's went to help her. V24 stated she stopped them and told them she could get him in bed. V24 stated they transferred R4 to bed. V24 stated V27 (CNA) was standing at the foot of the bed, V23 and V26 were standing between the bathroom and closet door. V24 stated R4, kicked V27 and hit V23 in the face. V24 stated V23 grabbed R4's wrist and she V24 called V17 (Assistant Director of Nursing/ ADON) and told her what happened and she was afraid to leave the facility and leave R4 alone. V24 stated V17 told her she was on her way into the facility and would check on him. V24 stated she wrote a statement about it and gave it to V1 (Former Administrator).On 6/23/26 at 2:54 PM, V23 stated R4 was calling 911 and the police were calling the facility so she called V64 (R4's Significant Other) and she said R4 wouldn't listen to her if she tried to talk to him. V23 stated she went to R4's room and he was calling 911 and screaming at the top of his lungs. V23 stated she entered his room, and two midnight shift CNA's V27 (CNA) and V26 (CNA) came in to assist her when they heard R4 screaming obscenities at V23. V23 stated R4 was swinging, hitting, kicking and V27 and V26 showed up so he wouldn't knock the crap out of V23. V23 stated she took R4's phone and gave it to the day shift nurse and told her V64 was coming to get it. When asked how V23 got the phone if R4 was being combative and V23 stated R4 finally gave it to her.On 6/23/26 at 12:58 PM, V17 said no one reported the 4/8/26 incident to her.On 6/18/26 at 4:23 PM, V18 (Regional Clinical Nurse) and V42 (Regional Director of Operations) were asked if there was an investigation of R4's 4/8/26 incident and V42 responded the 4/8/26 incident was investigated with a 5/15/26 incident. V42 was asked why the 4/8/26 incident was not listed in the 5/27/26 final report and V42 responded she was not sure and would have to review the 5/27/26 final report. V42 was asked if a Facility Reported Incident had been completed for R4's 4/8/26 incident and V42 responded no it had not. R4's Facility Reported Incident of 5/15/26 final report on 5/27/26 documented sent to the Illinois Department of Public Health did not document an incident that occurred on 4/8/26.During the course of this investigation, the facility was unable to provide reproducible evidence of an investigation or a Facility Reported Incident of R4's 4/8/26 incident was reported to the Illinois Department of Public Health.The facility's 11/2025 Abuse, Prevention and Prohibition Policy documented in part .The facility Administrator, employee, or agent who is made aware of any allegation of abuse or neglect shall report of cause a report to be made to the mandated state agency per reporting criteria. Such reports may also be made to the local law enforcement agency in the same manner. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the Administrator. The person made aware of allegations of abuse or neglect or the Administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than 2 hours, or per state regulations, after the allegation is made.

Based on interview and record review the facility failed to thoroughly investigate allegations of abuse for 2 of 6 (R4 and R11) residents reviewed for abuse in the sample of 15.Findings Include:1. R4's admission Record documented an admission date of 3/9/26 with diagnoses including dependence on renal dialysis, muscle weakness, and need for assistance with personal care. R4's 6/8/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R4 was cognitively intact. R4's Care Plan Report documented a revised 6/8/26 Focus area . has a behavior problem yells out frequently for staff and at times cursing at staff. Resident curses staff & residents. Makes accusations about staff and missing items. (R4) has a cell phone & has been provided with the person to contact if he has a concern. Resident can become physically aggressive with staff. With a 5/28/26 intervention if resident is upset provide support revised 6/8/26 intervention of Behavior #1: Yelling out for staff. 1. Engage in conversation with resident. 2. Provide resident with reassurance. 3. Provide positive attention. (ask resident if he wants his back scratched) and a revied 6/8/26 intervention of Behavior #2: Physical aggression (Grabbing hair). 1. Providing resident with opportunity to voice concerns and engage in conversation. 2. Provide reassurance. 3. Take resident out to courtyard to talk. R4's Facility Reported Incident of 5/15/26 final report on 5/27/26 documented in part .IDPH (Illinois Department of Public Health) surveyor informed (V42) Regional Director and (V18) Regional Nurse Consultant that resident (R4) alleged that a staff member had ripped his phone out of his hands and took his phone from him. A staff member stated that (V17 Assistant Director of Nursing/ ADON) had gone to the resident's room and took the resident's phone. (V17) was suspended pending investigation. (V2 Director of Nursing/ DON) stated that during their morning clinical meeting it was discussed that (R4) had called 911 multiple times and family was going to pick up his phone. It was mentioned at this time that the phone was in the resident's room. (V60 Director of Therapy) stated that she had just been with the resident and his phone was in his room. (V60) stated that she could go get the phone. (V60) stated that she went to (R4's) room and without incident was able to get his phone and gave it to (V17). (V17) was interviewed. (V17) stated that she did not go to the resident's room and take his cell phone. (V17) stated that she was in morning clinical meeting when they discussed (R4) calling 911. (V60) stated that she would go get the phone. (V60) returned with the phone and handed it to her (V17). (V17) stated that she took the phone to the nurse (V22 Licensed Practical Nurse/ LPN). (V17) was told that the family was going to come to the facility and pick up the phone. (V60) was interviewed. (V60) stated that she was in the morning clinical meeting when the team was discussing (R4) calling 911. (V60) stated that she was just with the resident and the phone was still in the room and offered to get the phone. (V60) stated that she went to the room to get the phone, and without incident obtained the phone and gave it to (V17). Other staff who were interviewed had no direct knowledge of the incident reported. (R4) was interviewed. (R4) stated that he had not had any issues with his phone being taken away and denied having words with anyone regarding his phone. (R4) stated that he called 911 because he felt threatened. When asked to describe the staff member he said it was a woman, do not know her name, she is black, she is heave and had a wig on. (R4) stated that this person came into his room and went over to his roommate, pulled the curtain and gave a finger gesture. (R4) stated that he gave it right back and called her a fat b***h. (R4) stated that it wasn't anything she said that made him feel threatened, but it was because she didn't help him and went to the roommate. (R4) stated that another staff member came in and went to the other side of the room and went behind the curtain. (R4) stated that when she left, she was carrying a bag. (R4) stated that he knows his phone was in the bag. (R4) stated that is why he called the police. (V22) was interviewed. (V22) stated that (R4's) family was notified that he had called 911 multiple times. (V22) stated that family was coming to the facility to get the phone. (V22) stated that she was not sure who took the phone, but (V17) brought it to her, and she locked it up in the cart until family arrived. (V22) stated that she did go into the room to provide care for (R4's) roommate. (V22) stated that (R4) was throwing things across his room and was cursing. (V22) said that she pulled the privacy curtain but make no physical contact with (R4). (V64 R4's Significant Other) was interviewed. (V64) stated that she was aware (R4) called 911. (V64) gave the staff directions to get the phone, and someone would come to pick it up. Then IDT (Interdisciplinary Team) reviewed the allegation. Based on statement/ discrepancy provided by (R4), and staff and family interviews, the facility is unable to substantiate the allegation of abuse. The investigation determined that (V17) was not the staff member involved. (R4) was unable to identify the staff member during the investigation. R4's 4/8/26 at 10:24 PM Progress Note authored by V23 (Licensed Practical Nurse/ LPN) documented in part .Resident up in wheelchair propelling towards front door of facility. Facility phone rang and this nurse answered, finding that resident was on the phone with the police due to him calling 911. Nurse explained that resident was fine and in wheelchair at nurse's station. Resident had refused to go to bed earlier and now was telling police on phone to come and pick him up. This nurse called resident's significant other and explained what was going on with resident. Significant other said she was the POA and wanted for nurse to take resident's phone until tomorrow when she gets here. Nurse asked significant other to speak with resident and maybe he would calm down. Phone given to resident for him to talk to family, but resident began cursing and yelling in phone and threw phone at nurse. Resident then grabbed items on nurse's station and started throwing items on floor and at staff. Resident assisted to his room by several staff due to resident kicking and punching. Resident face kicked CNA but only caught CNA glasses. Resident grabbed nurse's arm and started cursing nurse, stating, you are a f*****g b***h and I will kill you. Other staff present at the time and removed resident's hand from nurse's arm. R4's 4/9/26 at 1:30 PM Progress Note documented in part .Resident has been up in w/c most of today. No behaviors or aggression noted this shift. Resident's spouse came in and brought paperwork for POA (Power of Attorney), gave to Social Services to review and upload into chart. Resident's cell phone was given to spouse. The facility's investigation folder of R4's 5/15/26 incident contained an undated statement from V24 (Certified Nursing Assistant/ CNA) documenting in part . (V24) stated that she was aware of the phone being taken from (R4) the first time around the time (R4) was moved from the 400 hall (that was around 4/8/26). (V24) stated that (R4) called the police and (V23 Licensed Practical Nurse/ LPN) snatch [sic] the phone out of his hand and told him to get the hell down there. (V17) was in the building at the time. (V24) stated (V24) told (V17) and (V17) stated I know we need to have a meeting. (V24) stated that (R4) was combative with staff and had hit (V23) and (V23) forced (R4's) arms down on his lap. (V24) stated that (R4) told (V23) to stop, and (V23) told (V24) to get on my d**n hall. The last time I (V24) worked (R4) followed me around and asked for his phone. I (V24) asked (V17) about it and (V17) said absolutely not sir and then said I am not dealing with (R4). (V24) was asked if she reported this to anyone and she stated (V17). The abuse policy was discussed with (V24) and who and when alleged abuse must be reported. (V24) stated that the staff are all like family and you don't want to cause a problem. On 6/23/26 at 3:27 PM, V24 (CNA) stated R4 is loud and curses a lot. V24 stated during the incident involving V23 (LPN) R4 had just been moved from the 400 hall to the 200 hall and was confused. V24 stated R4 came to the nurse's station and was confused about where he was and asking to go home. V24 stated R4 was trying to talk to V23 and she said I'm not listening to this, go back to your room. R4 responded with listen b***h I'm going to call the police. V23 said hell no, spun R4's wheelchair around and R4 threw his feet on the ground. R4 grabbed the caboodle sitting on the nurse's station and smacked V23 (LPN) with it. V24 stated night shift was coming in and V23 said to the night shift CNA's to help her. V24 stated V23 was trying to get R4 down the hall and the night shift CNA's went to help her. V24 stated she stopped them and told them she could get him in bed. V24 stated they transferred R4 to bed. V24 stated V27 (CNA) was standing at the foot of the bed, V23 and V26 were standing between the bathroom and closet door. V24 stated R4, kicked V27 and hit V23 in the face. V24 stated V23 grabbed R4's wrist and she V24 called V17 (Assistant Director of Nursing/ ADON) and told her what happened and she was afraid to leave the facility and leave R4 alone. V24 stated V17 told her she was on her way into the facility and would check on him. V24 stated she wrote a statement about it and gave it to V1 (Former Administrator). The facility's investigation folder of R4's 5/15/26 incident contained an undated statement from V23 documenting in part . 7. Have you witnessed a staff member taking (R4') cell phone? Couple of months ago but this incident May. Comments: A couple months ago (R4) was calling 911 and he was being physically abusive c (with) staff so I called (V64 R4's Significant Other) (to come sit with (R4)). (V64) said to that (R4's) phone and (V64) would be in and get it. That is all I know personally. Denied ripping from hands. Told (R4) that (V64) was going to come and get. (Education provided- res. (resident) rights). On 6/23/26 at 2:54 PM, V23 stated R4 was calling 911 and the police were calling the facility so she called V64 (R4's Significant Other) and she said R4 wouldn't listen to her if she tried to talk to him. V23 stated she went to R4's room and he was calling 911 and screaming at the top of his lungs. V23 stated she entered his room, and two midnight shift CNA's V27 (CNA) and V26 (CNA) came in to assist her when they heard R4 screaming obscenities at V23. V23 stated R4 was swinging, hitting, kicking and V27 and V26 showed up so he wouldn't knock the crap out of V23. V23 stated she took R4's phone and gave it to the day shift nurse and told her V64 was coming to get it. When asked how V23 got the phone if R4 was being combative and V23 stated R4 finally gave it to her. On 6/23/26 at 12:58 PM, V17 said no one reported the 4/8/26 incident to her. On 6/18/26 at 4:23 PM, V18 (Regional Clinical Nurse) and V42 (Regional Director of Operations) were asked if there was an investigation of R4's 4/8/26 incident and V42 responded the 4/8/26 incident was investigated with the 5/15/26 incident. V42 was asked why the 4/8/26 incident was not listed in the 5/27/26 final report and V42 responded she was not sure and would have to review the 5/27/26 final report. V42 was asked if a Facility Reported Incident had been completed for R4's 4/8/26 incident and V42 responded no it had not. During the course of this investigation, the facility was unable to provide reproducible evidence of an investigation of R4's 4/8/26 incident. 2. R11's admission Record with a print date of 6/24/26 documents R11 was admitted to the facility on [DATE] with diagnoses that include ataxia, anxiety disorder, dementia, panic disorder, subdural hemorrhage, dysphagia, muscle weakness, and repeated falls. R11's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 13, indicating R11 is cognitively intact. R11's current Care Plan documents a Focus area of, (R11) has an ADL (activities of daily living) Self Care Performance Deficit. Date Initiated: 02/06/2024. This Focus area includes interventions of resident requires assist of one staff for bathing, toileting and transfers. The State Report dated 4/30/26 documents on 4/30/26 R11 stated she told V29 (CNA/Certified Nursing Assistant) she needed to use the restroom and V29 told her she was taking her to shower, and she could toilet in the shower room. The report documents as V29 and (V41/CNA) were transferring her to the commode there was feces noted inside, so they flushed the toilet and when they did the toilet tried to overflow. The report documents R11 was upset because she used the bathroom in the shower instead of on the commode. The report documents the allegation of abuse was not substantiated. There is no mention in this report of V29 pouring shampoo on R11's head. A written statement of the incident that occurred on 4/30/26 by V24 (CNA) included with the investigation documents R11 was crying and reported to V24 the following, .V29 refused to let her use the bathroom in her room demanded she use the bathroom in the shower, cause she was a shower, forced her to have BM (bowel movement) in shower cause toilet over flown resident stated (V29) dumped shampoo on her head refused to give her a wash cloth for her eyes, residents eyes were very red in color. She was very emotional, reported to (V41 LPN/Licensed Practical Nurse). On 6/23/26 at 3:27 PM, V24 (CNA) stated R11 reported to her V29 had taken her to the shower room and dumped cold soap on top of her head after not taking her to the bathroom when she requested so she had a bowel movement on the shower room floor. V24 stated she reported this to V1 (former Administrator) and an unknown shift key nurse who was on duty. On 6/24/26 at 10:23 PM, V41 (LPN) stated a month or so ago, R11 told unknown CNA's, V29 made her use the bathroom in the shower room and dumped shampoo on her head while in the shower. V41 stated she filled out a risk management and turned it into V1 (Former Administrator). V41 stated V29 said she didn't make R11 use the bathroom in the shower, but she put her on the toilet and had to pull her back up because the toilet was clogged from previous use. On 6/25/26 at 2:34 PM, V43 (CNA) stated V29 gave R11 a shower on an unknown day and R11 was crying. V43 stated they wrote a statement on it, and she told them she didn't give her a towel to wash her eyes and there was stuff (shampoo) in them. V43 stated R11 was crying and very upset. V43 was unable to recall the exact date but said it happened 2-3 months ago. When asked if she felt like the incident was purposeful, V43 stated that is not V29's character but if she was provoked, she may do something like that and having a bowel movement in the floor would have provoked R11 and R11 getting upset would/could have provoked V29. On 7/6/26 at 9:44 AM, when asked about the incident that occurred on 4/30/26 with R11 in the bathroom, V29 (CNA) stated she took R11 to the shower room and she had to use the bathroom. V29 stated there was feces in the commode but she thought it would go down, so she asked the other CNA who was with her to flush the commode. V29 stated she put R11 on the commode and it started overflowing so she got her off the toilets so she wouldn't get dirty water with feces in it on her. V29 stated R11 was upset but she didn't poop on the floor. V29 stated she put a trash can under the shower chair for her to use the bathroom in. V29 stated she then gave R11 a shower and washed her hair like she did everyone else's. V29 stated she washed R11's body, rinsed her off, then gave her a rag to put over her eyes so she wouldn't get soap in them. V29 stated she also used her hand to shield R11's eyes. V29 stated R11 was fine at that time and asked V29 to blow dry her hair. V29 stated she did that and R11 acted like nothing was wrong. V29 stated 20-30 minutes after finishing R11's shower, V24 (CNA) asked her about R11's shower and V29 told her she didn't do anything wrong. V29 stated she then went to V17 (Former Assistant Director of Nurses) and spoke with her about it. V29 stated V17 told her she did the right thing and to not worry about it. V29 stated V17 told her she would bring it up in morning meeting. V29 stated when the unknown nurse did her report V1 (Former Administrator) said it hit as potential abuse. V29 stated V1 called and asked her to step outside, so she did, and V1 told her she was being suspended for potential abuse and neglect. V29 stated V1 asked her about R11's shower. V29 stated she told V1 the same thing she had shared with this surveyor. V29 stated after the investigation she was in-serviced on toileting residents in their rooms before taking them to the shower room. V29 stated V1 asked her about the shampoo, and she told her she gave R11 a rag to cover her eyes. On 7/6/26 at 10:11 AM, R11 stated V29 insisted on her pooping in the shower floor because the commode in the shower room was flowing over and nasty. R11 stated she had to go to the bathroom before she left her room and for some reason V29 wouldn't let her use the bathroom in her room. When asked if there were any issues with getting her hair washed, R11 stated there wasn't anything but she did go front to back and used hand gestures to show rubbing from the neck area to the forehead area. R11 denied any negative impact while getting her hair washed. On 7/6/26 at 10:17 AM, V52 (CNA) stated she helped V29 transfer R11 to her chair so she could take her to the shower room, but she was never in the shower room with V29 and R11. V52's handwritten statement dated 4/30/26 included with the abuse investigation dated 4/30/26 documents, I, (V52) assisted (V29) with transferring (R11) to the bathroom in the shower room. She was complaining of needing to go to the restroom. (V29) explained to her we would take her to the restroom in the shower room. Once, we transferred her to the shower chair, onto the toilet, I noticed there was poop clogged. I flushed it causing it to overflow. That's when we then expressed that if you still are in urgent need of using the restroom, we'll have to push you to the shower drain and allow you to go and we'll clean after you. We also were unable to find (name of maintenance) to help us with the issue, let alone a plunger. Signed by V52 (CNA). On 7/6/26 at 11:14 AM, V52 (CNA) reviewed her statement for the investigation dated 4/30/26 and stated some of the statement wasn't correct. V52 stated V29 caught her in the hallway and asked her to help transfer R11. V52 stated she assisted V29 in R11's room and never went to the shower room with them. V52 stated she had no knowledge of what happened in the shower room. V52 stated V29 told her about the clogged toilet and asked her to get maintenance. When asked if it was her signature on the written statement, V52 stated it was. When asked if it was her printed handwriting in the body of the statement, V52 stated it was. V52 then stated she wanted to tell this surveyor the truth and then said to this surveyor when V1 (Former Administrator) was working she would tell them she would have them fired or put on the do not return list if they spoke with state other than to answer yes/no. V52 stated V1 told her what to write in her statement dated 4/30/26 and it was not accurate. V52 stated the information wasn't accurate but she couldn't afford to lose her job, so she did what V1 (Former Administrator) told her to do. The facility State Report dated 6/23/26 includes the following. On 6/23/26 during an open survey, an (State Agency) surveyor reported an allegation of staff conduct toward a resident when providing care.C.N.A. (Certified Nursing Assistant) was previously suspended related to another allegation. Nurse completed a head-to-toe assessment. Physician, POA, (Power of Attorney), local police and ombudsman notified.On 6/23/26, (R11) reported to an (State Agency) Surveyor that (V29) (CNA) poured shampoo into her eyes while giving her a shower. (V29) was actively suspended when this allegation was made related to a separate investigation. In a follow-up interview on 6/24/26 with (R11), it was reported about a month ago, (V29) poured cold shampoo on her head, and it ran into her eyes. Multiple residents were interviewed and denied any similar issues related to this allegation. A follow up interview was conducted with V41 (LPN/Licensed Practical Nurse) who reported this incident was previously documented on and was reported to (V1) (former) Administrator. (V41) reported that she didn't personally witness anything, but it was reported to her by staff. (V24) (CNA) stated that (R11) was upset and crying, which was not a typical behavior for her. (R11) stated that the CNA poured shampoo on her head and made her poop on the floor in the shower. (V41) reported speaking with (V29) about the alleged incident, and she denied dumping shampoo on (R11's) head and the toileting issue was due to the toilet backing up. After review of V52 (CNA) statement from the investigation initiated on 4/30/2026 she reported that she assisted (V29) with transferring (R11) during toileting and confirmed that the toilet was backed up. (V52) denied being present when the shampoo was put on (R11) head. As a result of this investigation, it was identified that the facility had prior knowledge of the allegation and that it was reported on 4/30/2026. This report reflects an investigation related to (R11) having a bowel movement on the shower-room floor. This investigation resulted in findings that the resident did in fact have a bowel movement on the shower-room floor following a transfer when the toilet backed up and could not be used. Additional statements were reviewed from the 4/30/26 investigation that noted shampoo was dumped on (R11's) head. A follow up interview was conducted with to reported [sic] that she assisted with transferring (R11) during toileting but was not present when shampoo was put on (R11's) head. (V29) was re-interviewed via phone on (V52) reported that (V1), prior Administrator, had questioned her previously related to the complaint made by (R11) with the shampoo. (V29) stated, 'I never put shampoo directly on a residents head, I put in my hands, lather it, then wash their hair.' (V29) acknowledged that (R11) was upset that day but denied any inappropriate conduct during bathing. At the conclusion of this investigation, it was identified that portions of the allegation were previously investigated and reported to the Department on 4/30/2026 with a final report being submitted on 5/4/2026. Additional follow-up and interviews were conducted but the facility could not validate that there was inappropriate conduct by the employee related specifically to (V29) pouring shampoo on (R11's) head. As of 6/26/2026, (V29) is no longer employed by the facility. On 7/6/26 at 10:21 AM, V18 (Regional Clinical Director) stated after reviewing the investigation dated 4/30/26 they found a statement from a staff member regarding soap in R11's eyes. V18 stated that it was not investigated during the 4/30/26 investigation and as the regional she wasn't told about it during the 4/30/26 investigation. On 7/7/26 at 12:13 PM, V1 (former Administrator) stated she did not recall V24's statement in the 4/30/26 investigation regarding soap being poured on R11's head and did not remember anything about shampoo on R11's head. V1 stated she did not investigate it and stated sometimes soap does get in their eyes. V1 stated she did not ask V52 (CNA) to change her 4/30/26 statement and did not tell her what to write in the statement. The facility Abuse, Prevention and Prohibition Policy dated November 2025 documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Resident abuse [NAME] be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action.

Based on observation, interview, and record review the facility failed to prevent, identify, and treat Moisture Associated Skin Damage (MASD) and failed to follow physician orders for lab testing after a change in condition for 2 (R1 and R2) of 3 residents reviewed for change in condition in a sample of 7. This failure resulted in R2 developing wounds that caused pain due to MASD.Findings include:1. R2's admission Record documented an admission date of 7/19/17 with diagnoses including multiple sclerosis, abnormalities of gait and mobility, and abnormal posture.R2's 4/7/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Section GG documented R2 was dependent for toileting hygiene and section H documented R2 was always incontinent of bowel and bladder.R2's Care Plan documented a revised 5/24/23 focus area of (R2) has potential/ actual impairment to skin integrity r/t MS (related to multiple sclerosis), decreased mobility with a 5/24/23 intervention of Monitor pressure areas for changes in color, sensation, temperature and report any change to nurse.R2's Order Summary Report documented a 4/22/26 order to .gently cleanse buttocks and upper posterior thighs with wound spray and pat dry, apply zinc paste to buttocks and thighs, attach (incontinence brief) loosely when in bed per (Wound Treatment Company).R2's weekly skin assessment documented on 5/19/26 at 10:12 AM by V5 (Licensed Practical Nurse/LPN), prior to skin check, MASD (Moisture Associated Skin Damage) with no open areas.On 5/19/26 at 9:52 AM, V3 (Certified Nursing Assistant/ CNA) said she thought R2 had open wounds that were not documented and were not being treated.On 5/19/26 at 4:06 PM, V3 and V4 (CNA) were assisting R2 to bed and performing incontinence care. Upon removal of R2's incontinence brief, R2 was observed to have MASD to her inner upper thighs and buttocks with 3 open areas. 1 open area to the right buttock, 1 open area to the right posterior thigh, and 1 open area to the right front groin fold. V2 (Director of Nursing/ DON) was alerted by the surveyor of R2's open wounds and V2 said she would have V5 (Licensed Practical Nurse/ LPN) reassess R2.R2's weekly skin assessment documented on 5/19/26 at 5:40 PM by V5, documented MASD with an open wound to the pubis measuring 1.81 cm x 3.09 cm x 0 cm (length x width x depth), an open wound to the right gluteal fold measuring 0.76 cm x 1.27 cm x 0 cm, and an open wound to the right rear thigh measuring 0.45 cm x 0.82 cm x 0 cm. With the accompanying progress note documenting in part .resident does not wish to use appropriate cream treatment as ordered and only wishes to use barrier cream r/t (related to) the zinc paste being thicker and harder to wash off. Educated resident on the difference in the cream treatments and will continue to monitor area.On 5/20/26 at 10:00 AM, V5 said she did not initially see R2's open areas due to R2 have scar tissue that was lighter than the surrounding tissue. R2's 5/20/26 progress note at 8:19 AM documented in part . This nurse notified (Nurse Practitioner) with (Wound Treatment Company) r/t (related to) resident refusing zinc Tx (treatment) and has some small open area r/t MASD, pending reply at this time.On 5/19/26 at 8:04 PM, V4 (CNA) said R2 had the open areas for about a month and R2's perineal area had been macerated for at least a couple weeks. V4 said the facility did not have any cloth incontinence pads and all incontinent residents wore an incontinence brief at all times. V4 said instead of cloth incontinence pads, staff folded up a bath blanket to use as an incontinence pad in case the resident's incontinence brief leaked so staff would not have to change the whole bed.On 5/21/26 at 1:47 PM, R2 stated my goodness, when I'm lying in bed my bottom gets to hurting real bad for about the last month. R2 said she liked the cream with the blue top (barrier cream) and not the one with the orange top (zinc paste). R2 was asked why she didn't like the cream with the orange top and R2 stated I think it eats away at you. R2 said she wore an incontinence brief at all times. R2 was asked if she ever asked for her incontinence brief to be taken off and R2 said no, but one night staff put on her incontinence brief but didn't fasten the sides and she thought her bottom was a little bit better that day. On 5/22/26 at 10:49 AM, V2 said the Wound Treatment Company did not see residents with MASD, only residents with pressure wounds stage 3 and 4. V2 said she had a conversation with the medical provider with the Wound Treatment Company and was told they would order zinc paste for someone with MASD and open wounds associated with MASD. V2 was asked if R2 was refusing the treatment, what was the facility going to do and V2 said she was going to have a conversation with V11 (Physician/ Medical Director) later that day when he rounded to attempt to change R2's orders.On 5/26/26 at 2:07 PM, V11 (Physician/ Medical Director) said if new wounds are discovered staff would notify him or the on call medical provider company and the wound consultant company. V11 said he could not recall if he had changed R2's orders from zinc paste to something else but had told the facility to refer R2 to the wound consultant company which was completed on 5/22/26.2. R1's admission Record documented an admission date of 4/10/26 with diagnoses including intertrochanteric fracture of right femur, dysphagia, need for assistance with personal care. R1's 4/17/26 MDS documented a BIMS score of 15, indicating R1 was cognitively intact. R1's 4/17/26 MDS section GG documented R1's Prior Functioning: Everyday Activities were Need Some Help- Resident needed partial assistance from another person to complete any activities for Self-Care and Independent with Indoor Mobility, Stairs, and Functional Cognition. R1's 4/17/26 MDS section GG also documented Functional Abilities, assessment period is the first 3 days of the stay, R1 was dependent for toilet hygiene, substantial/ maximal assist with shower/ bathe self, lower body dressing, putting on/ taking off footwear, partial/ moderate assist with oral hygiene, upper body dressing, personal hygiene, and independent with eating. R1's 5/16/26 BIMS assessment documented a score of 3, indicating R1 was severely cognitively impaired.On 5/20/26 at 9:00 AM, R1 was sitting in the recliner in his room talking to V6 (Registered Nurse/ RN). R1's speech did not make sense and R1 was becoming frustrated with V6. R1 was very agitated and confused. Upon entry to R1's room for interview R1 refused to be interviewed.On 5/20/26 at 9:04 AM, V6 said R1 had a severe decline in his mental state. V6 said she was not sure if R1 had been sent to the hospital for further evaluation and testing. V6 said R1 had been seen by a doctor but was unsure what treatments had been ordered. V6 said she would review R1's medical record.R1's 5/12/26 physician progress note documented in part . being seen for regulatory H&P (History and Physical). He currently is without any specific complaints. However, staff has voiced concerns thathis [sic] mental status has deteriorated over the last couple days. Patient is alert and oriented to time place in [sic] person. According to staff, he?s [sic] been off at times. Patient was a little slow to respond, but ultimately answered questions appropriately. Confusion was noted per staff. He also initially stated that I was the one that got hospice in it involved with him. Which is not true. Disorientation, unspecified: There has been a change from his baseline according to the nursing staff. Will need to check a urinalysis, chest, x-ray [sic] and some blood work. Other relevant intervention: We?ll [sic] get some bloodwork and check a magnesium level.R1's Order Summary Report documented R1 was not receiving hospice services. R1's Order Summary Report under Laboratory documents orders for a Complete Blood Count (CBC), Complete Metabolic Panel (CMP), and Magnesium levels with an order date of 5/12/26 and an order for a CBC, CMP, and Magnesium level on 5/20/26.On 5/20/26 at 9:35 AM, V2 (Director of Nursing/ DON) said she reviewed R1's medical record during morning meeting and had found the 5/12/26 progress note. V2 said the facility had missed ordering the labs for R1. V2 said she had called the doctor and obtained orders for a CBC, CMP, and Magnesium level to be drawn.On 5/20/26 at 9:40 AM, V2 was asked when a medical provider is rounding, who puts in the orders and V2 said usually V6 (RN) rounds with medical providers and puts their orders in. V2 was asked how R1's lab orders were missed and V2 said the medical provider was new and had rounded on his own or with floor nurses. V2 was asked who is responsible for ensuring orders are accurately taken and completed and V2 said she was responsible.On 5/20/26 at 2:47 PM, V6 was asked if R1's labs that had been drawn earlier that day had been faxed back to the facility and V6 said she just spoke with the lab to have them faxed over. V6 said while she was talking to the laboratory technician they asked if V6 wanted the urine culture faxed over too and V6 told them she had not sent any urine. V6 said she was told R1 had a urine culture from 5/10/26 and V6 told them to fax it as well because she was not aware of a urinalysis.On 5/26/26 at 2:07 PM, V11 (Physician/ Medical Director) said he expected the facility to follow Physician orders. V11 said he expected staff to review Physician progress notes and if it was unclear what labs the Physician wanted, the facility should contact them to get clarification.The facility's 2/2026 Skin Identification, Evaluation, and Monitoring Policy documented in part . A licensed nurse will evaluate skin integrity through a physical skin evaluation upon admission, weekly, and when a significant change is identified. Licensed nurses will evaluate the resident's risk for skin breakdown using the Braden Risk Assessment tool upon admission. and when a significant change is identified. Licensed Nurse Weekly: A. Complete a Weekly Skin Check to evaluate for changes in skin integrity. B. Document in medical record the finding of weekly skin assessment. b. If new wound is identified: i. Initiate protective dressing. ii. Notify health care provider of findings and for further treatment orders. C. Document evaluation in the medical record. Identification of Skin Conditions. B. Moisture Associated Skin Damage (MASD) is a general term for skin damage that occurs when the skin is exposed to moisture such as perspiration, urine or feces or both. for a prolonged period. b. MASD can be presented as mild, moderate, or severe and can occur in all client age groups; i. Mild MASD presents as irritation and inflammation of the skin. ii. Moderate to severe MASD presents with blistering and erosion and/ or denudation of the epidermal layer to the dermis. c. Secondary fungal and bacterial infections may occur. Interventions and Prevention: Skin. Incontinence Management. e. Utilize properly fitting incontinence briefs that are absorbent and wick moisture away from the skin on incontinent residents.The facility's 12/2024 Significant Condition Change and Notification policy documented in part . To ensure that the resident's family and/ or representative and medical practitioner are notified of resident changes such as those listed below: A significant change in the resident's physical, mental or psychosocial status (See below for examples). new wounds, bruises or skin tears. change in level of consciousness such as agitation, lethargy, sudden lack of responsiveness or manic behavior. a need to significantly alter treatment. When any of the above situations exists, the licensed nurse will contact the resident's representative and their medical practitioner. the medical practitioner will e contacted immediately for any emergencies regardless of the time of day. Non-emergency notifications may be made the next morning if the situation occurs on the late evening or night shift. All significant changes will be recorded. in the resident record. Change of condition is reviewed by DON or designee for the continued need for additional documentation.

Based on observation, interview, and record review the facility failed to provide prescribed pain medication to 1 (R5) of 3 residents reviewed for medication administration in a sample of 7. This failure resulted in R5 experiencing lower back pain that radiated down her legs causing increased pain and insomnia. Findings include:R5's admission Record documented an admission date of 12/30/25 with diagnoses including hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side, hypertensive urgency, hyperosmolality and hypernatremia, personal history of transient ischemic attack and cerebral infarction without residual deficit, type 2 diabetes mellitus, unspecified viral hepatitis C without hepatic coma, borderline personality disorder, mild persistent asthma, unsteadiness on feet, muscle weakness, hypokalemia, essential hypertension, hypoxemia, and weakness. R5's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R5 is cognitively intact. Section J, Health Conditions, documents that R5 takes a PRN (as needed) pain medication and documents R5 has pain frequently. R5's Care Plan includes a Focus area of R1 has pain Fibro-myalgia (initiated on 1/6/26) with a corresponding intervention to monitor/record/report to nurse resident complaints of pain or requests for pain treatment (initiated 1/6/26). On 5/20/26 at 2:47 PM, R5 asked this surveyor if something could be done about her medications as she had not had any pain medication in 4 days. R5 said when she asks for her pain medication, the nurses tell her they don't have any pain medication to give her. R5 stated she was told they had called the pharmacy and the doctor but still had not received any pain medication. R5 said her back pain was really bad and rated her pain to be 10 on a scale of 0-10. R5's Order Summary Report documented a 12/31/25 order for Tramadol 50 mg (milligrams), 1 tablet by mouth every 8 hours as needed for pain. On 5/20/26 at 2:56 PM, the medication cart that served R5's room was observed to have no tramadol tablets present for R5. V6 (Registered Nurse/RN) said R5 did not have any tramadol available. V6 said R5 had asked for a tramadol that morning and V6 told R5 we don't have any for her. V6 said the facility had emailed V11 (Physician/ Medical Director) again that morning requesting a tramadol prescription for R5 but had not heard back. V6 said she had not called the on-call medical provider because she was waiting to see if V11 responded. V6 said she could not obtain any tramadol out of the emergency backup supply because R5 did not have an active order for tramadol. V6 was asked if R5 rated her pain to be a 10 out of 10, could V6 offer R5 a Tylenol and V6 said yes if R5 had an order for Tylenol. R5's Controlled Substances Proof of Use documented 15 tablets of tramadol 50 mg were delivered to the facility on 5/2/26, with the last administration of those 15 tablets being given on 5/15/26. R5's Medication Administration Record (MAR) dated 5/1/26 - 5/31/26 documented 5/15/26 was the last administration of R1's PRN (as needed) tramadol 50 mg until 5/21/26. The MAR shows there were no administrations of R1's PRN tramadol from 5/16/26 through 5/20/26. On 5/20/26 at 2:10 PM, V12 (Regional Clinical Consultant) was alerted of R5 not having any tramadol available and of V6's interview (above) and V12 sighed heavily and said she would have V6 call the on-call provider immediately to obtain a prescription. V12 stated the on-call provider should have already been contacted. On 5/21/26 at 1:53 PM, R5 said she was thankful for getting her pain medication back. R5 said she had a fall prior to her admission to the facility and had an injury to her spine that caused chronic lower back pain that radiated down her legs. R5 said she can't go without pain medication and the days the facility did not have any tramadol for her she could not sleep because she was hurting so bad and at times was in tears. On 5/26/26 at 2:07 PM, V11 (Physician/ Medical Director) said if a resident reported pain and did not have an active prescription for pain medications, he expected staff to call him and he would sign the order or to call the on-call medical provider company to get a prescription. A facility policy for pain/pain management was requested. V12 provided the undated facility policy titled Medication Administration Policy for Senior Living under PRN Medication Guidelines documents Pro Re Nata (PRN/as needed) medication may only be administered based on a written and signed order from a licensed healthcare professional. The order must include medication name, dosage, route of administration, frequency, and any necessary precautions or contraindications. PRN medications shall only be administered as prescribed following the provided instructions and guidelines.Staff members administering the medication must adhere to the 'Five Rights.' Medication administration shall be documented promptly and accurately, including the dateof administration, time of administration, name of medication, dosage, route, and reason for administration. Controlled substances must be signed out on an inventory sheet and counted during shift change with on-coming nurse. Resident's response to medication must be documented within 30 - 60 minutes, along with any observed or reported side effects or reactions. Significant changes in the resident's condition in response to the PRN medication must be documented and reported to the appropriate licensed healthcare professional immediately. There was no reference to the management of pain documented in this policy.

Based on observation, interview, and record review the facility failed to administer an antianxiety medication for 1 (R4) of 3 residents reviewed for medication administration in a sample of 7. This failure resulted in R4 developing withdrawal symptoms including insomnia, sweating, and shaking.Findings include:R4's admission Record documented an original admission date of 11/8/23 with diagnoses including early onset cerebral ataxia, anxiety disorder, and depression. R4's 4/8/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating R4 was cognitively intact.R4's Care Plan Report documented a revised 1/7/26 focus area of R4 has anxiety and currently takes anxiety medications with a 2/12/24 intervention of administer medication as ordered and monitor/ document for side effects and effectiveness.R4's Order Summary Report documented a 3/30/26 order for Ativan 0.5 mg 1 tablet every morning and at bedtime for anxiety.On 5/21/26 at 1:32 PM, R4 said a couple weeks ago the facility ran out of her Ativan and did not tell R4. R4 said she had experienced withdrawal symptoms like sweating and shaking, feeling like she was very hot and then would be ice cold. R4 said there were several nights she couldn't sleep and felt like my insides were trembling. R4 said she had been taking Ativan for a long time. R4 said she was not sure of the name of the nurse she talked to about her symptoms, but that was the nurse that informed R4 the facility had run out of R4's Ativan and would try to reach the doctor to get it refilled.On 5/19/26 at 11:31 AM, V9 (Licensed Practical Nurse/ LPN) said R4 did not have any Ativan for several days and V2 (Director of Nursing/ DON) was aware. V9 said R4 was very tearful during that time but was not aware of R4 having any withdrawal symptoms.On 5/19/26 at 12:22 PM, V2 said she was not aware R4 was not receiving her Ativan.On 5/26/26 at 2:07 PM, V11 (Physician/ Medical Director) said if a resident has been taking Ativan and stops it suddenly the resident could experience withdrawal symptoms such as headache, muscle pains, nausea and vomiting, tremors, etc.R4's Controlled Substances Proof of Use form documented the facility received 4 Ativan 0.5 mg tablets on 5/3/26 with the last tablet being administered on 5/5/26 at 8:00 AM.R4's Controlled Substance Proof of Use form documented the facility received 6 Ativan 0.5 mg tablets on 5/12/26 with the first one being administered on 5/13/26 at 8:00 AM, 8 days after the last dose of Ativan was administered indicating R4 had missed 15 doses of Ativan.R4's 5/1/26-5/31/26 Medication Administration Record (MAR) documented R4's Ativan 0.5mg tablet had been administered from 5/5/26-5/13/26 twice a day, the morning dose on 5/9/26 documented a 5 with the key indicating hold, the morning and even dose on 5/10/26 documented a 6 with the key indicating other- see progress note, the bedtime dose on 5/11/26 documented a 6, and the morning dose on 5/12/26 documented a 6.The undated facility policy titled Medication Administration Policy for Senior Living under Medication Administration documents Medications should be administered according to the 'five rights' of medication use: right resident, right drug, right time, right dose, and the right route.

Based on observation, interview, and record review, the facility failed to ensure meals were served at the scheduled times posted. This failure has the potential to affect all 62 residents residing in the facility. Findings include: R2's admission documented an admission date of 7/19/17. R2's Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. R5's admission Record documented an admission date of 12/30/25. R5's MDS assessment dated [DATE] documented a BIMS score of 15, indicating R5 was cognitively intact. R7's admission Record documented an admission date of 11/25/25. R7's MDS assessment dated [DATE] documented a BIMS score of 14, indicating R7 was cognitively intact. On 5/20/26 at 2:47 PM, R5 and R7 stated they always eat in their room and the meals are always delivered late. R7 said breakfast was usually on time but the noontime and evening meals are sometimes 30 minutes to an hour and a half late. On 5/21/26 at 1:47 PM, R2 said she always eats in the big dining room and the noontime and evening meals are often served late. On 5/21/26 at 12:08 PM, V10 (Licensed Practical Nurse/ LPN) said meals are served late often. V10 said a couple weeks prior to this investigation a meal had been served an hour and a half late. V10 said there is a posted schedule of when meals are to be served. V10 said she was not sure why meals were served late so often. On 5/20/26 at 12:35 PM, V8 (Certified Nursing Assistant/ CNA) stated the noontime meal was over 30 minutes late at the time of this interview. V8 said this was a common occurrence and when meals are late it makes staff get behind in completing other tasks. The facility's undated The Dining Experience posted documented the noontime meal was to be served as follows: Small Dining Room at 12:00 PM, Large Dining Room at12:20 PM, 400 Hall Cart at 12:35 PM, 300 Hall Cart at 12:40 PM, 100 & 200 Hall Cart at 12:50 PM. On 5/20/26 at 12:33 PM, residents were sitting in the small dining room waiting for the noontime meal to be served. On 5/20/26 at 12:49 PM, the meal cart for the small dining room arrived, 49 minutes late, and staff started serving resident meal trays. On 5/20/26 at 1:10 PM, the 400 hall meal cart arrived, 35 minutes late. On 5/20/26 at 1:17 PM, the 300 hall meal cart arrived, 37 minutes late. On 5/20/26 at 1:32 PM, the 100 and 200 hall meal cart arrived, 42 minutes late. The last meal tray on the 100 and 200 hall meal tray cart was delivered at 1:38 PM. On 5/21/26 at 12:07 PM, residents were sitting in the small dining room waiting for the noontime meal to be served. At 12:30 PM, the small dining room meal cart arrived, 30 minutes late. The facility's 5/19/26 Assignment Location List Report documented 62 residents residing in the facility.

Based on observation, interview, and record review the facility failed to ensure timely acquisition of medication refills for 2 (R4 and R5) of 3 residents reviewed for medications in a sample of 7.Findings include:1. R4's admission Record documented an original admission date of 11/8/23 with diagnoses including early onset cerebral ataxia, anxiety disorder, and depression. R4's 4/8/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating R4 was cognitively intact.R4's Care Plan Report documented a revised 1/7/26 focus area of R4 has anxiety and currently takes anxiety medications with a 2/12/24 intervention of administer medication as ordered and monitor/ document for side effects and effectiveness. R4's Order Summary Report documented a 3/30/26 order for Ativan 0.5 mg 1 tablet every morning and at bedtime for anxiety.On 5/21/26 at 1:32 PM, R4 said a couple weeks ago the facility ran out of her Ativan and did not tell R4. R4 said she had experienced withdrawal symptoms like sweating and shaking, feeling like she was very hot and then would be ice cold. R4 said there were several nights she couldn't sleep and felt like my insides were trembling. R4 said she had been taking Ativan for a long time. R4 said she was not sure of the name of the nurse she talked to about her symptoms, but that was the nurse that informed R4 the facility had run out of R4's Ativan and would try to reach the doctor to get it refilled. On 5/19/26 at 11:31 AM, V9 (Licensed Practical Nurse/ LPN) said R4 did not have any Ativan for several days and V2 (Director of Nursing/ DON) was aware. V9 said R4 was very tearful during that time but was not aware of R4 having any withdrawal symptoms. V9 said she could not obtain any Ativan for R4 from the emergency backup stock because R4 did not have an active Ativan prescription at that time but had called the pharmacy several times. V9 said the nursing staff were not allowed to call V11 (Physician/ Medical Director) for medication prescriptions. V9 said if a prescription is needed for a resident nursing staff were to alert V2 and V2 would call V11 to get the prescription.On 5/19/26 at 12:22 PM, V2 said she was not aware R4 was not receiving her Ativan. V2 said if a nurse documents a 5 or 6 on the Medication Administration Record (MAR) the system does not flag it for V2 to review. V2 said if a resident did not have a medication, she expected staff to contact the on call medical provider company to obtain an order. V2 said once the order is received the staff could obtain the medication from the emergency backup medication supply and if the medication was not available, she expected staff to contact the pharmacy for an emergency medication delivery. On 5/19/26 at 3:12 PM, V7 (LPN) said if a resident did not have a medication, she would call the on call medical provider company. V7 said the on call medical provider company would give a 3 day prescription for medications until V11 could be contacted to give a longer prescription. On 5/26/26 at 2:07 PM, V11 said if they did not have an active prescription for anxiety medications he expected staff to call him and he would sign the order or to call the on call medical provider company to get a prescription. V11 said if a resident has been taking Ativan and stops it suddenly the resident could experience withdrawal symptoms such as headache, muscle pains, nausea and vomiting, tremors, etc.R4's Controlled Substances Proof of Use form documented the facility received 4 Ativan 0.5 mg tablets on 5/3/26 with the last tablet being administered on 5/5/26 at 8:00 AM.R4's Controlled Substance Proof of Use form documented the facility received 6 Ativan 0.5 mg tablets on 5/12/26 with the first one being administered on 5/13/26 at 8:00 AM, 8 days after the last dose of Ativan was administered indicating R4 had missed 15 doses of Ativan.R4's 5/1/26-5/31/26 Medication Administration Record (MAR) documented R4's Ativan 0.5mg tablet had been administered from 5/5/26-5/13/26 twice a day, the morning dose on 5/9/26 documented a 5 with the key indicating hold, the morning and even dose on 5/10/26 documented a 6 with the key indicating other- see progress note, the bedtime dose on 5/11/26 documented a 6, and the morning dose on 5/12/26 documented a 6.2. R5's admission Record documented an admission date of 12/30/25 with diagnoses including hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side, hypertensive urgency, hyperosmolality and hypernatremia, personal history of transient ischemic attack and cerebral infarction without residual deficit, type 2 diabetes mellitus, unspecified viral hepatitis C without hepatic coma, borderline personality disorder, mild persistent asthma, unsteadiness on feet, muscle weakness, hypokalemia, essential hypertension, hypoxemia, and weakness. R5's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R5 is cognitively intact. On 5/20/26 at 2:47 PM, R5 asked this surveyor if something could be done about her medications as she had not had any pain medication in 4 days. R5 said when she asks for her pain medication, the nurses tell her they don't have any pain medication to give her. R5 stated she was told they had called the pharmacy and the doctor but still had not received any pain medication. R5 said her back pain was really bad and rated her pain to be 10 on a scale of 0-10. R5's Order Summary Report documented a 12/31/25 order for Tramadol 50 mg (milligrams), 1 tablet by mouth every 8 hours as needed for pain. On 5/20/26 at 2:56 PM, the medication cart that served R5's room was observed to have no tramadol tablets present for R5. V6 (Registered Nurse/RN) said R5 did not have any tramadol available. V6 said R5 had asked for a tramadol that morning and V6 told R5 we don't have any for her. V6 said the facility had emailed V11 (Physician/ Medical Director) again that morning requesting a tramadol prescription for R5 but had not heard back. V6 said she had not called the on-call medical provider because she was waiting to see if V11 responded. V6 said she could not obtain any tramadol out of the emergency backup supply because R5 did not have an active order for tramadol. R5's Controlled Substances Proof of Use documented 15 tablets of tramadol 50 mg were delivered to the facility on 5/2/26, with the last administration of those 15 tablets being given on 5/15/26. R5's Medication Administration Record (MAR) dated 5/1/26 - 5/31/26 documented 5/15/26 was the last administration of R1's PRN (as needed) tramadol 50 mg until 5/21/26. The MAR shows there were no administrations of R1's PRN tramadol from 5/16/26 through 5/20/26. On 5/20/26 at 2:10 PM, V12 (Regional Clinical Consultant) was alerted of R5 not having any tramadol available and of V6's interview (above) and V12 sighed heavily and said she would have V6 call the on-call provider immediately to obtain a prescription. V12 stated the on-call provider should have already been contacted. On 5/21/26 at 1:53 PM, R5 said she can't go without pain medication and the days the facility did not have any tramadol for her she could not sleep because she was hurting so bad and at times was in tears. On 5/26/26 at 2:07 PM, V11 (Physician/ Medical Director) said if a resident reported pain and did not have an active prescription for pain medications, he expected staff to call him and he would sign the order or to call the on-call medical provider company to get a prescription. The facility's pharmacy policy and procedures were requested from V12. V12 provided a document/sign from the facility's contracted pharmacy dated 2024 that documents the heading Medication Not Available. What Now? and further states Check: Check eMAR (electronic medication administration record) for last order/fill date. Verify transmission to pharmacy for new orders and refills. Check fax machine or eMAR for communication from pharmacy. Obtain: Obtain from (emergency medication kit), if available. Call: Call the pharmacy for order status (e.g., prior authorization pending, refill too soon, order clarification). Notify prescriber if dose is missed. Follow facility process if additional notifications are required. Documentation: Document steps taken to obtain medication and prescriber notification. Prevention: Reorder 3-5 days prior to last remaining dose. Check pharmacy placard for cut-off times. Receive delivered medications in eMAR.The undated facility policy titled Medication Administration Policy for Senior Living was also provided. Under PRN Medication Guidelines documents Medication administration shall be documented promptly and accurately, including the date of administration, time of administration, name of medication, dosage, route, and reason for administration.

Based on interview and record review, the facility failed to notify a medical provider of elevated blood glucose levels for 1 (R4) of 3 residents reviewed for glucose monitoring. This failure resulted in R4 having blood glucose levels greater that 600 putting R4 at risk to develop Diabetic Ketoacidosis (DKA) which could result in coma and possible death.The Immediate Jeopardy began on 3/2/26 at approximately 8:00 AM when R4's blood glucose reading was not obtained and sliding scale insulin was not administered per Physician orders. V1 (Administrator), V11 (Assistant Director of Nursing/ ADON), V2 (Director of Nursing/ DON), V12 (Licensed Practical Nurse/ LPN/ Wound Nurse), V22 (Regional Clinical Director), and V23 (Regional Director of Operations) were notified of the Immediate Jeopardy on 3/20/26 at 9:06 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 3/19/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include:R4's admission Record documented an admission date of 2/3/26 with diagnoses including: type 2 diabetes mellitus, need for assistant with personal care. R4's 2/10/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R4 was cognitively intact.R4's Care Plan Report documented a 2/4/26 Focus of diabetes mellitus with a 2/4/26 intervention documenting in part .diabetes medication as ordered by doctor. Monitor/ documents for side effects and effectiveness. R4's Medication Review Report documented a 2/11/26 order for Insulin Lispro (Humalog) Injection Solution 100 UNIT/ML (milliliter) (Insulin Lispro) Inject as per sliding scale: if 80 - 150 = 0; 151 - 200 = 2; 201 - 250 = 6; 251 - 300 = 12; 301 - 350 = 16; 351 - 400 = 20; Over 400 Call MD (medical doctor), subcutaneously before meals and at bedtime for DM 2 (type 2 Diabetes Mellitus).R4's Electronic Medical Record (EMR) documented a 3/2/26 at 10:47 AM progress note documenting in part .Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 80 - 150 = 0; 151 - 200 = 2; 201 - 250 = 6; 251 - 300 = 12; 301 - 350 = 16; 351 - 400 = 20; Over 400 Call MD, subcutaneously before meals and at bedtime for DM 2. Pt BG>600, 20U Hum given at this time (Patient's Blood Glucose greater than 600, 20 units Humalog (Lispro) given at this time.).R4's EMR documented a 3/2/26 at 7:49 PM progress note authored by V4 (Registered Nurse/ RN) documenting in part .Resident having hyperglycemia issues today. Resident BG was >600 and received 20U humalog and 14U Lantus at 1047 (10:47 AM) and then she was still >600 at 1157 (11:57 AM), so this nurse contacted staff to obtain instructions to speak with the provider. At 1259 (12:59 PM) I was able to call the telemed group after receiving their contact information. (V6/Physician Assistant) asked to recheck and pt BG was 531. VORB (Verbal Order Read Back) to give 22U Humalog, SQ (subcutaneous), x1, once, now and recheck BG (blood glucose) in 2 hours. Resident was checked again around 1600 (4:00 PM) and she was down to 272 and within the scope of her ordered sliding scale.R4's provider progress note dated 3/2/26 authored by V6 documented in part .Notified by nursing that patient blood sugar was given late in the morning around 10:50 am. Glucose was over 600. Recheck an hour later was over 600. Nursing notified me of results two hours later. Patient asymptomatic. Request nursing to recheck glucose. Nurse called back blood sugar reading of 531. Patients sliding scale for breakfast cover is 20 units Humalog at a blood sugar reading of 400. Recommended nurse give a total of 22 units (additional 2 units). Nursing to continue to monitor and recheck blood sugar in 2 hours and notify of abnormal value. Nursing to notify of any symptoms.On 3/13/26 at 10:51 AM, V4 (RN) said she was still passing 8:00 AM medications and I never have my meds passed on time. V4 said on 3/2/26 she was running late passing medications and R4's morning accu check read HI on the glucometer so V4 knew R4's blood glucose was over 600. V4 said she administered the highest does on insulin on R4's insulin sliding scale at that time. V4 said R4 did not have any signs or symptoms of Diabetic Ketoacidosis (DKA) so V4 knew R4 did not need to be sent to the hospital. V4 said she rechecked R4's accu check an hour later and it still read HI on the glucometer. V4 said she then had to find out how to contact a medical provider. V4 said she contacted a medical provider as soon as she could (2 hours later) because R4 was not in any distress.On 3/13/26 at 1:26 PM, V3 (Physician/ Medical Director) said if an accu check was obtained and the glucometer read HI he expected staff to contact a medical provider within 15 minutes and that's giving them time to walk to the phone, it should be immediately. V3 said most glucometers registered blood glucose up to 600 and if the glucometer read HI you would not know how high the blood glucose actually was, you would just know it was greater than 600. V3 said if an hour after treatment with insulin the glucometer reads HI again the resident should be sent to the emergency room (ER) due to the high likelihood the resident could develop DKA. V3 said a person developing DKA did not always show any signs or symptoms in the early stages and the likelihood of developing DKA was high if not treated quickly. V3 said DKA was life threatening. V3 said he expected staff to call 911 for an ambulance if they did not know how to reach a provider if a medical emergency occurred. V3 also said he was not sure why staff would not know how to get in touch with him because his number was listed in the EMR of the resident.R4's March 2026 Medication Administration Record did not document a 3/2/26 order for Lispro 22 units.R4's March 2026 Medication Administration Record documented on 3/5/26 at 8:00 AM R4's blood glucose was 411 and at 11:00 AM R4's blood glucose was 434. Both of those entries included a #6 that directs you to see Administration notes.R4's Orders Administration Note dated 3/5/26 at 12:01 PM documents sliding scale insulin was administered. This nurse contacted the physician.The facility's Medication Admin Audit Report printed 3/20/26 at 11:56 AM documented R4's 3/5/26 at 8:00 AM Insulin Lispro was scheduled for 8:00 AM, Administered at 12:01 PM, and Documented at 12:11 PM.R4's Orders Administration Note dated 3/5/26 at 12:13 PM documented in part, This nurse contacted (V3) regarding blood glucose readings.The facility's Medication Admin Audit Report printed 3/20/26 at 11:56 AM documented R4's 3/5/26 at 11:00 AM Insulin Lispro was scheduled for 11:00 AM, Administered at 12:33 PM, and Documented at 12:37 PM.R4's Orders Administration Note 3/5/36 at 12:33 PM documented in part . Sliding scale insulin administered.On 3/19/26 at 1:06 PM, V5 (RN) said he had contacted V3 about R4's 411 and 434 accu checks after talking to R4 about using an automated insulin delivery system. V5 was asked how much insulin V5 administered to R4 after obtaining the 411 accu check and V5 said, I gave the 20 units because that was the highest dose on the sliding scale. V5 was asked how much insulin V5 administered to R4 after obtaining the 434 accu check and V5 said again, I gave the 20 units because that was the highest dose on the sliding scale. V5 was asked why the 8:00 AM accu check was not completed until 12:01 PM and V5 said he was not sure. V5 said he made a progress note about his conversation he had with the MD about R4's high accu checks.On 3/16/26 at 2:48 PM, V2 (Director of Nursing/ DON) said she expected staff to obtain blood glucose readings and administer medications as ordered. V2 said blood glucose should be checked prior to the resident eating. V2 said if the resident's order was to contact a medical provider if the blood glucose is greater than 400 she expected staff to contact a medical provider as soon as possible for new orders.The facility's 12/2024 Significant Condition Change and Notification policy documented in part . medical practitioner are notified of resident changes such as those listed below. abnormal blood glucose results, or above or below set parameters. The facility's revised 3/24 Blood Glucose Monitoring System User's Guide documented in part . Solving Problems. This section details the significant display screen messages and error codes you will encounter. what you see. HI. What it means. Test result is higher than 600 mg/ dl (milligram per deciliter). What should you do. Wash and dry your hands and repeat the test on a different fingertip with a new test strip. If the result is still HI, contact your physician or a healthcare professional immediately.The Immediate Jeopardy that began on 3/2/26 was removed on 3/19/26 when the facility took the following actions to remove the immediacy and correct the deficient practice as confirmed through observation, interview, and record review:1). Immediate Resident Safety:The identified resident (R4) discharged from the facility to home on 3/6/26.A house-wide review of all current residents with blood glucose monitoring was completed to ensure no other critical values required physician notification (completed by Nurse Managers: V2 (Director of Nursing/DON), V11 (Assistant Director of Nursing/ADON), V12 (LPN/ Wound Care Nurse) and V13 (RN/ MDS Coordinator) on 3/19/26).2). Immediate Staff Education:All licensed nurses were immediately re-educated on change in condition and physician notification requirements under F 580, with emphasis on timely reporting of abnormal/critical blood glucose results, required timeframes and documentation standards. Physician notification will be made immediately for any emergencies regardless of the time of day. Non-emergency notifications may be made the next morning if the situation occurs on the late evening or night shift. This applies to any day of the week including holidays. Education includes verbal competencies (Education was completed by Nurse Managers: V2, V11 and V12 on 3/19/26.). All nurse managers received education. Licensed staff will not be permitted to work until education is complete.3). Clarification of Parameters:The facility reinforced change in condition and clear parameters for physician notification of blood glucose results (physician's will be notified if blood glucose above 400), including defined critical values and required escalation timeframes (Nurse Managers: V2, V11 and V12 educated with verbal reinforcement on 3/19/26). 4). Audit and Monitoring:The facility initiated a 100 % audit of all Accu-Check results each shift to ensure abnormal/critical values are timely reported to the physician and documented appropriately (Nurse Managers: V2, V11, V12 and V13 completed 100 % audit on 3/19/26). Audits will occur daily x14 days, weekly x4 weeks then monthly through QAPI (Quality Assurance and Performance Improvement). The audits will be completed by V2 DON or V11 ADON, in the DON absence. (Audit will be initiated 3/19/26 to completion date).5). Leadership Oversight:The Director of Nursing/designee will review all abnormal glucose results and corresponding physician notifications daily to ensure compliance (monitoring during clinical QA meeting. The QA clinical meeting is in addition to the QAPI process). The QA clinical meeting reviews will occur daily Monday through Friday. Saturday and Sunday review will take place the following Monday as this is an internal process that will remain ongoing per policy and procedure.6). Accountability:Licensed staff found non-compliant with timely physician notification will be subject to progressive discipline and/or up to termination as per facility policy.

Based on observation, interview and record review the facility failed to ensure residents are free from significant medication errors for 5 (R4, R5, R9, R12, and R11) of 8 residents reviewed for medication administration in a sample of 14. This failure resulted in R9 experiencing a lack of sleep and feeling exhausted throughout the day.Findings include:1. R9's admission Record documented an admission date of 1/26/20 with diagnoses including: insomnia, adult failure to thrive, and type 2 diabetes mellitus with diabetic polyneuropathy.R9's 1/14/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R9 was cognitively intact.R9's Care Plan report documented a revised 8/20/24 focus area documenting in part . (R9) has diabetes mellitus (R9) is non-compliant with her diet. with 5/31/22 intervention documenting in part . Diabetes medication as ordered by doctor. Monitor/ document for side effects and effectiveness. and a revised 12/12/25 focus area documenting in part . disturbed sleep pattern, insomnia. with a 12/12/25 intervention documenting in part .Administer hypnotic as ordered.R9's Medication Review Report printed 3/20/26 documented a 12/11/25 order for belsomra 5 mg tablet give 1 tablet by mouth at bedtime for insomnia and 6/6/25 order for glyburide 5 mg tablet give 1 tablet by mouth 1 time a day for antidiabetics.On 3/26/26 at 12:48 PM, R9 was lying in bed watching television. R9 said the week prior to this interview she had not been receiving her sleeping medication. R9 stated without her sleeping medication I can't fall asleep and I just lay here all night and then feel bad the next day because I'm so tired. I just felt exhausted. R9 said she was not able to nap though the day and had always had trouble sleeping then stated that's why I take medication to sleep. R9 said she had type 2 diabetes and took medication for it but was not sure what medication she was prescribed or if she was receiving it.R9's February 2026 Medication Administration Record (MAR) documented R9 received a Belsomra 5 mg tablet by mouth at bedtime 8:00 PM every day and glyburide 5 mg tablet by mouth every morning at 8:00 AM throughout February 2026.R9's March 2026 Medication Administration Record (MAR) documented R9 had received a Belsomra 5 mg tablet by mouth at bedtime at 8:00 PM 3/1/26-3/15/26 and 3/21/26-3/24/26 and R9 had received a Glyburide 5 mg tablet by mouth every morning at 8:00 AM from 3/1/26- 3/14/26 and 3/16/24-3/24/26.On 3/26/26 at 1:10 PM, V2 (Director of Nursing/ DON) said she had called the pharmacy to ask when and how many of R9's Belsomra and glyburide had been delivered to the facility and was told R9's Belsomra 5 mg tablets were delivered in packages of 10 tablets and had been delivered to the facility on 2/10/26, 3/3/26, and 3/20/26. V2 said the pharmacy told V2 that R9's glyburide was not covered by R9's insurance and 7 tablets were delivered to the facility on 1/30/26 and 3 tablets were delivered on 2/10/26. V2 was asked why the nursing staff were documenting they were giving medications to a resident when that resident's medication was not in the building and not kept in the emergency kit and V2 responded she was unsure. V2 said if a nurse did not have a resident's medication she expected staff to call a medical provider.R9's Weights and Vitals Summary printed 4/1/26 documented R9's blood glucose results from 1/30/26-2/14/26 fluctuated with the highest on 2/1/26 at 258 and the lowest on 2/12/26 at 98. R9's blood glucose results from 2/15/26- 3/26/26 gradually started to increase consistently being greater than 300 on 2/27/26 at 351, 3/9/26 at 302, 3/13/26 at 383, 3/14/26 at 346, 3/16/26 at 340, 3/20/26 at 398, 3/22/26 at 344, and 3/24/26 at 337.2. R4's admission Record documented an admission date of 2/3/26 with diagnoses including: type 2 diabetes mellitus, need for assistant with personal care. R4's 2/10/26 MDS documented a BIMS score of 14, indicating R4 was cognitively intact. R4's Care Plan Report documented a 2/4/26 Focus of diabetes mellitus with a 2/4/26 intervention documenting in part .diabetes medication as ordered by doctor. Monitor/ documents for side effects and effectiveness. R4's Medication Review Report documented an order for Insulin Lispro (Humalog) Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 80 - 150 = 0; 151 - 200 = 2; 201 - 250 = 6; 251 - 300 = 12; 301 - 350 = 16; 351 - 400 = 20; Over 400 Call MD, subcutaneously before meals and at bedtime for DM 2 (type 2 Diabetes Mellitus) with an order date of 2/11/26.R4's Medication Admin Audit Report printed 3/20/26 at 11:56 AM for medications administered 3/1/26 to 3/8/26 documented the Insulin Lispro sliding scale was administered greater than an hour late for the 8:00 AM scheduled dose on 3/2/26, 3/4/26, 3/5/26, and 3/6/26. R4's 11:00 AM Insulin Lispro sliding scale was administered greater than an hour late on 3/2/26, 3/3/26, 3/4/26, 3/5/26, and 3/6/26. R4's 5:00 PM Insulin Lispro sliding scale was administered greater than an hour late on 3/4/26, 3/5/26, and 3/6/26.3. R5's admission Record documented an admission date of 7/2/24 with diagnoses including heart failure, atrial fibrillation, and hypertension.On 3/13/26 at 10:51 AM, V4 (Registered Nurse/ RN) said she was still passing the 8:00 AM medications. V4 said she never had her medications administered on time. V4 said there was no limits on how many residents a nurse could have and it was not realistic to get all the medications passed.On 3/13/26 at 11:51 AM, V4 was observed administering R5's sodium chloride 1 gm 1 tablet.R5's March 2026 MAR documented an order of sodium chloride 1 gm 1 tablet by mouth with meals at 8:00 AM, 12:00 PM, and 5:00 PM.On 3/13/26 at 12:51 PM, V12 (Licensed Practical Nurse/ LPN/ Wound Care Nurse) said V4 had been called to V2's (Director of Nursing/ DON) office and V12 had taken over V4's assignment and medication cart. V12 said she was going to finish V4's noontime medication pass. V12 started to pop medications out of a medication card into a medication cup when V12 was asked if a resident had a medication that was supposed to be administered 3 or 4 times a day how would V12 know when the medication was last administered due to V4 being so late administering resident's 8:00 AM medications and V12 stated I don't know how to give the noon meds for any QID (4 times a day) or TID (3 times a day) because I don't know when they were last given for the 8 AM dose. I guess we will have to skip all these doses. It'll be more med errors but the only safe thing to do is just give them at their next scheduled time.R5's March 2026 MAR documented the 3/13/26 at 12:00 PM dose of sodium chloride 1 gm by mouth with meals (3 times a day) with a 5. The Chart Codes on the MAR documents that 5 indicates Hold-See Progress Notes.R5's 3/12/26 Historical Lab Specimen Inquiry collected on 3/10/26 documented a sodium level of 122.0.On 3/19/26 at 9:21 AM, V24 (Hospital Lab Director) said R5's 3/12/26 sodium was measured in their lab. V24 said a critical sodium is less than 120 mmol/l (millimole/ liter) with a normal reference range between 134.5 - 145 mmol/l.R5's Electronic Medical Record (EMR) documented a 3/13/26 at 3:24 PM progress note authored by V2 (Director of Nursing/ DON) documenting in part . residents morning medications were administered late. MD (Medical Doctor) in facility made aware. Residents POA (Power of Attorney) aware as well.R5's EMR documented a 3/16/26 progress note authored by V2 documenting in part . Upon conclusion if [sic] investigation it was determined that the root cause of the late medication pass was that the (agency) nurse (V4) was ineffective and had poor communication skills. The immediate intervention was to assist the nurse in finishing her daily task/ medication pass and this particular (agency) nurse will not be allowed to return.4. R12's admission Record documented an admission date of 8/7/21 with diagnoses including chronic pain due to trauma, low back pain, and recurrent depressive disorders.On 3/13/26 at 11:33 AM, V4 was observed administering R12's pregabalin 100 mg 1 tablet.R12's Medication Review Report with a print date of 3/31/26 documents an order for pregabalin 100 mg 1 tablet by mouth 3 times a day for nerve pain dated 3/22/26.R12's March 2026 MAR documented R12's 2:00 PM dose on 3/13/26 of Pregabalin 100 mg give 1 tablet by mouth 3 times a day documents a 5. The Chart Codes on the MAR documents that 5 indicates Hold-See Progress Notes.R12's March 2026 MAR had an order with a start date of 8/3/25 ordering tylenol 325 mg 2 tablets by mouth every 4 hours as needed for mild pain order with no documentation Tylenol had been given on 3/13/26.5. R11's admission Record documented an admission date of 3/4/22 with diagnoses including major depressive disorder, schizophrenia, and epilepsy.R11's Medication Review Report with a print date of 3/31/26 documented the following medication orders: lamotrigine 25 mg 1 tablet by mouth every morning at 8:00 AM dated 2/11/26, levetiracetam 500 mg/ 5ml give 5 ml by mouth every morning at 8:00 AM and at bedtime 8:00 PM dated 2/10/26, and topiramate 25 mg 1 tablet by mouth every morning at 8:00 AM dated 2/11/26.On 3/13/26 at 11:21 AM, V4 was observed administering R11's lamotrigine 25 mg 1 tablet, levetiracetam 500 mg/ 5ml oral liquid, and topiramate 25 mg 1 tablet all ordered to be administered at 8:00 AM.The facility's revised April of 2021 Administration of Medications policy documented in part . C. Immediately after a drug is ingested, it should be recorded on the MAR: 1. If for any reason a physician's order cannot be followed, the physician shall be notified as soon as is reasonable. 2. Nursing staff will report immediately to the attending physician any medication errors, or adverse drug reactions. E. The facility shall check the Physician's Order Sheet and MAR against the current Physician's Orders, to assure proper administration of medication to each resident.

Based on interview and record review, the facility failed to treat residents with dignity and respect related to timely response to requests for assistance, valuing residents' private space, and refraining from practices that have the potential to feel demeaning or intimidating for 6 (R4, R8, R9, R10, R33 and R37) of 6 residents reviewed for resident rights in the sample of 46. This failure resulted in R8 experiencing feeling vulnerable, belittled, and intimidated and would cause a reasonable person to feel frustration and humiliation when R4 was put to bed without the opportunity to toilet and subsequently was incontinent. Findings Include: 1. R8's admission Record documented an admission date of 05/20/25 and included diagnoses of encounter for other orthopedic aftercare, muscle weakness, type 2 diabetes mellitus, sleep apnea, occlusion and stenosis or unspecified cerebral artery, seizures, diverticulitis of intestine, radiculopathy, and dizziness and giddiness. R8's MDS dated [DATE] documents a BIMS score of 15, indicating R8 is cognitively intact. R8's Care Plan includes a focus area related to activity preferences dated 05/28/25 with a corresponding intervention of: R8 likes doing things with groups of people dated 06/03/25. A facility grievance form dated 09/22/25 – 09/29/25 documents the following: The section for Resident Name has Community Complaint (Social Media) handwritten in and beside Grievance From, two boxes are checked indicating the grievance was from Resident and Family. Beside Name, R8's name is handwritten in, with (V21) shared on social media written to the side of R8's name. The grievance documents it was initiated by V1. Under the section where boxes can be checked to define the issue, all boxes are left blank, even though food issue is an option to be checked. The section for Description documents (Name of V21) - son of (name of R8) shared on social media pictures of food that they were not happy with. The next sections indicate they are to be completed by staff. The section titled Investigation documents: (R8) did not address with staff - she told (V2) that she did not mean for (V21) to post on social media. The section titled Summary/Findings documents food was edible – she is more than welcome to something different such as an alternative. Sausage was overcooked but could have received different sausage or substitution. The section titled Recommendations/Action Taken documents Resident (R8) to ask for substitution if she feels food she is receiving is less desirable or does not like what is being served. The date resolved is listed as: 09/29/25 and Person Notified of Resolution has R8's name written in and documents the notification was In Person. V1 signed the form on 9/29/25. On 09/30/25 at 2:30 PM, R8 stated she never filled out any grievance about the food or anything and she never signed any grievance. On 09/30/25 at 3:25 PM, R8 stated the food has not been good here lately and apparently V21 (Family) posted some pictures of her food (on a social media website). R8 stated she didn't know what V21 was doing, but he can do whatever he wants. R8 said about a week ago, she initially didn't know the reason, but they (staff) came and took her away from her card game and took her into a meeting with a bunch of department heads. R8 stated I think they were trying to intimidate me. R8 said they didn't talk to V21, they didn't have one of them come talk to R8 in her room, it was four of them and her in a meeting she didn't know anything about, and it made her very uncomfortable and it was intimidating. On 10/17/25 at 11:10 AM, R8 stated she has talked to the staff about her food concerns and maybe some other residents. R8 said the other residents were eating the same food and saying the same things about the food not being good. R8 said the staff here had a meeting with her because of voicing her concerns and V21 posting some pictures of her food trays. R8 said she was sitting in the dining room playing cards with R29 and V84 (previous Activities Director) when V54 (Social Services Director/SSD) came and got R8 and said V1 (Administrator) wanted to have a meeting with her. R8 stated they didn't ask her if she could meet when they were done playing cards or say they would like to meet with her at a certain time that day, they just came and got her and took her from the card game to the meeting where three more staff were waiting. R8 said she asked why there were four of them and just her and V1 stated it was because they needed a witness, but R8 questioned why there were three witnesses. R8 said she felt it was intimidating, and she was very uncomfortable being brought into this meeting. R8 stated being taken from an activity and brought into a meeting where there are four staff members and you is intimidating. R8 said if they wanted to talk, why didn't V1 come out to the dining room, or just come down to R8's room? R8 stated one of the first things they brought up was the pictures V21 posted on (name of social media website). R8 stated she told them they could go get her phone from her room, she didn't even think the thing took pictures and she did not have a (name of social media website). R8 stated someone in the meeting pulled up the pictures and showed them to her and asked if V21 was related to her. R8 stated he was, and she didn't care what he did on (social media website), he can do whatever he likes. R8 stated all the pictures they showed her were pictures of some of her actual food trays she was given. R8 stated she did not tell V21 to post the pictures, but she didn't care that he did either. R8 said V21 has been at the facility several times during meals. R8 stated she asked V1 (Administrator) to come and see some of the trays they are brought without the kitchen knowing in advance and to try the food they receive. R8 stated V1 never did come see or try a tray. R8 said V1 told her she can ask for a substitution and R8 told V1 she knows, and has done that before, along with R6, and they have been told several times they can't get it, don't have it, don't have time to get it, or if they do get a substitution, it could take a couple hours to receive it. R8 said she felt like the only reason they had that meeting was because those pictures were posted, and they were upset with R8 because it made them look bad. R8 said she believed they wanted to intimidate her, stating why else would they talk to her like that? On 10/22/25 at 1:43 PM, V55 (Public Relations Coordinator) stated they did have a meeting with R8, and the meeting included herself, V1 (Administrator), V2 (Director of Nursing), and V54 (Social Service Director/SSD). V55 said she was in the meeting representing admissions. V55 stated they felt all departments needed to be represented. V55 said she does not know if any other residents had a meeting and stated the meeting was casual. V55 said she does not know who suggested having the meeting, but it was to see if R8 had any concerns. V55 stated V21's (social media) post was brought up in the meeting. On 10/22/25 at 1:58 PM, V54 (SSD) stated she attended the meeting they had with R8 as they wanted to discuss the unhappiness and concerns R8 had, so she went and got R8 from the dining room where she was playing cards. V54 said R8 was a little hesitant when she went to get her for the meeting. At the beginning of the meeting, they went around and introduced everyone to R8. V54 said R8 did not have a family member there as R8's BIMS score is 15. V54 stated she was there to represent R8. V54 stated they did not have any meetings with any other residents and acknowledged there were other residents with dietary concerns. V54 said the meeting was not only because of V21's (social media) post, R8 wasn't happy with the meals, had specific concerns, and R8 was vocal. V54 said they did tell R8 they would put referrals out to other facilities for her if she chose for them to do that and R8 told them she would wait for after her doctor's appointment to decide. V54 stated she could see where that meeting could have felt intimidating to R8. V54 said R8 wondered why there was four people in the meeting and did ask about that at the beginning of the meeting. V54 stated it was brought up in the facility's morning meeting to have a meeting with R8, but there was never a specific date. V54 stated she was not sure why R8 did not have a family member with her in the meeting or why one was not invited. V54 stated she does not remember who brought up having the meeting with R8. On 10/22/25 at 2:12 PM, V2 (DON) stated they did have a meeting with R8, and herself, V1, V55, and V54 were present. V2 said V1 asked her to set up the meeting with R8 and said it was to see if there was anything they could do to make R8 happier. V2 stated originally, V2 did not realize she was intended to be part of the meeting. V2 stated she did not say much during the meeting. V2 stated R8 did say she did not like to be talked to by a lot of people at once. V2 said V21's (social media) posts were brought up in the meeting. V2 confirmed that R8 wanted V1 to come down to her room and look at one of her food trays without the kitchen staff knowing in advance. V2 stated she doesn't think the intention of the meeting was to intimidate R8, but she could see where it could be intimidating. V2 stated she is not sure why they only had a meeting with R8 and no other residents when other residents had dietary concerns at the time. V2 stated they had never discussed holding a similar meeting like a care meeting and inviting a family member to be present. On 10/22/25 at 2:28 PM, V1 (Administrator) stated the facility had a meeting with R8 because R8 had concerns with the food. They wanted to let R8 know there were other options out there for her to eat, they had substitutions R8 could ask for. V1 stated herself V55, V2, and V54 were present in the meeting with R8. V1 stated there were four department heads in the meeting so R8 could address any concerns she might have had. V1 stated they did not ask R8 if she wanted a family member in the meeting due to it being a last-minute meeting. V1 stated she could see where it could be intimidating being brought into a meeting last minute with four of the department heads without knowing what it was about, but that was not the intention. V1 stated they did not have a meeting with any other residents. V1 said they only had the meeting with R8 as she was the one talking loudly to other residents and staff about the concerns she had. V1 stated the meeting had nothing to do with the posts on V21's (social media) page. However, the (social media) post was part of the concern. R8 had been talking about the food, saying she was not going to eat it, and they were concerned. On 09/30/25 at 6:05 PM, V21 (Family) stated he did take pictures of R8's food and post them to his (social media) page and doesn't know why he would not be allowed to do that. V21 stated V1 never said anything to him about any of the pictures he posted. V21 stated R8 called him and told him about the meeting facility staff had with her. V21 stated he does not think that is right as R8 was uncomfortable and felt intimidated in that meeting. V21 said R8 was upset about it when she called him. V21 said if they had a problem with the pictures, they should have talked to him about them because he is at the facility regularly but instead, they try to intimidate R8. V21 stated, how would that not be the intention by pulling one resident from playing cards and bringing one resident into a meeting with four of them? The undated facility policy titled, Resident Rights documents: Employees shall treat all residents with kindness, respect, and dignity. Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will make every effort to assist each resident in exercising his or her rights to assure that the resident is always treated with respect, kindness, and dignity. The section titled, resident rights documents: federal code section 483.10 focuses on ways that the rights, dignity, and privacy of long-term care residents are maintained. There are many specific regulations that our facility must follow. In addition to federal requirements, there are also state regulations that we must follow. 2. R4's admission Record with a print date of 10/01/25 documents an admission date of 7/14/21 and included diagnoses of pressure ulcer, acute kidney failure, dementia, osteoporosis, chronic kidney disease, hypertension, glaucoma, muscle weakness, and reduced mobility. R4's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 03, indicating R4 has severe cognitive impairment. This same MDS documented R4 is dependent on staff for toileting hygiene and requires substantial/maximal assistance for transfers. R4's current Care Plan documents a Focus area of (R4) has bladder incontinence with a date initiated of 01/22/2025. Corresponding interventions initiated on 1/22/25 included Brief Use: the resident uses disposable briefs; Encourage fluids during the day to promote prompted voiding responses; Incontinent: Check the resident as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes; Monitor/document for s/sx (signs/symptoms) UTI (urinary tract infection). R4's Care Plan also documented a Focus area of (R4) has an ADL (activities of daily living) Self Care Performance Deficit Impaired Balance with a date initiated of 01/22/2025. Corresponding interventions initiated on 1/22/25 included Toilet Use: The resident requires 1 staff participation to use toilet; Transfer: The resident requires 1 staff participation with transfers. On 10/20/25 at 12:28 PM, V7 (Caregiver) stated she sits with R4 from 7 AM to 1 PM and from 5PM to 7 PM. R4 was sleeping in her chair at the time this interview started. R4 woke up during the interview and stated she didn't get to go to the bathroom before she went to bed on 10/19/25. R4 stated the CNA (Certified Nursing Assistant) told her to just go to bed because she couldn't take her to the bathroom by herself and there wasn't anyone else to help. R4 stated the CNA didn't even try to take her to the bathroom. V7 stated R4 was soaking wet this morning (referring to 10/20/25). V7 stated R4's clothes were drenched up her back and her whole bed was wet. On 10/20/25 at 12:57 PM, V14 (CNA) stated she worked as a CNA and provided care to R4 on the morning of 10/20/25. V14 stated she arrived to work at 6 AM on 10/20/25 and R4 was in bed and dry when she checked her a little after 6 AM. V14 stated she did not get R4 out of bed that morning and she wasn't sure who did. On 10/20/25 at 2:21 PM, V65 (CNA) stated she worked night shift beginning on 10/19/25 and ending on the morning of 10/20/25. V65 stated she was R4's CNA from 6 PM to 10 PM and was the CNA who assisted R4 to bed. V65 stated she told R4 they didn't have staff to take her to the bathroom before going to bed. V65 stated her partner was on break and she couldn't find anyone else to assist her and it takes two staff to take R4 to the bathroom. V65 stated she told R4 she could wait about thirty minutes, but R4 wanted to go to bed. V65 stated she thought this occurred around 6 PM on the evening of 10/19/25. V65 said they had seven CNA's working at the time (from 6 PM to 10 PM), explaining there were 2 CNA's per hall except for the rehab hall, which had one CNA. V65 stated R4 is normally incontinent but had recently started wanting to use the toilet. V65 stated if R4 wants to go to the toilet and they have the staff available to assist her, V65 will take her to the toilet. V65 stated R4 was not a resident she was responsible for doing bed checks on from 10 PM to 6 AM as the staffing level changed to three CNA's during that time, with a fourth CNA who was orientating. V65 stated she was not the CNA who assisted R4 up on the morning of 10/20/25 prior to leaving the facility for the day. On 10/22/25 at 1:36 PM, V7 (Caregiver) stated when she got to the facility on the morning of 10/20/25, R4 was sitting in her chair with a blanket over her wearing her pajama top and an incontinence brief. V7 stated R4's incontinence brief and pajama top were both wet. V7 stated she found R4's pajama bottoms in the dirty clothes inside out and saturated with urine. V7 stated the bottoms were so wet she had to put them in a plastic bag. V7 stated R4 told V7 she needed to change her bed, and V7 told R4 the bed was already made. V7 stated R4 told her the bed was wet, so V7 pulled the covers back on the made bed and the sheet and bed pad were both visibly saturated with urine. V7 stated she didn't report it to anyone because she used to report incidents that occurred, but it never did any good. V7 stated when there is only one staff on the hall, she expects the care will be lacking because it is hard for the staff to keep up. V7 stated she is just glad she is there to assist R4 but feels for the other residents on the hall who don't have a (private) care giver. On 10/21/25 at 2:38 PM, this surveyor spoke to V2 (Director of Nurses/DON) regarding R4 not being toileted prior to bed on 10/19/25 and her clothes and bed being saturated on the morning of 10/20/25. V2 stated that was unacceptable and she expected the licensed nurses to assist the CNA's with providing care to the residents when needed. 3. R9's admission Record with a print date of 10/07/25 documented an admission date of 3/26/25 and included diagnoses of end stage renal disease, absence of right leg above the knee, osteomyelitis, heart failure, and muscle weakness. R9's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R9 is cognitively intact. This same MDS documents R9 requires substantial/maximal assistance of staff for toileting. R9's current Care Plan documents a Focus area of, (R9) has an ADL (activities of daily living) Self Care Performance Deficit Fatigue. Date Initiated: 03/30/2025. This Focus area includes the following intervention, Toilet Use: the resident requires 1 staff participation to use toilet. Date Initiated: 03/30/2025. A facility Grievance Form dated 8/6/25 documents R9 filed a grievance related to an issue of Nursing Care. Under Description the form documents, Call light is not getting answered in a timely manner. Under Investigation the form documents, Call light audit done 8-4-25 - 8-8-25. Nursing met with resident and addressed concerns. Resident states he understands during certain times it takes longer to answer and he appreciates everything the staff does. Under Recommendations/Action Taken the form documents, Staff educated to continue answering call lights as promptly as possible. On 10/23/25 at 12:30 PM, R9 stated if the regular staff is working his call light gets answered timely. R9 stated some agency staff are ok, some are not. R9 stated it has taken up to an hour and ten minutes. R9 stated two nights ago he had to sit in feces and wait for assistance. 4. R10's admission Record with a print date of 10/22/25 documented an admission date of 5/22/25 and included diagnoses of diabetes, anemia, heart failure, muscle weakness, reduced mobility, and atrial fibrillation. R10's MDS dated [DATE] documents a BIMS score of 11, which indicates a moderate cognitive deficit. This same MDS documents R10 is dependent on staff for toileting. R10's current Care Plan documents a Focus area of, (R10) has bladder incontinence. Date Initiated: 07/15/2025. This Focus area includes an intervention of, Brief Use: the resident uses (Size) disposable briefs. Check & (and) change Q2 (every 2 hours) and prn (as needed). On 10/15/25 at 6:20 PM, R10 stated it takes a long time for them to answer the call lights, and she's had incontinent episodes while waiting for staff to assist her. 5. R37's admission Record with a print date of 10/22/25 documented an admission date of 7/7/22 and included diagnoses of osteoarthritis, hypertension, atrial fibrillation, pain, muscle weakness, and reduced mobility. R37's MDS dated [DATE] documents a BIMS score of 10, indicating R37 has a moderate cognitive deficit. R37's current Care Plan documents a Focus area of, (R37) has frequent bladder incontinence. Date Initiated: 09/25/2024. This Focus area included an intervention of, Incontinent: Check the resident Q2 (every 2 hours) and as required for incontinence. Date Initiated: 09/25/2024. On 10/15/25 at 6:18 PM, R37 stated they don't usually have enough staff to meet her needs timely. R37 stated it can take up to two hours for them to answer the call lights. R37 stated she's had incontinent episodes while waiting for staff to assist her. On 10/16/25 at 2:56 PM, V51 (Certified Nurse Aide/CNA) stated they sometimes have enough staff to meet the needs of the residents timely but most of the time they are really short staffed. V51 stated he works the 2-10 pm shift, and they are supposed to have two CNA's on the main halls and one CNA on the rehabilitation hall. V51 stated sometimes they only have one on each hall. V51 stated sometimes people have incontinence episodes because they can't assist them as quickly. On 10/20/25 at 11:44 AM, V62 (CNA) stated she works night shift 10 pm to 6 am. V62 stated they have 70-80 residents and work with only three CNA's on night shift. V62 stated, I am not able to provide quality care. V62 stated on 10/19/25 she was responsible for 26 residents, seven of them required two staff to assist them and 21 required assistance with incontinence care. When asked if there was any negative outcome related to staffing, V62 stated residents have incontinence episodes because they have to wait on us, they have had to sit in urine/feces longer than they should. On 10/20/25 at 12:54 PM, V32 (Licensed Practical Nurse/LPN) stated he didn't feel like one CNA on each hall was enough to meet the needs of the residents timely. V32 stated two CNA's for each hall is more effective. V32 stated with one CNA per hall, residents have to wait a long time and have incontinent episodes. On 10/21/25 at 2:01 PM, V13 (CNA) stated they don't always have enough staff to meet the needs of the residents. V13 stated when there are call in's they don't really try to get anyone to help. V13 stated residents have incontinent episodes due to how long it takes them to answer the call light. On 10/30/25 at 2:48 PM, V2 (Director of Nurses/DON) stated she expected call lights to be answered as soon as possible. The facility was unable to provide this surveyor with a policy regarding call lights. 6. R33's admission Record dated 10/22/25 documented an admission date of 10/22/20 and included diagnoses of vascular dementia, chronic kidney disease, dysphagia, psychosis, and cognitive communication deficit. R33's Care Plan documented a focus area of R33 has impaired cognitive function/dementia or impaired thought processes dated 10/22/20. One of the interventions listed is to break tasks into small sub tasks to support short term memory deficits. Another focus area on R33's care plan documents R33 is at risk for burns from hot liquids dated 4/4/24. R33's MDS dated [DATE] documented a BIMS score of 11, indicating R33 is moderate cognitive impairment. On 10/20/25 at 9:35 AM, R33 stated CNA staff often put their energy drinks in his room while they are working. R33 stated he doesn't like it because he's worried the drinks will spill on his clothes. R33 named V47, and V48 (both CNA's) as staff who put their personal drinks in his room. On 10/20/25 at approximately 10:00 AM, V17 (CAN) stated other CNA staff put their personal drinks or their personal bags on the top shelf of a resident's closet. V17 stated she had witnessed V47 put personal items in a resident's room. V17 stated it was R33's room. V17 showed this surveyor the closet in R33's room where she had witnessed V47 put her personal belongings. At this time of observation there were no other belongings in R33's closet besides his own. On 10/22/25 at 11:33 AM, V48 (CNA) stated she does keep her personal drink and lunch bag in the closet of R33's room. V48 stated she has asked R33 in the past if he minds if she puts her personal things in his closet and R33 reportedly told her it was fine. V48 stated there is a break room where staff may place their personal belongings. On 10/22/25 at 11:45 AM, V47 (CNA) stated she does store her personal drink and lunch box in the top of R33's closet in his room. V47 stated the staff do have a break room where they can store their personal belongings but stated if a staff leaves it in there someone will mess with your lunch or even eat it. V47 referenced R33's room as where she usually keeps her drink and lunch bag stored while on shift. V47 stated she has asked R33 in the past if he minds if she stores her personal items in his room, and he had reportedly told her he doesn't mind. On 10/22/25 at 12:07 PM, R33 stated he did not remember giving permission to any staff member to store their personal items in his room or closet. R33 stated he does not want them to because he is worried it will spill on his clothes. On 10/22/25 at 12:13 PM, V2 (DON) stated the staff have lockers in the break room they can put their drinks and lunch bags in. They are welcome to bring their own locks to use if they are concerned about theft. V2 stated the facility also has a refrigerator in the lunchroom for lunch boxes. V2 stated she would not expect staff members to store their personal items in a resident's closet. V2 stated she did not consider it appropriate for staff to store their personal items in resident's closets or rooms. On 10/22/25 at 12:29 PM, V1 (Administrator) stated she would expect staff members to store their personal belongings in the locker rooms or in the break room. V1 stated she would not expect for staff to store their personal items in a resident's closet. V1 stated she does not believe it is right for staff members to store their personal items in a resident's room. On 10/22/25 at 12:45 PM, the men's and women's locker rooms were observed to have lockers for use by staff members that could be locked. The facility's undated Residents' Rights policy documents a resident has the right to make personal decisions, right to privacy, and the right to be treated with consideration, respect, and dignity. The Ombudsman's Residents' Rights pamphlet with a revised date of 11/18 documents the resident has a general right to privacy and confidentiality. The pamphlet states a resident has a right to keep and use their own property.

Based on observation, interview, and record review the facility failed to ensure residents were free from staff abuse for 2 of 3 residents (R6 and R19) reviewed for abuse in the sample of 46. This failure resulted in R19 being spat in the face by a staff member which would cause a reasonable person to experience feelings of humiliation, anger and fear and resulted in staff verbally abusing R6 causing R6 to be visibility upset and fearful.Findings Include:1. The facility Final Reportable for R19 dated 10/02/25 documents under Complete Description of Occurrence: Initial Report: Initial: Abuse Coordinator was notified on 10/2/2025 at around 10:30pm about an alleged incident that took place between a staff member and resident, (R19). Staff were immediately suspended. Police, Family Representative and Physician were notified. Immediate investigation was initiated. Final: A thorough investigation was conducted between October 2, 2025, and October 8, 2025. Interview Statements: Resident, (R19) was unable to state what happened: (R19) has a BIM score of 7. (V65), C.N.A. (Certified Nursing Assistant) - (R19) was at the nurse's station on front hall where she was reaching and feeling for things (d/t (due to) her blindness and hard of hearing) She proceeded to grab (V56), LPN's (Licensed Practical Nurse) lunch bag. (V56) told (R19) to stop reaching for things and to stop yelling because she was disturbing other residents. (R19) continued behavior, (V56) then grabbed her hands and told her to Stop! (R19) then grabbed (V56) hands and started to pull and bend her fingers. (V56) claimed that (R19) hurt her left thumb. (R19) started shouting, stop touching me, leave me alone. (R19) was near (V56) face during the shouting. (V56) then leaned into (R19) face and yelled, How do you like it? (R19) then said she needed to go to the sink and spit. (V56) told her, Swallow it. (R19) replied, I'll spit on you. (V56) replied, if you spit on me, I will spit on you. (R19) replied, no you won't. (R19), spit on (V56)! (V56) in turn spit on (R19). (V56) placed (R19) in the large dining room to roam around. I then brought (R19) to the T.V. (television) room o 200 halls. (V56) asked if I would vouch for her, if she were to deny the claims made against her. I replied to (V56), You did spit on her, we saw you. (V56) became upset and went outside to smoke. Incident Analysis: Based on the consistent accounts of the staff interview statements, the incident of resident abuse was substantiated. Correction actions and Prevention Plan: Based on the investigation, the following actions have been implemented to protect (R19) and all other residents. No change in Psychosocial baseline since incident occurred. Employee, (V56), LPN was immediately suspended at time of incident. Employee, (V56), LPN will be terminated with a Do Not Rehire. Employee, (V56), LPN, all information will be sent to IDFPR (Illinois Department of Professional Regulation). Updated findings will be sent to (name of local police department) . Resolution and Conclusion: the investigation concluded that (V56), LPN, was upset that (R19) spit on her, which in turn she then spit on (R19). All necessary medical and physical assessments were completed. Corrective measures and care plan updates have been put in place. Inservice: Abuse and neglect training provided.R19's admission Record with a print date of 10/22/25 documents R19 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction, encephalopathy, diabetes, legal blindness, lack of coordination, muscle weakness, difficulty in walking, major depressive disorder, and anxiety disorder.R19's MDS (Minimum Data Set) dated 9/2/25 documents a BIMS (Brief Interview for Mental Status) score of 07, indicating a severe cognitive deficit. This surveyor attempted to speak with R19 several times throughout the survey process. R19 did not respond to questions.R19's current Care Plan includes the Focus area, (R19) has a behavior problem 1. (R19) startles easily due to blindness & (and) will strike out at others in response. The interventions for this Focus area include, Behavior #1 Physical aggression: Hitting/yelling at staff and roommate. 1. Offer activities to (R19). 2. Offer to call (R19's) sister.3. Offer to take (R19) to a different area to calm down. Date Initiated: 07/09/2025. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 12/19/2024. Minimize potential for the resident's disruptive behaviors by helping (R19) out of areas that are crowded with a lot of people such as hallways and the dining room. Date Initiated: 12/19/2024.R19's Progress Notes dated 10/03/25 documents the following Telehealth note, Per RN (Registered Nurse), allegedly the patient was yelling at a (sic) one of the nurses, grabbed her hand and threatened to spit on her but the nurse told her not to and then the nurse ing (sic) staff spit on the patient. No other physical altercation happened. Admin (administrator) notified and nursing staff responsible was sent home. There is no other documentation in R19's progress notes related to the incident.On 10/15/25 at 6:24 PM, V40 (CNA/Certified Nursing Assistant) stated she was working the night the incident occurred between V56 and R19. V40 stated she had just given report to the next shift, so it was around 10:00 PM or a little after. V40 stated she was walking down the hall when she heard, V56 say to R19, how would you like it if someone spit on you. V40 stated then she heard the spit sound and saw R19 wiping her face off. V40 stated, R19 then said to V56, You b**ch. V40 stated, V2 (Director of Nurses) was called immediately who told staff to call V1 (Administrator), which they did. V40 stated, V1 asked her what happened and had her write a statement. V40 stated she left the facility shortly after. V40 stated she knows V56 was suspended and hadn't been back to work since the incident occurred.On 10/20/25 at 11:44 AM, V62 (CNA) stated she was working on the night of 10/02/25 and was walking down the hall when she heard V56 say, How would you like it if someone spit in your face. V62 stated then she heard the spitting sound and heard R19 say, you bi**h. V62 stated she called, V1 (Administrator) and reported it. V62 stated, V65 (CNA) removed R19 from the area while V62 called V1.On 10/20/25 at 2:21 PM, V65 (CNA) stated she was working on 10/02/25 when the incident with V56 and R19 occurred. V65 stated R19 was having behaviors, shouting down the hallways and V56 took her to the nurse's station and told her she couldn't be shouting because she would wake other residents up. V65 stated R19 told V56 they could fall back asleep if they woke up. V65 stated R19 is blind and was feeling around the nurse's desk and kept touching V56's lunch bag. V65 stated V56 told R19 to stop moving her stuff around and grabbed R19's hands. V65 stated when V56 grabbed R19's hands, R19 bent V56's thumb back. V65 stated she started to remove R19 from the nurse's station and V56 told her she could stay. V65 stated R19 told them she needed a sink to spit in and V56 told her to just swallow it. V65 stated R19 shouted in V56's ear and V56 shouted back, How do you like it? V65 stated R19 told V56 she would spit on her and V56 told R19 if she did, she would spit back on her. V65 stated R19 told V56 she wouldn't spit on her and V56 spit in R19's face. V65 stated R19 wiped her face and said, you bi**h. V65 stated she moved R19 to another room and V62 (CNA) called V1 (Administrator).This surveyor attempted to contact V56 via telephone with no success.On 10/21/25 at 11:35 AM, V1 (Administrator) stated she was notified V56 had spit on R19 on 10/02/25. V1 stated V56 went outside the facility, called V1, and told her she spit but it was just while she was talking to R19, not an intentional spit. V1 stated while she was on the phone with V56 other calls were beeping in. V1 stated she told V56 to stay outside and fill out her statement. V1 stated she spoke with the other staff working with V56, and V56 was suspended immediately. V1 stated after the investigation was completed V56 was terminated and reported to the professional regulation.2. R6's admission Record with a print date of 10/01/2025 documents R6 was admitted to the facility 2/6/25 with diagnoses that include acute respiratory failure, heart failure, chronic obstructive pulmonary disease, aortic valve stenosis, dementia, anxiety disorder, major depressive disorder, and cognitive communication deficit. R6's MDS (Minimum Data Set) dated 8/15/25 documents R6 is independent with making consistent/reasonable decisions, with no cognitive impairment documented. R6's current Care Plan was reviewed with no Focus area related to abuse and/or behaviors documented. On 10/16/25 at 10:16 AM, R6 was interviewed and was alert and oriented to person, place, and time at the time of the interview. R6 stated she had issues with V56. R6 stated she was short of breath and scared and V56 didn't help her. R6 stated she wrote down the things V56 said to her during that time. R6 showed this surveyor a piece of paper on her bedside table, and it listed these items with no times or dates listed next to them, choke on that, it's all in your head, you can breathe if you try, you are crazy. R6 stated it happened on a couple of different dates and she reported it to unknown staff. R6 was visibly upset when speaking to this surveyor regarding V56. On 10/15/25 at 10:31 PM, V59 (CNA/Certified Nursing Assistant) stated R6 reported V56 told R6 she was ridiculous and yelled in her face. V59 stated R6 was really upset and crying when she reported it to her. V59 stated she told R6 she needed to tell V1 (Administrator) when she came to work the next day. V59 stated she did not report the allegation to V1 since she didn't witness it. On 10/16/25 at 2:56 PM, V51 (CNA) stated R6 reported to her quite a few times (unknown dates), V56 (LPN/Licensed Practical Nurse) had told her she was crazy. V51 stated R6 reported V56 was verbally mean to her, and she was afraid of V56. V51 stated she reported the allegation to V1 (Administrator) and V2 (Director of Nurses). On 10/16/25 at 3:13 PM, V10 (CNA) stated V56 isn't a very nice nurse. V10 states she was afraid of repercussions if she reported allegations against V56. V10 stated R6 reported (unknown date) V56 was rude to her and got mad when she asked for anything. V10 stated she reported it to an unknown day shift nurse. On 10/20/25 at 12:09 PM, V2 (Director of Nurses) stated she was unaware of any allegations of verbal abuse regarding V56 and R6. On 10/21/25 at 11:35 AM, V1 (Administrator) stated she wasn't aware of any reports of allegations of V56 being verbally abusive towards R6. V1 stated it should have been reported immediately. V2 (Director of Nurses) who was in this same interview stated she did have staff report R6 was upset with a staff member but when she talked to R6 she told V2 she didn't want anyone to get in trouble.On 10/21/25 at 1:01 PM, V31 (CNA) stated R6 and R8 (roommates) had reported allegations of inappropriate staff behavior to her. V31 stated R6 was crying and told her a nurse was being mean to her, calling her names, and saying awful things. V31 stated she told R6 she could speak with V2 (Director of Nurses). V31 stated she reported the allegations to V2 (Director of Nurses). V31 stated V2 spoke with R6 and R8 and after speaking with them, V2 told V31 since the residents would not give her the name of facility staff member, she could not do anything more about it. V31 stated the residents told me it was V56, and it was reported to V2, but because they wouldn't tell V2 who it was she was unable to investigate it further. On 10/24/25 at 10:11 AM, R8 stated, a nurse whose name sounded like V56's was mean to R6. R8 stated V56 would tell R6 she was crazy and ridiculous. R8 stated V56 would tell R6 she was watching her when R6 wasn't aware, and she could breathe just fine. R8 stated she reported this to V32 (LPN/Licensed Practical Nurse) who she thought reported it to administration. On 10/27/25 at 5:10 PM, V32 (LPN) stated he did not remember R6 and/or R8 reporting any allegations to him. On 10/21/25 at 2:38 PM, V2 (Director of Nurses) was asked to tell this surveyor about the time R6 reported a staff member was mean to her. V2 stated she wasn't sure which staff member reported it to her. V2 stated they told her R6 was upset after morning meeting and V1 (Administrator) told her and the Social Services Director (SSD) (V27) to talk with R6. V2 stated the CNA (who reported it) told her something was wrong but reported not knowing why R6 was upset. This surveyor reviewed with V2, V31's interview where she stated she reported the allegation and the name of the alleged perpetrator (V56) to V2. V2 stated that was not accurate. V2 stated she was not told who R6 was upset with or what she was upset about. V2 stated R6 didn't want anyone to get in trouble. On 10/22/25 at 1:23 PM, V27 (LPN/SSD) stated she did write a grievance for R6, but she couldn't remember what the details were. When asked if R6 ever reported anything concerning V56, V27 stated that was probably what the grievance was about but R6 would not tell her who the staff member was. V27 stated R6 would never say who it was and didn't report it as abuse just that someone wasn't very nice to her. V27 wasn't sure about a CNA reporting the allegation. The facility Grievance Form dated 7/28/25 documents R6 filed a grievance which included a check mark next to Staff Concern. This same form documents under Description: (R6) feels as though staff member had poor customer service with her. There are no specific details documented on what the poor customer service includes. The form documents under Recommendations/Action Taken: SSD/ Social Services Director) to meet with (R6) once a week x (times) 4 weeks to ensure customer service has improved. There are no SSD meetings/audits attached to this form. Documentation regarding the SSD meeting/audits were requested from V1 (Administrator) via email on 10/27/25. V1 provided this surveyor with R6's SSD progress notes dated 8/5/25 that documents, This writer met with resident at this time to follow up with her regarding recent grievance. Resident states she is doing well, and she is happy with her care in the facility. This writer provided support to resident at this time. There were no other progress notes provided to this surveyor that documented follow up regarding the grievance that was filed by R6. V1 (Administrator) stated in the email that she was unable to locate any other documentation of meetings once a week for four weeks. On 10/22/25 at 3:23 PM, this surveyor reviewed the allegation of abuse regarding V56 and R6 with V1 (Administrator) and she stated she had started an investigation and spoke with R6's power of attorney who reported to her R6 had an issue with a nurse telling her she was ridiculous. The facility Abuse Prevention and Prohibition Policy dated 03/2025 documents, .Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Prevention: The resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse; corporal punishment and involuntary seclusion. The owner, licensee, Administrator, employee, or agent of the facility shall not abuse or neglect a resident and must prohibit the misappropriation of resident property. Resident behaviors will be monitored for changes, which trigger abusive behaviors.

Based on observation, interview and record review, the facility failed to ensure physician orders were accurate and implemented for recommended changes in treatment after a hospitalization and a fall, and failed to assess and treat lymphedema/wounds per physicians orders for 3 of 3 residents (R6, R7, R20) reviewed for quality of care/treatment in a sample of 46. This failure resulted in R6 struggling to breathe, causing anxiety, sleep disturbance, and significant discomfort due to recommended medications changes not being administered/implemented to treat newly diagnosed congestive heart failure. This failure also resulted in R7's developing redness, increased swelling, tenderness, and altered mental status and R7's subsequent hospitalization with a diagnosis of cellulitis and septic shock.Findings include:1. R6's admission Record documented an admission date of 02/06/25 and included diagnoses of acute respiratory failure with hypercapnia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, heart failure, dementia, anxiety disorder, major depressive disorder, dysphagia, type 2 diabetes mellitus with diabetic nephropathy, and acute kidney failure. R6's Minimum Data Set (MDS) dated [DATE] documents a BIMS score of 15, indicating cognitively intact. R6's Care Plan documented a focus area of oxygen therapy dated 05/20/25, with interventions including: give medications as ordered by physician, monitor/document side effects and effectiveness; monitor for signs or symptoms of respiratory distress and report to medical doctor PRN (as needed): respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, and skin color; position resident to facilitate ventilation/perfusion matching, use upright high Fowlers position whenever possible to allow for optimal diaphragm, when on side the good side should be down (e.g., damaged lung should be up) all dated 02/06/25 and oxygen settings; the resident has O2 (oxygen) via nasal prongs dated 02/11/25. R6's care plan documents a focus area of R6 has SOB (shortness of breath) while lying flat r/t (related to) respiratory failure dated 02/11/25 with interventions listed of: administer PRN medications as ordered dated 02/06/25 and elevate HOB (head of bed) dated 02/06/25. R6's June 2025 Medication Administration Record (MAR) documents an order for albuterol sulfate nebulization solution (2.5 mg/3ml) 0.083%, 3 ml inhale orally via nebulizer every 4 hours as needed for shortness of breath with a start date of 04/02/25 at 10:44 AM and a D/C (discontinue) date of 08/20/25 at 9:15 AM and an order for furosemide oral tablet 40 mg, give one tablet by mouth every 24 hours as needed for edema/swelling with a start date of 02/06/25 at 2:30 PM and a D/C date of 08/20/25 at 9:15 AM. R6's hospital records with an admission date of 08/15/25 document: history of present illness: [AGE] year old female with past medical history of hypertension, COPD (Chronic Obstructive Pulmonary Disease), on 2-3 liters (oxygen) per NC (nasal cannula) anxiety, and depression presented to the ER (emergency room) from (facility name) with respiratory distress. Nursing staff at (facility name) noticed her in respiratory distress sometime yesterday evening. No mention of cough, fever, or other symptoms. On EMS (emergency medical service) arrival, O2 (oxygen) saturation was 70%. Her oxygen was increased and albuterol nebulizer was given en route. Chest x-ray showed bilateral pleural effusions BNP (B-type natriuretic peptide) 10,000, pH 7.27, pCO2 (partial pressure of carbon dioxide) 83. She was given duoneb, Lasix, and placed on BIPAP (bilevel positive airway pressure), ABG (arterial blood gas) improved after 1 hour on BIPAP. admitted to med/surg inpatient. The section titled, patient visit information; activity restrictions or additional instructions: discharge to skilled nursing facility; follow up with PCP (primary care physician) in 3 days, recommend repeat blood work to monitor HGB/BUN (hemoglobin/blood urea nitrogen), continue good bowel regimen, DX (diagnosis): ileus, EKG (electrocardiogram) changes, CHF (congestive heart failure); prescriptions (in part): furosemide (Lasix) 40 mg (milligrams) oral daily #30 tablet. Additional documents given: patient health summary and home medications list. The home medication list includes furosemide (Lasix) 40 mg tablet, stop taking: 40 mg oral daily as needed, start taking: 40 mg oral daily. The section titled problems documents active problems: acute exacerbation of CHF. Under the section titled, discharge plan documents in part: dx: ileus, EKG changes, CHF. Prescriptions: changed: furosemide (Lasix) 40 mg tablet, 40 mg PO (per oral) daily. Under the continued medications listed: albuterol sulfate 2.5mg/3ml (milliliters) solution for nebulization, 2.5 mg inhalation Q (every) 4 hours PRN (reason: shortness of breath or wheezing). R6's hospital discharge records dated 08/21/25 documented to follow up with primary care physician in 3 days, recommend repeat blood work to monitor hemoglobin and blood urea nitrogen. R6's Dietary Progress Note dated 08/25/25 documented in part, Dietitian chart review for RA (recent admission). August weight: 143.7# (pounds) 08/12/25 weight recorded (prior to hospitalization).some varied history but overall stable. Sent to hospital 08/15/25 with diagnosis: acute respiratory failure, BLE (bilateral lower extremities) increased swelling. Diagnosis: new onset of CHF (congestive heart failure) use of Lasix 20mg (milligrams) Q (every) 8 hours and 1800 ml fluid restriction with hospital weight recorded: 131.34 pounds RA (recent admission) here 08/21.Continue diet order of NAS (no added salt) as least restrictive therapeutic intervention. Monitor weight, lab and consumption with new order for Lasix 40mg QD (every day) may see fluid shifts affecting weight patterns. Record weekly weight or 4 weeks, follow up as needed with new concerns. R6's Medication Review Report documents an active order with a start date of 8/21/25 documenting furosemide oral tablet 40 mg, give 1 tablet by mouth every 24 hours as needed for edema/swelling. This document does not show the order change implemented at the hospital from furosemide 40mg tablet daily as needed to furosemide 40mg tablet daily. This report also documented an active order with a start date of 8/21/25 documenting albuterol sulfate inhalation nebulization solution 2.5mg/0.5ml (milliliter); 1 vial inhale orally every 4 hours as needed for COPD. This order does not match the hospital record's continued medications of albuterol sulfate 2.5mg/3ml solution for nebulization. R6's Progress Note dated 10/15/25 at 1:16 AM documented R6 complained of shortness of breath and O2 (oxygen) sats (saturation) at 94% on 3L (liters)/NC (nasal cannula). PRN (as needed) medications administered per MD (Medical Doctor) orders. R6's October 2025 MAR documented an albuterol sulfate inhalation nebulization solution 2.5mg/0.5ml treatment was given on 10/15/25 at 1:15 AM. R6's Progress Note dated 10/15/25 at 2:20 AM by V53 (Licensed Practical Nurse/LPN) documented: resident continues to c/o (complain of) SOB (shortness of breath) and unable to breath. Nurse explained to resident that she needed to go to ER (emergency room) and get checked out. Resident refused and said she would make it. This nurse requested (V78/Registered Nurse-RN) to come and evaluate resident. Resident also told V78 that she was not going to the hospital, and she would just wait. X-ray ordered and (x-ray company) called to schedule. R6's Progress Note dated 10/15/25 at 7:00 AM by V77 (Nurse Practitioner/NP) documented, Visit Type: Telehealth: the nurse reported dyspnea accompanied by low oxygen saturation and abnormal lung sounds with crackles. A chest x-ray was requested, along with adjustments to the respiratory treatment plan. Ordered chest x-ray and a one-time PRN dose of 2 ml albuterol sulfate neb (nebulizer) treatment. Rounding to follow up. R6's October 2025 MAR showed no administration of a one-time dose of 2ml albuterol sulfate neb treatment ordered by V77 as documented in the progress note above for the corresponding time of 7:00AM. On 10/15/25 at 10:29 AM, R6 was sitting on her bed with an anxious facial expression. R6 appeared to be struggling to breathe with loud crackles heard. At this time, R6 was alert and oriented and stated she was having a hard time breathing. R6 said she would make it if she could have a breathing treatment and would not have to go to the hospital. R6 stated she had not had one since about 1:00 AM this morning. R6 stated she asked the nurse for a breathing treatment earlier but was not given a treatment. R6 said the nurse was not nice to her and told her just to spit it out. R6 stated, she can't, and her breathing is getting worse. On 10/15/25 at 10:34 AM, V27 (Licensed Practical Nurse/LPN) was at the nurse's station when surveyor requested V27 to go check on R6. V27 stated R6's SPO2 (saturation of peripheral oxygen) was fine, R6 has an x-ray ordered, and she is fine. V27 did not go assess R6 at this time. On 10/15/25 at 10:35 AM, another surveyor entered R6's room and immediately noticed R6 displaying symptoms of anxiety due to respiratory difficulty including trying to sit up straight, use of accessory muscles, and gasping and anxious/fearful facial expression. There were noted audible crackles that could be heard without a stethoscope while standing next to R6. On 10/15/25 at 10:36 AM, V2 (Director of Nursing/DON) stated R6 is having trouble breathing, R6 definitely should get a breathing treatment. V2 stated V27 (LPN) should have come down to visually assess R6. V2 stated there could be more going on than what SPO2 percentages can show. V2 stated R6 should have received a breathing treatment when she had asked for one earlier, it is not appropriate for the nurse just to tell her to spit it out. V2 stated R6 knows when she needs a breathing treatment and should be given one when she asks. R6's Progress Note dated 10/15/25 at 10:54 AM by V27 (LPN) documented: reported to this nurse that resident had an acute change in condition. This nurse entered resident's room and resident was noted to be sitting on edge of bed. No new onset shortness of breath noted, resident did not appear to be in distress, cognition continues to be baseline. No complaints of pain, No audible wheezing present. VS (Vital Signs) as follows: BP (blood pressure) 112/56, P (pulse) 81, R (respirations) 20, O2 (oxygen) 99% via NC (nasal cannula). Temperature 98.0. Resident has received scheduled nebulizer treatments this AM, this nurse asked resident if she felt as if she needed to go to the hospital and she refuses at this time stating she would like to wait and have her in house chest x-ray. I informed resident that chest x-ray has been scheduled but she can still go to hospital if she feels she needs to. Resident verbalized understanding at this time. On 10/15/25 at 10:55 AM, V2 (DON) administered a breathing treatment of albuterol sulfate nebulization solution 2.5mg/0.5ml to R6. At this time, R6 asked why there was barely any medication in there anymore (while shaking the nebulizing chamber in her hand). R6 took a couple breaths and stated, look it is gone already. R6's Progress Note dated 10/15/25 at 11:27 AM by V2 documented: after PRN breathing treatment resident stated she was still SOB. Lung sounds audible and crackles could be heard. Residents current O2 sat is 99% on 2 L NC. Resident wanted another treatment and denied going to hospital for evaluation. This nurse called on call NP, (V77) and obtained order for a one-time PRN dose of 2ml albuterol sulfate neb treatment. Treatment given at this time. On 10/15/25 at 11:45 AM, V2 administered the one-time dose of 2ml albuterol sulfate neb treatment ordered by V77. R6's October MAR documents administration of albuterol sulfate inhalation nebulization solution 2.5mg/0.5ml at 10:59AM and a subsequent administration of albuterol sulfate inhalation nebulization solution 0.63mg/3ml (Albuterol Sulfate), give 2ml inhale orally via nebulizer one time only for SOB for 1 day at 11:45 AM. R6's MAR shows no administration of albuterol sulfate inhalation nebulization treatment after the 10/15/25 1:15 AM administration until the 10:59 AM and 11:45 AM administrations. On 10/16/25 at 9:19 AM, V2 (DON) was questioned about R6's Progress Note entry dated 10/15/25 by V27 and why it did not match observations of R6's condition on that date and time. V2 stated V27 put in the change in condition progress note because V2 asked her to. V2 stated what V27 documented was not an accurate assessment of R6 at the time. R6's Progress Note dated 10/16/25 at 7:00 AM by V82 (Physician Assistant) documents: visit type: telehealth: resident chest x-ray showed signs of pulmonary edema and the patient complains of dyspnea and cough, no fevers. She is Lasix 40mg prn, will change to Lasix 40mg daily for 5 days and then add potassium 10mEq (milliequivalents) daily for 5 days as well. Rounding to assess. On 10/16/25 at 10:15 AM, R6 was again struggling to breathe, was tearful and anxious. At this time, R6 stated she is still having trouble breathing. R6 stated she did not get a breathing treatment last night or this morning and she asked for one. R6 stated she is just so tired because she could not sleep because she couldn't breathe. R6's October MAR documents no further administrations of albuterol sulfate inhalation nebulization treatments after 10/15/25. R6's October MAR documents an order for furosemide oral tablet 40 mg, give 1 tablet by mouth one time a day for CHF for 5 days with a start date of 10/17/25 at 8:00 AM. R6's MAR documents furosemide 40 mg given on 10/17/25 at 8:00 AM. On 10/16/25 at 11:01 AM, V2 (DON) stated R6 is still having trouble breathing, she should have received a breathing treatment last night and/or early this morning. V2 stated R6 knows when she needs a breathing treatment. R6's Progress Note dated 10/17/25 at 5:53 AM by V74 (Nurse Practitioner) documented in SOAP (Subjective, Objective, Assessment, and Plan) format included: note text: S-dyspnea with anxiety; O-review of CXR (chest X-Ray): initial was incomplete not viewing lung bases. Repeat on 10/16 showed worsening of bilateral opacities with edema, possible pneumonia, COPD-end stage on supplemental oxygen. Currently on multiple medications for this. Newly diagnosed CHF (congestive heart failure) in August 2025 with PRN Lasix. See new orders from on-call (V78). A-COPD exacerbation. Community acquired pneumonia. CHF exacerbation. P-1. See plan for Lasix/KCL (potassium chloride), recommend new facility draw BMP Monday, 2 augmentin, 3 prednisone, 4 check if (brand name) inhaler will be covered by insurance to replace current ICS/[NAME] (inhaled corticosteroid/long-acting beta-agonist), 5 recommend referral to pulmonologist. R6's October 2025 MAR documents furosemide oral tablet 40mg; give one tablet by mouth every 24 hours as needed for edema and swelling with documentation noting it was administered on 10/08/25 at 7:38 AM and 10/16/25 at 7:38 PM. These are the only two administrations of furosemide documented for the whole month of October. R6's Discharge Summary documents discharge from the facility on 10/17/25 to another nursing facility in a neighboring town. R6's Progress Notes dated 10/17/25 at 10:43 AM documented receiving facility here to transport resident. On 10/22/25 at 7:40 AM, R6 was observed in her new facility. R6 stated she still has some problems breathing but it is some better. R6 said after she returned from the hospital last time at the end of August, she kept telling the nurses she was supposed to have another medication that she was given in the hospital but the nurses either said she was crazy, or they said they did not have any new orders for medication for her. R6 still appeared to have some difficulty with breathing but did not appear to be in respiratory distress, was not anxious during this observation and no crackling sounds were heard during the visit. On 10/22/25 at 1:32 PM, V2 (DON) stated she does not see a physician follow up appointment that was set up for R6, but she will provide one if she can find one. V2 said she does not know why the diagnosis of CHF was not added to R6's diagnosis list after her hospital visit. V2 said she does not know why the order for the furosemide was not changed to daily for R6. V2 stated she can see in the hospital paperwork where R6 was given a diagnosis for CHF and R6's order for Lasix was changed to daily from as needed. V2 said she does not see where there have been any notes from any doctors for the furosemide not to be changed to daily. V2 also stated she does not see where or why R6's order was changed from the albuterol sulfate 2.5mg/3ml to the 0.5ml dosage after she returned from the hospital. On 10/23/25 R6's electronic health record (EHR) did not contain any documentation of a follow up visit with a physician after R6's hospital visit. On 10/23/25 at 9:40 AM, V2 stated she had not found any other documentation for R6 from after her hospital visit. On 10/24/25 at 10:11 AM, R8 (R6's previous roommate) stated when R6 returned from the hospital in August, R6 kept telling the nurses she was supposed to have another medication from the hospital, but some nurses told her she was crazy and some just stated R6 did not have any new medications. On 10/28/25 at 1:05 PM, V74 (Nurse Practitioner) stated she was not aware of the medication changes of the Lasix or the albuterol nebulizer treatment after 08/21/25 when R6 was discharged from the hospital. V74 said she was unaware of the updated diagnosis of congestive heart failure for R6. V74 said she has told the facility several times she can only see the records in (EHR company name), therefore when residents return from the hospital with new medications or diagnoses she either needs to be sent the hospital records or the resident's medical record needs to be updated so she can be notified and be aware of what is going on with the resident. V74 stated a diagnosis of CHF and medications changed to Lasix daily could make a significant difference to a resident. V74 stated she was not notified of any of the information and if it was not put into (name of EHR company) she would not know. On 10/29/25 at 2:22 PM, V75 (Nurse Practitioner) stated, he has seen R6 for her anxiety. V75 stated R6 does get more anxious when she cannot breathe. On 10/29/25 at 2:48 PM, V79 (Hospital Nurse Practitioner) stated R6 was given a diagnosis of CHF while in the hospital from 08/15 – 08/21/25 and upon discharge from the hospital, R6's Lasix was changed from as needed to daily. V79 stated would have expected R6 to have CHF added to her diagnoses and the Lasix to be given daily as prescribed at the hospital, upon discharge to the facility. V79 stated she can see on R6's discharge paperwork from the hospital they did not change her albuterol nebulizer dosage. V79 stated R6 should have had a follow up appointment with her primary care physician as in her discharge paperwork from the hospital. The facility's Medication Administration Policy documents Adherence to this Medication Administration Policy is essential to ensure the well-being and safety of our residents. All staff members are expected to follow these guidelines strictly and to repot any issues or deviations from the policy. Continuous improvement and open communication are encouraged to uphold best practices in medication administration. The policy further documents that it applies to all staff members involved in the administration of medication, including nurses. Under Guidelines, Medication Orders and Documentation: 1. All medication orders must be prescribed by a licensed healthcare professional and documented accurately in the resident's medical records. 2. Written, verbal, or telephone orders may only be received and transcribed by an LPN or RN. 3. Any changes in medication orders must be documented in the resident's medical record. 4. Medication administration records (MARs) should be maintained for each resident and must be up-to-date and easily accessible. On 11/06/25 at 10:31 AM, V2 (Director of Nurses) stated she was unable to locate a significant change in condition policy. 2. R7's admission Record dated 10/7/25 documents an admission date of 7/10/24. R7's face sheet documents the following diagnoses including but not limited to lymphedema, reduced mobility, localized edema, and congestive heart failure. R7's MDS dated [DATE] documented a BIMS score of 15, indicating R7 is cognitively intact. R7's MDS documents R7 is a substantial/maximum assist for all mobility needs including repositioning in bed and is at risk for pressure ulcers/injuries. R7's Care Plan dated 10/7/25 documents R7 has a focus area for potential/actual impairment to skin integrity related to decreased mobility and lymphedema to left lower leg dated revised on 4/23/24. R7's care plan documents interventions for the above focus area includes but is not limited to administer treatments as ordered and monitor for effectiveness dated 7/10/24; float heels while in bed as tolerated dated 7/10/24; for dry and flaky skin use high quality moisturizers to rehydrate skin dated 7/10/24; monitor pressure areas for changes in color, sensation, temperature and report any change to nurse dated 7/10/24. R7's physician's orders sheet dated 10/7/25 documents physician's orders including but not limited to ace wrap for compression to bilateral lower extremities related to edema. Change daily. Wrap leg with ace wrap from foot to knee every day shift with a start date of 6/8/25. R7's physician's order from same physician's order sheet documents cleanse left lower extremity with wound cleanser, apply puracol cut to fit open areas and wrap with kerlix (gauze wrap) every day and night shift for wound care with a start date of 6/27/25. R7's physician's order from same form documents another order for a low air loss mattress with a start date of 5/1/25. R7's physician's order documents an order for lymphedema pump to be used three times weekly times three weeks with a start date of 6/26/25. R7 has skin/wound assessments for dates 6/3, 6/10, 6/17, 6/25, 7/2, 7/8, 7/16, 8/18, 8/25, 9/1, 10/14, and 10/16. There were no skin/wound assessments for the weeks of 7/20-7/26, 7/27-8/2, 8/3-8/9, 8/10-8/16, 9/7-9/13, 9/14-9/20, 9/21-9/27, 9/28-10/4, 10/5-10/1, and 10/19-10/25. R7's skin/wound assessments fail to document the circumference of R7's legs indicating the amount of lymphedema being monitored. R7's skin/wound assessments fail to document on the dates completed what type of wounds R7 has, where the wounds are located on the left lower extremity, size of the wounds, how many wounds, and/or if any exudate from wounds. There is also no mention of monitoring of R7's weights to aid in monitoring R7's lymphedema. The most descriptive assessment dated [DATE] given for any of the dates skin/wound assessments were completed documents R7's left lower leg has lymphedema present with wounds, and treatments are in place. R7's progress notes from June – October 2025 including dieticians, nurse practitioners, medical doctors, and all nursing staff progress notes do not document R7's lymphedema was being measured/monitored for increase/decrease in size/amount, that medical doctor was being notified of R7's frequent refusals of dressing changes, or that R7 wanted a different treatment to left lower extremity wounds. R7's progress note dated 10/28/25 at 9:19 A.M., documents R7 was sent to local hospital for left lower extremity being red, warm to touch, having altered mental status, and increased left sided facial drooping. R7's hospital records dated 11/5/25 documents R7 was admitted to local hospital from [DATE] – 11/3/25. R7's hospital records documents on page 8, R7 was started on broad spectrum antibiotics intravenously to treat her diagnosis of septic shock and cellulitis of left lower extremity. R7's hospital records documented no treatment of left lower extremity regarding how and what type of dressing was being done, except left lower extremity was not being wrapped for compression due to severe swelling. R7's same hospital records documents R7 went to local hospital emergency room on [DATE] for altered mental status, fever, leg pain and swelling. Page 17 of same hospital records documents R7's admitting diagnosis was septic shock secondary to lower extremity cellulitis. Page 18 documents from medical doctor's notes R7 is at high risk of recurrence due to underlying lymphedema and poor wound care. On 10/15/25 at 10:35 A.M., R7, who was alert and oriented, stated the nurses frequently do not do her dressing changes or at least all her dressing change. R7 stated her legs are to be wrapped with ace wraps every day, but frequently the staff tell her they do not have ace wraps, or they simply don't do the dressing change. R7 stated she doesn't know and/or has not asked why they weren't done. R7 stated she feels concern for her legs because the cracked, open, bleeding, and weeping skin on her legs could cause infections. At this time, R7's legs were not currently wrapped in ace wraps. There was noted gauze wrap to left lower leg with some light-yellow staining of the gauze in multiple areas from what appears to be weeping and/or serosanguineous drainage from wounds. R7's left leg was extremely swollen with edema. Unable to visualize skin due to gauze wrap. R7's right leg also had severe edema noted but is less than the left leg. There were also no lymphedema pumps noted at R7's bedside. On 10/16/25 at 1:29 P.M., observed the dressing change and treatment of R7's wounds and lymphedema of both lower extremities. V30, (Licensed Practical Nurse/LPN) was the nurse performing the treatment with V2, (Director of Nursing/DON) and V31, (Certified Nursing Assistant/CNA) assisting. Upon entering room the V30 brought the treatment cart into R7's room to perform dressing. V30, V2, and V31 were all wearing gloves, but no one had donned a disposable gown before beginning wound care. V30 performed hand hygiene and then donned gloves. V30 removed the old dressing which was only the gauze wrap using scissors. Upon removal of R7's old dressing R7's left leg skin was cracked and peeling with numerous open cracks that were not actively weeping but appeared to be moist with serosanguineous fluid and/or blood. The skin was very tight in appearance also. There were also what appeared to be blister like formations near the posterior region of the left knee above and below the knee joint. The lesions were intact and not currently open or draining. R7's right leg was also severely swollen with edema, but the skin had not started to crack, peel and open like the left leg. Skin to right leg was intact and appeared healthier than the left leg's skin condition overall. V30 then performed hand hygiene and donned new set of gloves. V30 washed both legs with soap and water changing gloves and performing hand hygiene according to current standards of practice. R7's left leg was rinsed with water and washcloths. Left leg was dried, then lotion applied. There was no medicated creams or ointments applied to R7's open areas on her left leg. Then gauze wrap was applied from toes to knee on the left foot and then two four-inch ace wraps applied to left leg. Right leg was then completed with lotion being applied and two four-inch ace wraps applied. On 10/16/25 at 11:01 A.M., V32, LPN stated as far as treatment/dressing supplies the facility is frequently out of ace wraps. V32 stated the trouble with obtaining wound supplies has been ongoing for about the last two months periodically. On 11/6/25 at 12:12 P.M., V32, LPN stated when he realized on the incidents, he was out of ace wraps to do R7's dressing changes with he would notify V2. V32 couldn't say how frequently he was out of ace wraps, but did mention it was more than once. V32 stated he would notify V2 the same day because he worked day shift, and she was usually in the building. V2 stated as far as he is aware administration did not go to a local store and pick any ace wraps up that same day. V32 stated administration would tell him the ace wraps were on back order or delayed. V32 stated he did not notify the medical doctor when R7 would frequently refuse her dressing changes. V32 stated R7 frequently refused her dressing changes because he would not do it the way she wanted but only do it according to doctor's orders, or R7 would state she was too tired or wanted to sleep at that particular time. V32 stated because he would only do the dressing according to doctor's orders she would refuse it. V32 stated he thought notifying the wound care nurse V30, LPN and V2 would be sufficient. On 11/5/25 at 1:32P.M., V32, LPN stated R7 frequently wanted him to put Nystatin powder in her open wounds because she said that was what healed them. V32 stated on 9/9/25 when it was documented in R7's treatment administration records that she refused the treatment that day it was because he refused to do the dressing like R7 wanted it done versus how the dressing and treatment were ordered. V32 stated he did notify the nurse practitioner of R7's refusal that day on 9/9/25. V32 stated when he notified V74, nurse practitioner that day, he stated he received no new orders from V74 regarding R7's treatments to wounds or lymphedema. R7's only progress note dated 9/9/25 documents there was no notification to V74 of R7's refusal of dressing change. On 11/5/25 at 1:36 P.M. V29, LPN stated R7 would frequently refuse her dressing changes to her left lower leg because the nursing staff wouldn't put Nystatin powder on the open wounds and/or sometimes R7 would tell the nursing staff she was just too tired or hurting. V29 stated she would notify V2, DON of her refusal of dressing changes, but does not remember notifying the medical doctor or nurse practitioner. V29 stated R7 would refuse the entire treatment including wrapping her legs with the ace wraps when V29 refused to put the nystatin powder on them when it wasn't what the doctor ordered. V29 stated looking back on R7's refusals she should have notified the doctor or nurse practitioner if and/or when R7 refused her treatments. On 11/5/25 at 5:30 P.M. V53, LPN stated she could not remember the exact dates or date R7 had refused her dressing changes to her legs including application of the ace wraps, but remembered it was frequently R7 did refuse. V53 stated the reason given from R7 for frequently refusing her dressing changes was because she wanted the nursing staff to do it a certain way including rubbing nystatin powder or cream into her open wounds on her legs and then dressing them. V53 stated she explained to R7 couldn't do that because it wasn't the doctor's orders. V53 stated when she would explain this to R7 she would then refuse the dressing all together. V53 stated she did not notify the medical doctor when R7 would refuse her dressing changes because it was in the evening and R7 refused frequently. V53 stated there were shifts she was working when there were no ace wraps in the building she knew of. V53 stated she would not notify V2, DON or the wound nurse immediately, but would leave a note on the shift report in the electronic health record system and let them know that way. V53 stated she would expect them to find the notificat

Based on observation, interview and record review the facility failed to provide the prescribed diets, nutritional supplements and the appropriate portion sizes according to the approved menus for 7 of 7 residents (R2, R3, R13, R15, R18, R19 and R42) reviewed for weight loss in a sample of 46. This failure further contributes to continued harm to R3 and R18, who are currently considered severely thin and underweight. Findings include:1. R3's admission Record documents an admission date of 05/14/24 with diagnoses including: Alzheimer's disease with late onset, dementia, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, pleural effusion, abnormal posture, and body mass index 19.9 or less.R3's Minimum Data Set (MDS) dated [DATE] documents a dash for the question, should brief interview for mental status (BIMS) be conducted? and a dash for the BIMS summary score. R3's MDS section L documents none of the above were present with the boxes included B. no natural teeth or tooth fragments and F. mouth or facial pain, discomfort or difficulty with chewing. R3's MDS section GG documents R3's eating ability requires supervision or touching assistance indicating helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.R3's Order Summary Report documents a dietary order for a regular diet with regular consistency and minced meats for nutrition with an order date of 01/28/25 and an order status of active. R3's order summary report documents a dietary supplement order of fortified foods with an order date of 07/15/24 with an order status of active.R3's Care Plan documents a focus area of R3 has a nutritional problem or potential nutritional problem dated 07/01/25 and interventions listed as: provide and serve diet as ordered and registered dietician to evaluate and make diet change recommendations as needed with a date initiated 05/30/24. R3's care plan documents a focus area of R3 has an ADL (Activities of Daily Living) self care performance deficit related to dementia dated 05/14/24 with an intervention listed as: eating: the resident requires 1 staff participation to eat dated 05/14/24.R3's weight summary documents weights as follows: 08/02/25 as 69.7 pounds, 09/01/25 as 69.5 pounds, 10/02/25 as 68.9 pounds. R3's weight summary documents that R3 is 62 inches tall, has a BMI (Body Mass Index) of 12.6 and her IBW (Ideal Body Weight) Range is 131.0-159.0 pounds.On 11/13/25 at 10:04 AM, R3 was in the dining room in her wheelchair, she appeared thin, R3 was assisted to stand on scale by V35 (Certified Nurse Aide/CNA), R3's weight was 68.0 pounds.According to the Adult BMI Calculator on the CDC (Centers for Disease Control) website at https://www.cdc.gov/bmi/adult-calculator/index.html, R3 has a BMI of 12.4 and is considered underweight. According to the World Health Organization at https://apps.who.int/nutrition/landscape/help.aspx?menu=0&helpid=420#:~:text=Moderate%20and%20severe%20thinness%20%E2%80%93%20A,population%20has%20a%20BMI%20%3C18.5, a BMI of less than 17.0 indicates moderate and severe thinness. According to the WHO the consequences and implications of moderate and severe thinness: A BMI < 17.0 indicates moderate and severe thinness in adult populations. It has been linked to clear-cut increases in illness in adults studied in three continents and is therefore a further reasonable value to choose as a cut-off point for moderate risk. A BMI < 16.0 is known to be associated with a markedly increased risk for ill health, poor physical performance, lethargy and even death; this cut-off point is therefore a valid extreme limit.R3's dietician nutrition assessment dated [DATE] at 2:46 PM documents: R3 has a regular diet with fortified foods, nutritional drink at 120 ml (milliliters) two times a day with varied intakes at review of available records since 08/16/25. R3's height is 62 inches dated 05/16/24 at 6:21 PM by method of standing with a weight on 08/02/25 at 1:51 PM of 69.7 pounds with a BMI of 12.7 %. R3's usual body weight is listed as 69.5 pounds. R3's goal weight is listed as 110 pounds and the comment section documents: R3 is at base weight and stable, her weight is low with low BMI but usual.R3's most current dietary note dated 04/09/25 at 1:36 PM documents: dietitian weight review for loss at 3 months. April weight is 69.2 pounds with a body mass index of 12.7%, R3 has a weight loss of 8.7 % over the last 3 months. R3 appears to have fluid related/CHF (Congestive Heart Failure) family wanted no further evaluation, use of Lasix noted. R3 has no wounds and has wound preventative in place. May give R3's medications in pudding if accepted. R3's lab review on 04/05 notes R3 is nutritionally stable except BUN (blood urea nitrogen) which is elevated at 33. R3's diet order is regular diet with regular texture with fortified food, boost 120 ml (milliliters) twice a day on 01/28/25. Meal consumption at review of available records since 03/27/25 is 26-100% with no refusals which is baseline. Although low body weight is stable with interventions. Continue per orders and follow up as needed with new concerns.R3's dietary ticket dated 09/29/25 documents for lunch: supplement: 1 #8 scoop FB (fortified blended) vanilla pudding - supplement.On 09/29/25 at 12:55 PM, R3 did not receive any fortified pudding at lunch. R3 received: 1 each ground cheeseburger, 1/2 cup French fries, 4 ounces seasoned green beans, 2 each chocolate chip cookies. R3's dietary ticket 09/30/25 documents for breakfast: supplement: 1 #8 scoop FB vanilla pudding - supplement.On 09/30/25 at 8:19 AM, R3 was eating in the dining room and did not receive any fortified pudding at breakfast. Staff were noted in the dining room, no one was sitting with R3. Facility menu: Summer menu 2025 - week 1, Tuesday, lunch, general/regular documents: 2 each hard taco shells, 3 ounces ground taco chicken filling, 2 fluid ounces salsa fresh, 4 ounces Spanish rice, 4 ounces refried beans, 1 each churro, 8 fluid ounces 2% milk, 6 fluid ounces coffee, 1 each butter, 1 each sugar, and 6 fluid ounces hot tea. (9/30/25)R3's dietary ticket 09/30/25 documents for lunch: supplement: 1 #8 scoop FB vanilla pudding - supplement.On 09/30/25 at 1:18 PM, R3 received 2 hard taco shells and a churro with her lunch. At that time R3 put the churro in her mouth, took it out, and hit it on her plate. R3 was observed not to have any teeth. R3 did not receive any fortified pudding with her lunch tray. V16 (Family) was noted sitting at the table with R3. On 09/30/25 at 2:25 PM, V16 stated R3 did not get her pudding today. V16 stated, the churro R3 received with lunch was hard and R3 could not bite it. The taco shells were too hard for her to bite because R3 does not have any teeth, so she took the meat out of the shells and gave her that. On 09/30/25 at 3:10 PM, V16 stated, R3 does not have any teeth and has ground meat on her order that she gets most of the time, however there are times they will still give her hard crunchy foods such as the hard shell taco shells and the churro that they know she cannot eat.On 10/15/25 at 1:12 PM, R3 did not receive any fortified pudding at lunch.On 10/16/25 at 1:35 PM, R3 was sitting in the dining room eating lunch with no staff present in the dining room until 1:46 PM.On 10/22/25 at 12:34 PM, R3 was noted sitting in the dining room, there were staff on the other side of the dining room. At that time R3 was noted to be attempting to eat her rice with her knife. R3 continued until 12:46 PM when surveyor encouraged her to use her spoon, R3 then looked at the spoon for a few seconds and then picked it up and started using it to eat her rice. On 10/27/25 at 5:21 PM, V16 (Family) stated she never requested for V72 (Registered Dietician) to not evaluate R3. V16 stated, she only requested before R3 was sent to the hospital or had x-rays she would like to be contacted. V16 stated, her mother is small and she needs the extra nutrition. V16 stated, she unfortunately does not always get the fortified pudding she is supposed to receive. V16 stated she has gone to the kitchen to get it for R3 before and the staff would not give it to her and sometimes they would state they did not have any.On 11/13/25 at 11:17 AM, V72 stated, R3's weight has been fairly consistent over the past year. R3 will have some peaks and valleys, that will happen. V72 stated, she did her last assessment on R3 on 08/29/25, she has not looked at her closer since then because she has been fairly consistent. V72 stated, she does have the expectation that R3 would receive the supplements she has recommended for her.2. R18's admission Record documents an admission date of 06/03/23 with diagnoses including: Huntington's disease, chorea, severe protein calorie malnutrition, body mass index 19.9 or less, adult failure to thrive, depression, dysphagia, abnormal posture, feeding difficulties, speech and language deficits following other cerebrovascular disease, extrapyramidal and movement disorder, chronic obstructive pulmonary disease, muscle weakness, lack of coordination, muscle wasting and atrophy, altered mental status, and ataxia following cerebral infarction.R18's Order Summary Report documents a dietary order of regular diet with mechanical soft texture dated 03/19/25 with no end date listed and a dietary supplements order of fortified foods two times a day for weight loss dated 03/19/25 with no end date listed.R18's MDS dated [DATE] documents no BIMS was conducted due to resident is rarely to never understood. Section GG documents R18's eating abilities require supervision or touching assistance indicating helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.R18's Care Plan documents a focus area of R18 has nutritional problem or potential nutritional problem, thickened liquids dated 05/08/25 with interventions including: explain and reinforce to the resident the importance of maintaining the diet ordered, encourage the resident to comply, explain consequences of refusal, and obesity/malnutrition risk factors dated 05/08/25. Monitor/document/report to physician as needed for signs or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat and appearing concerned during meals dated 05/08/25. Provide and serve diet as ordered dated 05/08/25. R18's weight summary documents weights of: 08/28/25 as 100.6 pounds, 09/03/25 as 99.0 pounds, 09/11/25 as 95.2 pounds, 10/02/25 as 95.0 pounds, 10/10/25 of 91.8 pounds, and 10/16/25 of 91.6 pounds. R18's weight summary documents that R18 is 70 inches tall, has a BMI of 14.1 and her IBW Range is 167-202 pounds. On 11/13/25 at 10:22 AM, V17 (CNA) weighed R18 who was sitting in a wheelchair in the dining room and appeared tall and very thin. R18 was smiling and talking but confused. R18's weight was 139.8 pounds, her wheelchair weight was documented on back of her wheelchair as 41.6 pounds which indicates R18's weight was 98.2 pounds. According to the Adult BMI Calculator on the CDC (Centers for Disease Control) website at https://www.cdc.gov/bmi/adult-calculator/index.html, R18 has a BMI of 14.1 and is considered underweight. According to the World Health Organization at https://apps.who.int/nutrition/landscape/help.aspx?menu=0&helpid=420#:~:text=Moderate%20and%20severe%20thinness%20%E2%80%93%20A,population%20has%20a%20BMI%20%3C18.5, a BMI of less than 17.0 indicates moderate and severe thinness. According to the WHO the consequences and implications of moderate and severe thinness: A BMI < 17.0 indicates moderate and severe thinness in adult populations. It has been linked to clear-cut increases in illness in adults studied in three continents and is therefore a further reasonable value to choose as a cut-off point for moderate risk. A BMI < 16.0 is known to be associated with a markedly increased risk for ill health, poor physical performance, lethargy and even death; this cut-off point is therefore a valid extreme limit.R18's dietician nutrition assessment dated [DATE] at 10:11 AM documents: most recent height is 70 inches dated 06/03/23 at 6:34 PM with a method of standing and R18's most recent weight of 95 pounds dated 10/02/2025 at 8:43 AM with a BMI of 13.6 % and a usual body weight of 100 pounds. The comment section notes: R18's usual body weight since last November 2024 a review of records is 95-104 pounds, R18 has low body weight/varied patterns with chronic diseases. R18's most current dietary note date 07/18/25 at 12:02 PM documents: chart review weight shifts up and down trends. July weight recorded: 7/8 at 102.8 pounds, 7/6 at 102.8 pounds, 07/17 at 96.2 pounds, R18's BMI is 13.8 percent. Patterns since 03/06/25: 95.4 - 104.4 pounds, trends very likely affected by chronic disease, declined swallow ability with Huntington's waiver signed for oral po (per oral) diet. By history of use of alternative feeding but when tube became dislodged 01/08/25 resident and POA (power of attorney) decided against replacing and po (per oral) diet for pleasure. No wounds noted. Recent fall. Diet order: regular with mechanical soft texture and honey thick liquids. 3 fortified foods daily (pudding twice a day and mashed potatoes every day per 06/06/25 recommendation), meal consumption is varied since 07/05 - 0-100% more 26-100%. Is not always adequate for needs however facility is honoring choice and preference that has been agreed to by POA as well. Continue all interventions and follow trends.Facility menu: Summer menu 2025, Monday, week 1, lunch, general/mechanical soft documents: 1 each ground cheeseburger, 1/2 cup French fries, 4 ounces seasoned green beans, 2 each chocolate chip cookies, 1 each sugar, 0.5 coffee creamer, 1 each butter, 8 fluid ounces 2% milk, 6 fluid ounces coffee, and 6 fluid ounces hot tea. (9/29/25)On 09/29/25 at 1:18 PM, R18 was sitting in her wheelchair in the dining room. R18's bones were prominently visible under her skin and she was very thin. R18's dietary ticket dated 09/29/25 lunch, documents at the bottom ice cream for lunch and dinner and grilled cheese with meal.On 09/29/25 at 1:18 PM, R18 did not receive ice cream, pudding, a grilled cheese, or fortified mashed potatoes for lunch. R18 received a ground cheeseburger, 1/2 cup French fries, 4 ounces green beans, and two chocolate chip cookies. Facility menu: Facility menu: Summer menu 2025 - week 1, Tuesday, lunch, general/mechanical soft documents: 2 each corn tortillas, 3 ounces ground taco chicken filling, 2 fluid ounces salsa fresh, 4 ounces Spanish rice, 4 ounces refried beans, 1/2 cup butterscotch pudding, 8 fluid ounces 2% milk, 6 fluid ounces coffee, 1 each butter, 1 each sugar, and 6 fluid ounces hot tea. (9/30/25)R18's dietary ticket dated 09/30/25 lunch, documents at the bottom ice cream for lunch and dinner and grilled cheese with meal.On 09/30/25 at 1:35 PM, R18 did not receive ice cream, fortified mashed potatoes, a grilled cheese or butterscotch pudding for lunch. R18 received 3 ounces ground taco chicken filling, 4 ounces Spanish rice, and 4 ounces refried beans. R18 did not receive corn tortillas either with her lunch meal. Facility menu: Facility menu: Summer menu 2025 - week 3, Wednesday, lunch, general/mechanical soft documents:1 #6 scoop ground sweet and sour pork, 4 ounces rice white, 4 ounces roasted Italian vegetables, 1 (2x2) assorted dessert, 1 each sugar, 1 each butter, 8 fluid ounces 2% milk, 6 fluid ounces hot tea, and 6 fluid ounces coffee. (10/15/25)On 10/15/25 at 1:17 PM, R18 did not receive ice cream, fortified mashed potatoes, or pudding for lunch. R18 received 1 #6 scoop ground sweet and sour pork, 4 ounces rice white, 4 ounces roasted Italian vegetables, and one brownie. On 11/13/25 at 11:17 AM, V72 (Registered Dietician) stated R18 is underweight but with her diagnosis of Huntington's disease she is a pleasure eater. R18's weight will fluctuate also, she believes her weight is up today.3. R42's admission Record documents an admission date of 02/25/22 with diagnoses including: spinal stenosis, weakness, osteoarthritis, pure hypercholesterolemia, long term (current) use of antithrombotics/antiplatelets, chronic obstructive pulmonary disease, dysphagia, vascular dementia, and anxiety disorder.R42's Order Summary Report documents a dietary order for a regular diet with a pureed texture and double portions with an order date of 11/07/25 and an order status of active.R42's MDS dated [DATE] documents a BIMS score of 05 indicating severe impaired cognition. R42's eating assistance is listed as setup or clean up assistance required. R42's height is listed as 72 inches.R42's Care Plan documents a focus area noting R42 has potential nutrition problem relating to being below IBW (Ideal body weight) of 177-214 pounds dated 08/14/24 with interventions listed as: double portions at meals dated 04/14/2021, provide and serve supplements as ordered dated 11/16/22, provide, serve regular, ground meat diet as ordered. Monitor intake and record every meal dated 04/26/21, and monitor/record/report to medical doctor as needed signs and symptoms of malnutrition: emaciation (cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, and >10% in 6 months dated 08/18/20.R42's weight summary documents weights as follows: 08/05/2025 as 163.2 pounds, on 09/06/25 as 159.8 pounds, and on 10/07/25 as 154.2 pounds.On 11/13/25 at 10:27 AM, R42 was weighed by V15 (Licensed Practical Nurse/LPN) R42 was weighed in his wheelchair with a weight of 200.0 pounds. The wheelchair had a weight of 42.2 pounds, indicating he weighs 157.8 pounds.According to the Adult BMI Calculator on the CDC (Centers for Disease Control) website at https://www.cdc.gov/bmi/adult-calculator/index.html, R42 has a BMI of 21.4 and is considered to be at a healthy weight. R42's dietary note dated 10/10/25 at 7:33 PM documents: dietitian chart review for weight trends, October weight 154.2 pounds with a BMI of 20.9%. At review history of gain and is currently trended down but remains with in usual body weight range. Trends may be reflective of cognition. R42 has no pressure wounds and recent lab review noted as stable. R42's diet order is regular with pureed texture and regular liquids with one fortified food twice a day, double portions at meals with meal consumption at review of records since 09/27 is 0(2) - 100%. R42 receives nutritional drink noted as well. Continue diet order with extra calorie and protein monitor intake, labs and weight for stability. Facility menu: Facility menu: Summer menu 2025 - week 1, Monday, lunch, general/puree documents: 8 ounce puree cheeseburger 3 ounce meat, 1 ounce sauce, 4 ounce bread, 4 ounce pureed French fries, 4 ounce seasoned green beans, puree cookie chocolate chip, 1 each butter, 1 each sugar, 8 fluid ounce 2 % milk, 6 fluid ounce coffee, 6 fluid ounce hot tea. (9/29/25)R42's dietary ticket dated 09/29/25 documents: supplement: FB vanilla pudding - supplement-fortified food. The bottom of the ticket notes: double portions and fortified pudding - 1/2 cup.On 09/29/25 at 1:18 PM, R42 did not received double portions or any fortified pudding with his lunch meal. R42 received a single portion, 8 ounce puree cheeseburger, 4 ounces of pureed French fries, 4 ounces of pureed green beans, and puree chocolate chip cookies.Facility menu: Summer menu 2025, Tuesday, week 1, breakfast, general/puree documents: 3 ounces puree western scramble, 6 fluid ounces puree oatmeal, 1 each sugar, 1 each butter, 0.5 fluid ounce coffee creamer, 1 each jelly, 6 fluid ounces orange juice, 8 fluid ounce 2% milk, and 6 fluid ounce coffee.On 09/30/25 at 8:11 AM, R42 did not receive double portions with his breakfast. R42 received 3 ounces puree western scramble and 6 fluid ounces pureed oatmeal.Facility menu: Summer menu 2025, Tuesday, week 1, lunch, general/puree documents: 2 each pureed corn tortillas, 3 ounces pureed taco chicken filling, 2 fluid ounces salsa fresh, 4 ounces pureed Spanish rice, 4 ounces pureed refried beans, 1/2 cup butterscotch pudding, 8 fluid ounces 2% milk, 6 fluid ounces coffee, 1 each butter, 1 each sugar, and 6 fluid ounces hot tea. (9/30/25)On 09/30/25 at 1:25 PM, R42 did not receive double portions, any fortified pudding, any butterscotch pudding, or any pureed corn tortillas with his lunch meal. R42 received 4 ounces pureed taco chicken filling, 4 ounces pureed Spanish rice, and 4 ounces pureed refried beans. Facility menu: Summer menu 2025, Wednesday, week 3, lunch, general/puree documents: 6 ounces puree sweet and sour chicken, 4 ounces pureed white rice, 4 ounces pureed vegetable roasted Italian, 4 ounces pureed brownie, 1 each sugar, 1 each butter, 8 fluid ounces 2% milk, 6 fluid ounces hot tea and 6 fluid ounces coffee. (10/15/25)On 10/15/25 at 1:02 PM, R42 did not receive double portions, pureed brownie or any fortified pudding with his lunch meal. R42 received 6 ounces pureed sweet and sour chicken, 4 ounces pureed white rice, 4 ounces pureed vegetable roasted Italian. 4. R2's admission Record documents an admission date of 02/23/24 with diagnoses including: dementia, hypertension, anxiety disorder, major depressive disorder, dysphagia, feeding difficulties, gastro-esophageal reflux disease, cognitive communication deficit.R2's Order Summary Sheet documents a dietary order of regular diet with pureed texture with an order date of 04/29/25 and no end date listed. The dietary supplements order documents: fortified foods in the afternoon for ice cream at lunch with an order date of 05/29/25 and no end date listed. The order summary documents an order for fortified pudding for dinner in the evening for nutrition with an order date of 11/14/24 and no end date listed.R2's MDS dated [DATE] documents a BIMS score of 03, indicating severely cognitively compromised. R2's eating assistance is listed as: partial to moderate assistance. R2's care plan documents a focus area of: dietary with interventions listed as: foods R2 dislikes are rice and mashed potatoes are not my favorite and R2 likes fruit cups and ice cream with a date initiated of 07/21/23.R2's Care Plan documents a focus area of: R2 has nutritional problem or potential nutritional problem dated 05/09/25 with interventions listed as: provide and serve supplements as ordered dated 05/27/25 and provide and serve diet as ordered dated 05/09/25.R2's most current dietary note dated 05/28/25 at 2:58 PM documents: dietitian review for weight change at 1 month. May weight: 124.4 pounds, up 6.1 % at one month post loss last month with a BMI (body mass index) of 22.0 %. R2's dietary order is regular diet with pureed texture and regular liquids, fortified food at dinner, ice cream every day, boost 120 ml (milliliters) two times a day. R2's meal consumption at review of available records since 05/15 with 26-100%. Continue diet order and monitor for texture tolerance, continue interventions and follow up as needed with new concerns.R2's Dietary ticket dated 09/29/25 lunch documents: supplement 4 ounces vanilla ice cream and at the bottom: 4 ounces assorted ice cream.On 09/29/25 at 12:55 PM, R2 did not receive ice cream with her lunch. Facility menu: Summer menu 2025, Tuesday, week 1, lunch, general/puree documents: 2 each pureed corn tortillas, 3 ounces pureed taco chicken filling, 2 fluid ounces salsa fresh, 4 ounces pureed Spanish rice, 4 ounces pureed refried beans, 1/2 cup butterscotch pudding, 8 fluid ounces 2% milk, 6 fluid ounces coffee, 1 each butter, 1 each sugar, and 6 fluid ounces hot tea. (9/30/25)R2's dining ticket documents 09/30/25 lunch: adaptive equipment of 2 handled cup with lid, Spanish rice, butterscotch pudding, and supplement: 4 ounce vanilla ice cream.On 09/30/25 at 1:23 PM, R2 did not receive ice cream, butterscotch pudding, or pureed corn tortillas with her lunch meal. R2 received 4 ounces pureed taco chicken filling, 4 ounces pureed Spanish rice, and 4 ounces pureed refried beans. Facility menu: Summer menu 2025, Wednesday, week 3, lunch, general/puree documents: 6 ounces pureed sweet and sour pork, 4 ounces pureed white rice, 4 ounces pureed vegetable roasted Italian, 4 ounces pureed brownie, 1 each sugar, 1 each butter, 8 fluid ounces 2% milk, 6 ounces hot tea, and 6 ounces coffee. (10/15/25)On 10/15/25 at 1:05 PM, R2 did not receive pureed brownie or any ice cream with her lunch meal. R2 received 6 ounces pureed sweet and sour chicken, 4 ounces pureed white rice, 4 ounces pureed vegetable roasted Italian. 5. R13's admission Record documents an admission date of 09/09/25 with diagnoses including: cerebral palsy, type 2 diabetes mellitus with hypoglycemia, epilepsy, dysphagia, disorder of urea cycle metabolism, major depressive disorder, poisoning by other antiepileptic and sedative hypnotic drugs accidental, dysphagia, metabolic encephalopathy, anemia, iron deficiency, intellectual disabilities, atrial fibrillation, and adult failure to thrive.R13's MDS dated [DATE] documented a BIMS score of 00, indicating severe impairment. R13's eating assistance is documented as partial/moderate assistance - helper does less than half the effort, helper lifts or holds trunk or limbs and provides less than half the effort. R13's Physician Order Sheet documents a dietary order of consistent carbohydrate diet of mechanical soft texture with add ice cream at lunch and supper for nutrition with an order date of 07/21/25 and no end date listed.R13's Care Plan documents a focus area of R13 has a potential nutritional problem PEG (percutaneous endoscopic gastrostomy) tube is in place due to history of poor intake and weight loss prior to admission dated 06/25/24 with an intervention of provide and serve diet as ordered dated 06/25/24.R13's dietary note dated 09/24/25 at 6:09 PM documents: dietitian review for weight change. September weight: 109.6#, 9/12: 110.4#, 9/19: 110 stable currently since 7/22/25 BMI: 20.8 Loss of 8.7% 3 months/loss of 10% 6 months. H/O hospitalization, seizure and medication adjustment. No wounds, no new labs, use of megace noted. Diet order: CCD, (Consistent carbohydrate diet) mechanical soft with regular liquids, use of scoop plate, ice cream BID (twice a day). Use of prostat BID (twice daily). Meal consumption is varied at review but usual for meals 25-75% plus snacks po (by mouth) fluids that she request. Long history of diet noncompliance which is her choice. Family is aware. Continue diet order as weight patterns are now stable. F/U (follow up) as needed with new concerns.R13's dietary ticket dated 09/29/25 lunch documents at the bottom: ice cream. On 09/29/25 at 12:53 PM, R13 did not receive any ice cream with her lunch. Facility menu: Summer menu 2025, Tuesday, week 1, lunch, general/mechanical soft documents: 2 each corn tortillas, 3 ounces ground taco chicken filling, 2 fluid ounces salsa fresh, 4 ounces Spanish rice, 4 ounces refried beans, 1/2 cup butterscotch pudding, 8 fluid ounces 2% milk, 6 fluid ounces coffee, 1 each butter, 1 each sugar, and 6 fluid ounces hot tea. (9/30/25)On 09/30/25 at 1:10 PM, R13 did not receive any corn tortillas, butterscotch pudding or ice cream with her lunch. On 10/15/25 at 1:12 PM, R13 did not receive any ice cream with her lunch. On 10/23/25 at 1:40 PM, V15 (Licensed Practical Nurse) stated, R13 does not have a PEG tube anymore. 6. R15's admission Record documents an admission date of 04/11/25 with diagnoses including: chronic kidney disease, dementia, major depressive disorder, atrial fibrillation, disease of intestine, and hyperglycemia.R15's MDS dated [DATE] documents a BIMS score of 03, indicating severe cognitive impairment. R15's eating assistance is listed as: setup or clean up assistance.R15's Order Summary Sheet documents a dietary order of mechanical soft texture and add one fortified food with all meals with an order date of 04/18/25 and no end date listed. The dietary supplements order documents: fortified foods two times a day for breakfast and lunch with an order date of 05/28/25 and no end date listed.R15's Care Plan documents a focus area of: R15 has nutritional problem or potential nutritional problem dated 07/29/25 with an intervention listed as provide and serve diet as ordered dated 05/09/25.R15's dietary note dated 09/24/25 at 2:39 PM documents: dietitian chart review for weight change. R15's September weight 151.6 pounds (August weekly had dropped but now rebounded). R15's BMI is 27.2%. Noted insidious changes. R15's diet order is regular diet with mechanical soft texture and regular liquids with fortified foods two times a day and nutritional drink 90ml. R15's meal consumption had been varied but since 09/11 is more stable 0-100% more often 51-75%. From review with ADON (Assistant Director of Nursing) there had been a history of medication refusal. Recently adjusted to liquid and tolerating better. Is also noted to accept the supplement. Based on current trends with extra nutrition opportunities in place continue all orders and follow up with new concerns.R15's dietary card documents 09/29/25, lunch, fortified pudding.On 09/29/25 at 1:32 PM, R15 did not receive any fortified pudding with lunch.On 09/30/25 at 8:32 AM, R15 did not receive any fortified food with her breakfast. The oatmeal on R15's tray was regular oatmeal. At that time, R15 who was alert and oriented stated, the oatmeal did not taste sweet or any different than plain oatmeal. R15's oatmeal was light in color and did not appear any different than the other oatmeal given.On 10/22/25 at 1:50 PM, V88 (Dietary Manager) stated, fortified cereal or oatmeal will be darker and sweater then regular oatmeal or hot cereal. Facility menu: Facility menu: Summer menu 2025 - week 1, Tuesday, lunch, general/mechanical soft documents: 2 each corn tortillas, 3 ounces ground taco chicken filling, 2 fluid ounces salsa fresh, 4 ounces Spanish rice, 4 ounces refried beans, 1/2 cup butterscotch pudding, 8 fluid ounces 2% milk, 6 fluid ounces coffee, 1 each butter, 1 each sugar, and 6 fluid ounces hot tea. (9/30/25)On 09/30/25 at 1:38 PM, R15 did not receive any corn tortillas or butterscotch pudding with the lunch meal. R15 did not receive any fortified pudding with lunch.R15's dietary ticket dated 10/15/25 lunch documents fortified pudding. On 10/15/25 at 12:52 PM, R15 did not receive any fortified pudding with her lunch. 7. R19's admission Record documents an admission date of 12/22/23 with diagnoses including: end stage renal disease, dementia, dependence on renal dialysis, gastro-esophageal reflux disease without esophagitis, combined systolic and diastolic heart failure, dysphagia, and cognitive communication deficit.R19's MDS dated [DATE] documents a BIMS score of 06, indicating severe cognitive impairment. Section GG documents R19's eating ability as set up or clean up assistance needed. R19's Order Summary Report documents a dietary order of no added salt diet with mechanical soft texture with an order date of 04/18/25 and no end date listed. R19's order summary report documents a dietary supplement order of fortified foods every day and evening shift with an order date of 03/31/25 and no end date listed.R19's Care Plan documents a focus area of R19 has a swallowing problem dated 02/03/25 with interventions including: diet to be followed as prescribed dated 10/01/24, monitor for shortness of breath, choking, labored respiration, lung congestion dated 10/01/24, and monitor/document/report to nurse/dietitian and physician as needed for difficulty swallowing, holding food in his mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, and pocketing food in mouth dated 10/01/24. R19's care plan does not include a focus area of nutrition.R19's dietary note dated 10/18/25 at 11:56 AM documents: dietitian chart review for weight trends. October weight was 127.2 pounds and BMI 24.8 % weight is 127.2 - 136.4 pounds since 2/2025. At review overall trends within UBW (usual body weight) range since admission. No pressure wounds and lab review on 09/19 notes glucose 181.5 which is elevated. Diet order has been individualized based on intake trends. Regular with regular texture, sugar free condiments

Based on interview and record review the facility failed to provide pain medications for pain management for 3 of 3 residents (R4, R5, and R31) reviewed for pain in the sample of 46. This failure resulted in R4 and R31 not having the medications available used to treat their pain resulting in uncontrolled pain. Findings Include:1. R4's admission Record with a print date of 10/01/25 documents R4 was admitted to the facility on [DATE] with diagnoses that includes polyneuropathy.R4's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 03, indicating R4 has a severe cognitive deficit.R4's current Care Plan documents a Focus area of (R4) has pain. Date Initiated: 01/22/2025. This Focus area includes the intervention of, Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Date Initiated 01/22/2025.R4's Order Summary Report dated 10/01/2025 documents a physician order for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (milligrams) give 1 tablet by mouth every 6 hours as needed for pain with an order date of 7/30/25.R4's Medication Administration Record (MAR) dated 9/1/25 to 9/30/25 documents a physician order for Hydrocodone-acetaminophen 5-325 mg give one tablet every 6 hours as needed for pain. This same MAR documents R4 is routinely administered the hydrocodone from 9/1/25 until 9/20/25. There is no documentation R4 was administered hydrocodone from 9/21/25 through 9/30/25. This MAR documents the following pain scale assessments using a 0-10 pain scale for R4: 9/22- night shift-2, 9/23-night shift-4, 9/24- night shift- 4, 9/26- evening shift- 4, 9/29/25 - night shit- 5. This MAR documents the physician order for acetaminophen 650 mg every four hours as needed was administered on 9/25 at 2:20 PM, 9/26 at 6:57 PM, 9/27 at 7:28 PM, and 9/28/25 at 6:46 PM. This indicates R4's pain was not treated with the physician ordered hydrocodone from 9/21 to 9/30/25 and was not treated with any pain-relieving medication on 9/23, 9/24, and 9/29 when she was assessed with pain scales of 4 and 5.R4's MAR dated 10/01/25 to 10/31/25 documents a physician order for hydrocodone-acetaminophen 5-325 mg give one tablet every 6 hours as needed for pain. This same MAR documents R4 is routinely administered hydrocodone from 10/09/25 until 10/31/25. There is no documentation of the hydrocodone and/or acetaminophen being administered from 10/01 through 10/8/25. This MAR documents the following pain scale assessments using a 0-10 pain scale: 10/01 - night shift- 5, 10/02 - night shift- 3, 10/03 - day shift - 3, 10/05 - night shift - 4, 10/6 - night shift - 3, 10/07 - night shift - 3, 10/08- night shift- 4. This indicates R4's pain was not treated with pain relieving medications from 10/01 to 10/8/25 when she was assessed as having pain at a scale of 3-5.On 10/20/25 at 12:28 PM, V7 (Caregiver) stated R4 currently had pain medications but she was out of them the end of September, and it took about a week and a half to get it in. V7 stated R4 would cry in pain after her lunch time nap. V7 stated the facility staff offered her Tylenol but it didn't relieve the pain. V7 stated she didn't know why the medications weren't available.On 10/20/25 at 12:54 PM, V32 (LPN/Licensed Practical Nurse) stated they run out of controlled substances (pain medications) at times. When asked why, V32 stated the NP (Nurse Practitioner), it's hard. V32 stated when a resident needs a new prescription, they let the physician know and then the facility staff call the pharmacy to get it and the pharmacy reports they don't have the prescription. V32 stated R4 was out of her pain medications about three weeks ago for four to five days. V32 stated R4 had an increase in pain, they tried Tylenol to control it, but it didn't work. 2. R31's admission Record with a print date of 10/22/25 documents R31 was admitted to the facility on [DATE] with diagnoses that include multiple sclerosis, stiffness, and polyosteoarthritis.R31's MDS dated [DATE] documents a BIMS score of 09, indicating R31 has moderate cognitive impairment.R31's current Care Plan documents a Focus area of, (R31) has potential for pain. Date Initiated: 10/15/2019. This Focus area includes the intervention of, Administer analgesia as per ordered. Date Initiated: 08/17/2020.R31's Order Summary Report dated 10/22/2025 documents a physician order for Gabapentin Oral Capsule give 900 mg by mouth at bedtime for Multiple Sclerosis with an order date of 09/28/2025.R31's Medication Administration Record dated 10/01/25 to 10/31/25 documents a 6 for the dates of 10/07/25-10/13/25 for the order of Gabapentin. Under the Chart Codes the MAR documents 6=Other-See Progress Notes. This same MAR documents R31's pain level, using a 0-10 pain scale, at 0 (indicating no pain) each shift from 10/1/25 to 10/22/25 except for the following dates: 10/09- and 10/17-night shift and 10/20/25 day shift, R31's pain is assessed as a 1. On 10/7 and 10/13/25, R1's pain level is assessed at a 3.On 10/15/25 at 7:01 PM, V53 (LPN) stated R31 had been without her gabapentin for about a week. V53 stated R31 would cry at night because she was in pain and didn't have the medication needed to treat it. V53 stated the physician wasn't ordering the medication and she wasn't sure why.3. R5's admission Record with a print date of 10/01/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include polyneuropathy.R5's current Care Plan documents a Focus area of, (R5) has pain r/t (related to) polyneuropathy. Date Initiated: 05/31/2022. This Focus area includes the following interventions, Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Date Initiated: 05/31/2022.R5's MDS dated [DATE] documents R5 has a BIMS score of 15, indicating R5 is cognitively intact.R5's Order Summary Report dated 10/01/2025 documents a physician order of Lyrica Oral Capsule 50 mg give 1 capsule by mouth every morning and at bedtime for Anticonvulsants with an order date of 6/11/2025.R5's MAR dated 9/1/25 to 9/30/25 documents a physician order for Lyrica 50 mg to be administered every morning and at bedtime. This same MAR documents a 6 at bedtime on 9/28, 9/29, 9/30/25 and at 8 am on 9/29 and 9/30/25. Under the Chart Codes the MAR documents 6=Other-See Progress Notes.R5's MAR dated 10/1/25 to 10/31/25 documents a physician order of Lyrica 50 mg to be administered every morning and at bedtime. There is a 6 documented at 8 am on 10/1, 10/2, 10/4, 10/10-10/19, 10/22, 10/23 and at 8 pm on 10/1-10/4, 10/11-10/17, and 10/19-10/22.On 11/3/25 at 1:32 PM, V2 (Director of Nurses) stated there should be a progress note written each time a 6 is documented for medication administration on the MAR. This surveyor asked for the progress notes to review and V2 stated she checked and there is not a progress note written for each time there is a 6 documented. V2 stated she spoke with the nurses, and they reported to her they document the 6 when the medication is not available from the pharmacy, but they don't write a progress note each time.R5's Weights and Vitals Summary documents Pain Level Summary of 0 (indicating no pain) on 9/28, 9/29, 9/30, 10/01, 10/4, 10/14, 10/15, 10/16, and 10/19-10/21/25. This same summary documents the following pain levels 10/2- 2, 10/10- 4, 10/11- 3, 10/13- 2, and 10/17/25- 1. This indicates on these dates R5 was experiencing pain that was not treated by her routine order of Lyrica.On 10/20/25 at 11:34 AM, R5 stated she doesn't remember not getting her medications as ordered. R5 stated her feet hurt from her diagnosis of diabetes. R5 stated she wasn't aware she didn't have all her medications as ordered.On 10/15/25 at 7:01 PM, V53 (LPN) stated R5 hadn't had her Lyrica for about a week. V53 stated she heard the physician wasn't ordering them, but she wasn't sure why.On 10/20/25 at 12:54 PM, V32 (LPN) stated R5 had been out of her Lyrica for about a week. V32 denied any negative impact on R5.On 10/21/25 at 12:44 PM, V34 (Registered Nurse/RN) stated she had issues with pain medications being available to administer to the residents as ordered by the physician. V34 stated she is an agency nurse and does not have access to the emergency medication kit.On 10/22/25 at 1:13 PM, V70 (RN) stated she had issues with medications not being available to administer to the residents. V70 was not able to recall the specific resident and/or medications.On 10/16/25 at 11:11 AM, V2 (Director of Nurses/DON) stated the facility pharmacy is in a different regional state and Gabapentin is considered a controlled substance in that state. V2 stated the physician (Medical Director) wasn't submitting the prescriptions to the pharmacy and that is why the residents went without their medications. V2 stated she called the physician, and he was coming to the facility in 2-3 days to see the residents. V2 stated the physician told them to call the on-call doctors who told the facility they could only write the prescriptions for 2-3 days since they didn't see the residents routinely. V2 stated she also contacted the physician services company, and they told the physician to write the prescriptions. V2 stated V74 (Nurse Practitioner) who sees the residents at least weekly, did not have a controlled substance license so was unable to write those prescriptions. V2 stated the pharmacy was attempting to come up with a solution to the problem and had made her an authorized signer for the narcotics prescriptions. V2 stated if the medication is in the emergency kit they can get them from there. V2 stated the agency nurses don't have access to them but if they needed something the on-call nurse could come get it for them.On 10/22/25 at 3:23 PM, V1 (Administrator) stated she had talked about getting a local pharmacy to have as a backup for medications that needed to be filled immediately.On 10/28/25 at 12:27 PM, V74 (Nurse Practitioner/NP) stated she was aware the facility was having issues keeping controlled substance/pain medications available for the residents. V74 stated she didn't have a Controlled Substance License and the Medical Director was supposed to be filling all controlled substances. V74 stated Gabapentin is not a medication you can stop without tapering it down. V74 stated it is approved to be used to treat pain, but it also has other intended uses that can cause sodium imbalances which can cause increased confusion. V74 stated she had brought this to the facilities attention during meetings she had with them. V74 stated it had been an issue since she started seeing residents at the facility (several months). V74 stated Lyrica is like gabapentin. V74 stated if someone who is taking an opioid routinely doesn't get it that can trigger opioid withdrawl symptoms. V74 stated the facility has always had the option to call the on-call physician and get three days' worth of medications anytime a resident is out. V74 stated they can call every three days until they are able to get a full supply of the medications in.The facility Pain Management policy dated 2/2025 documents, .It is the policy of this facility to respect and support the resident's right to optimal pain assessment and management. This facility recognizes the residents may have decreased sensations or perception of pain. Chronic pain may produce anorexia, lethargy, depression, immobility, social isolation.Strategies for pain management include but are not limited to.Pharmacological interventions.routine pain medication, as needed pain medication.All resident care providers will provide information to the resident and the resident's family/significant others that optimal management of pain is a primary goal of resident care, and is consistent with the mission and core values of this facility.

Based on observation, interview, and record review the facility failed to 1. ensure medications were available to be administered as ordered, 2. ensure medications were administered timely, and 3. ensure medications were stored in a secure area for 6 of 6 residents (R4, R5, R19, R31, R35, and R45) reviewed for pharmacy services in the sample of 46. This failure resulted in R4 and R31 not receiving their pain medication and R4 and R31 crying with uncontrolled pain.Findings Include:1(a). R4's admission Record with a print date of 10/01/25 documents R4 was admitted to the facility on [DATE] with diagnoses that includes polyneuropathy.R4's MDS (Minimum Data Set) dated 8/29/25 documents a BIMS (Brief Interview for Mental Status) score of 03, indicating R4 has a severe cognitive deficit.R4's current Care Plan documents a Focus area of (R4) has pain. Date Initiated: 01/22/2025. This Focus area includes the intervention of, Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Date Initiated 01/22/2025.R4's Order Summary Report dated 10/01/2025 documents physician orders for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (milligrams) give 1 tablet by mouth every 6 hours as needed for pain with an order date of 7/30/25 and Acetaminophen 650 mg by mouth every 4 hours as needed for pain/fever with an order date of 4/18/25.R4's Medication Administration Record (MAR) dated 9/1/25 to 9/30/25 documents a physician order for Hydrocodone-acetaminophen 5-325 mg give one tablet every 6 hours as needed for pain. This same MAR documents R4 is routinely administered the hydrocodone from 9/1/25 until 9/20/25. There is no documentation R4 was administered hydrocodone from 9/21/25 through 9/30/25. This MAR documents the following pain scale assessments for R4: 9/22- night shift-2, 9/23-night shift-4, 9/24- night shift- 4, 9/26- evening shift- 4, 9/29/25 - night shit- 5. This MAR documents the physician order for acetaminophen 650 mg every four hours as needed was administered on 9/25 at 2:20 PM, 9/26 at 657 PM, 9/27 at 7:28 PM, and 9/28/25 at 6:46 PM. This indicates R4's pain was not treated with the physician ordered hydrocodone from 9/21 to 9/30/25 and was not treated with any pain-relieving medication on 9/23, 9/24, and 9/29 when she was assessed with pain scales of 4 and 5.R4's MAR dated 10/01/25 to 10/31/25 documents a physician order for hydrocodone-acetaminophen 5-325 mg give one tablet every 6 hours as needed for pain. This same MAR documents R4 is routinely administered hydrocodone from 10/09/25 until 10/31/25. There is no documentation of the hydrocodone and/or acetaminophen being administered from 10/01 through 10/8/25. This MAR documents the following pain scale assessments: 10/01 - night shift- 5, 10/02 - night shift- 3, 10/03 - day shift - 3, 10/05 - night shift - 4, 10/6 - night shift - 3, 10/07 - night shift - 3, 10/08- night shift- 4. This indicates R4's pain was not treated with pain relieving medications from 10/01 to 10/8/25 when she was assessed as having pain at a scale of 3-5.On 10/20/25 at 12:28 PM, V7 (Caregiver) stated R4 currently had pain medications but she was out of them the end of September, and it took about a week and a half to get it in. V7 stated R4 would cry in pain after her lunch time nap. V7 stated the facility staff offered her Tylenol but it didn't relieve the pain. V7 stated she didn't know why the medications weren't available.On 10/20/25 at 12:54 PM, V32 (LPN/Licensed Practical Nurse) stated they run out of controlled substances (pain medications) at times. When asked why, V32 stated the NP (Nurse Practitioner), it's hard. V32 stated when a resident needs a new prescription, they let the physician know and then the facility staff call the pharmacy to get it and the pharmacy reports they don't have the prescription. V32 stated R4 was out of her pain medications about three weeks ago for four to five days. V32 stated R4 had an increase in pain, they tried Tylenol to control it, but it didn't work.1(b). R31's admission Record with a print date of 10/22/25 documents R31 was admitted to the facility on [DATE] with diagnoses that include multiple sclerosis, stiffness, and polyosteoarthritis.R31's current Care Plan documents a Focus area of, (R31) has potential for pain. Date Initiated: 10/15/2019. This Focus area includes the intervention of, Administer analgesia as per ordered. Date Initiated: 08/17/2020.R31's Order Summary Report dated 10/22/2025 documents a physician order for Gabapentin Oral Capsule 900 mg by mouth at bedtime for Multiple Sclerosis with an order date of 09/28/2025.R31's Medication Administration Record dated 10/01/25 to 10/31/25 documents a 6 for the dates of 10/07/25-10/13/25. Under the Chart Codes the MAR documents 6=Other-See Progress Notes. This same MAR documents R31's pain level, using a 0-10 pain scale, at 0 (indicating no pain) each shift from 10/1/25 to 10/22/25 except for the following dates: 10/09- and 10/17-night shift and 10/20/25 day shift, R31's pain is assessed as a 1. On 10/7 and 10/13/25, R1's pain level is assessed at a 3.On 10/15/25 at 7:01 PM, V53 (LPN) stated R31 had been without her gabapentin for about a week. V53 stated R31 would cry at night because she was in pain and didn't have the medication needed to treat it. V53 stated the physician wasn't ordering the medication and she wasn't sure why.1(c). R5's admission Record with a print date of 10/01/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include polyneuropathy.R5's Minimum Data Set, dated [DATE] documents R5 has a BIMS score of 15, indicating she is cognitively intact.R5's current Care Plan documents a Focus area of, (R5) has pain r/t (related to) polyneuropathy. Date Initiated: 05/31/2022. This Focus area includes the following interventions, Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Date Initiated: 05/31/2022.R5's Order Summary Report dated 10/01/2025 documents a physician order of Lyrica Oral Capsule 50 mg give 1 capsule by mouth every morning and at bedtime for Anticonvulsants with an order date of 6/11/2025.R5's MAR dated 9/1/25 to 9/30/25 documents a physician order for Lyrica 50 mg to be administered every morning and at bedtime. This same MAR documents a 6 at bedtime on 9/28, 9/29, 9/30/25 and at 8 am on 9/29 and 9/30/25. Under the Chart Codes the MAR documents 6=Other-See Progress Notes.R5's MAR dated 10/1/25 to 10/31/25 documents a physician order of Lyrica 50 mg to be administered every morning and at bedtime. There is a 6 documented at 8 am on 10/1, 10/2, 10/4, 10/10-10/19, 10/22, 10/23 and at 8 pm on 10/1-10/4, 10/11-10/17, and 10/19-10/22.On 11/3/25 at 1:32 PM, V2 (Director of Nurses) stated there should be a progress note written each time a 6 is documented for medication administration on the MAR. This surveyor asked for the progress notes to review and V2 stated she checked and there is not a progress note written for each time there is a 6 documented. V2 stated she spoke with the nurses, and they reported to her they document the 6 when the medication is not available from the pharmacy, but they don't write a progress note each time.R5's Weights and Vitals Summary documents a Pain Level Summary of 0 (indicating no pain) on 9/28, 9/29, 9/30, 10/01, 10/4, 10/14, 10/15, 10/16, and 10/19-10/21. This same summary documents the following pain levels 10/2- 2, 10/10- 4, 10/11- 3, 10/13- 2, and 10/17/25- 1. This indicates on these dates R5 was experiencing pain that was not treated by her routine order of Lyrica.On 10/20/25 at 11:34 AM, R5 stated she doesn't remember not getting her medications as ordered. R5 stated her feet hurt from her diagnosis of diabetes. R5 stated she wasn't aware she didn't have all her medications as ordered.On 10/15/25 at 7:01 PM, V53 (LPN) stated R5 hadn't had her Lyrica for about a week. V53 stated she heard the physician wasn't ordering them, but she wasn't sure why.On 10/20/25 at 12:54 PM, V32 (LPN) stated R5 had been out of her Lyrica for about a week. V32 denied any negative impact on R5.On 10/21/25 at 12:44 PM, V34 (Registered Nurse/RN) stated she had issues with pain medications being available to administer to the residents as ordered by the physician. V34 stated she is an agency nurse and does not have access to the emergency medication kit.On 10/22/25 at 1:13 PM, V70 (RN) stated she had issues with medications not being available to administer to the residents. V70 was not able to recall the specific resident and/or medications.On 10/16/25 at 11:11 AM, V2 (Director of Nurses/DON) stated the facility pharmacy is in a different regional state and Gabapentin is considered a controlled substance in that state. V2 stated the physician (Medical Director) wasn't submitting the prescriptions to the pharmacy and that is why the residents went without their medications. V2 stated she called the physician, and he was coming to the facility in 2-3 days to see the residents. V2 stated the physician told them to call the on-call doctors who told the facility they could only write the prescriptions for 2-3 days since they didn't see the residents routinely. V2 stated she also contacted the physician services company, and they told the physician to write the prescriptions. V2 stated V74 (Nurse Practitioner) who sees the residents at least weekly, did not have a controlled substance license so was unable to write those prescriptions. V2 stated the pharmacy was attempting to come up with a solution to the problem and had made her an authorized signer for the narcotics prescriptions. V2 stated if the medication is in the emergency kit they can get them from there. V2 stated the agency nurses don't have access to them but if they needed something the on-call nurse could come get it for them.On 10/22/25 at 3:23 PM, V1 (Administrator) stated she had talked about getting a local pharmacy to have as a backup for medications that needed to be filled immediately.On 10/28/25 at 12:27 PM, V74 (Nurse Practitioner/NP) stated she was aware the facility was having issues keeping controlled substance/pain medications available for the residents. V74 stated she didn't have a Controlled Substance License and the Medical Director was supposed to be filling all controlled substances. V74 stated Gabapentin is not a medication you can stop without tapering it down. V74 stated it is approved to be used to treat pain, but it also has other intended uses that can cause sodium imbalances which can cause increased confusion. V74 stated she had brought this to the facilities attention during meetings she had with them. V74 stated it had been an issue since she started seeing residents at the facility (several months). V74 stated Lyrica is like Gabapentin. V74 stated if someone who is taking an opioid routinely doesn't get it that can trigger opioid withdrawal symptoms. V74 stated the facility has always had the option to call the on-call physician and get three day's worth of medications anytime a resident is out. V74 stated they can call every three days until they are able to get a full supply of the medications in.On 11/03/2025 at 3:43 PM, V86 (Pharmacist) stated she wasn't familiar with any resident missing medications. V86 stated the facility faxes the prescriptions to the pharmacy and then they fill them. V86 stated they deliver to the facility twice daily Monday through Friday and once daily on Saturday, Sunday, and holidays. V86 stated they also have a cubex at the facility that has medications they can access, and they utilize a local back up pharmacy if they need to. This surveyor shared with V86 the interviews and record reviews documenting residents not getting Gabapentin, Lyrica, and opioids as ordered for up to a week at a time. V86 stated all the facility has to do is let them know they need a refill, and they will reach out to the provider and get the prescription. V86 stated they can even get an emergency supply if they can't get the prescription timely. V86 stated she couldn't say if there would be a negative impact to the residents that would be something the Nurse Practitioner would have to answer.The (name of regional pharmacy) Policy and Procedure Manual 2024 (dated July 2024) documents in section 2.15 Out of Stock Medication documents Procedure: In the event the facility orders a medication that the pharmacy does not currently stock: 1. Alternative suppliers will be contacted to check availability and expected date and time of delivery to (name of regional pharmacy). 2. (name of regional pharmacy) will contact the e facility to inform that the medication order is currently not in stock, along with an expected date from the supplier if stock will not be obtained by the following day. 3. The facility and the pharmacy will determine medical necessity. An agreement will be reached as to the time of delivery of the ordered medication that meets the resident's need. a. The facility should call the patient's physician to let him/her know that the ordered medication is not available. The physician can then decide whether to hold the medication until it is available or change the medication to one that is readily available in emergency dispensing kit. The original medication that was ordered will be sent as soon as it becomes available. 4. If the resident requires the medication sooner than (name of regional pharmacy) is able to obtain it, other area pharmacysources will be contacted to supply the item. 5. If it is determined that medications can be started when (name of regional pharmacy) is able to receive the product, the facility will receive the medication on the following delivery once (name of regional pharmacy) received the medication. 2(a). R5's admission Record with a print date of 10/01/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include cerebral infarct, heart failure, anemia, chronic obstructive pulmonary disease, adult failure to thrive, diabetes, and neuropathy.R5's Minimum Data Set (MDS) dated [DATE] documents R5 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R5 is cognitively intact.R5's current Care Plan documents a Focus area of, (R5) has Diabetes Mellitus. (R5) is non-compliant with her diet. Date Initiated: 05/31/2022. This Focus area includes the intervention of, Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Date Initiated: 05/31/2022.R5's Order Summary Report dated 10/01/2025 documents the following physician orders: Furosemide 20 mg (milligrams) Give 1 tablet by mouth one time a day for diuretics, Glyburide 5 mg Give 1 tablet by mouth one time a day for antidiabetics, Jardiance 25 mg Give 1 tablet by mouth one time a day for antidiabetics, Lantus 100 unit/ml (milliliter) Inject 10 unit subcutaneously at bedtime for antidiabetics, Levothyroxine 50 mcg (micrograms) Give 1 tablet by mouth one time a day for thyroid agents, Lyrica 50 mg Give 1 capsule by mouth every morning and at bedtime for Anticonvulsants, Metformin 500 mg Give 2 tablet by mouth one time a day for Antidiabetics, Potassium Chloride ER (extended release) 20 mEq (milliequivalents) Give 1 tablet by mouth every morning and at bedtime for Minerals and electrolytes, and Tradjenta 5 mg Give 1 tablet by mouth one time a day for Antidiabetics.R5's Medication Admin Audit Report dated 10/01/2025 to 10/20/2025 documents the following medications were administered late:10/03/25 - Lyrica 50 mg, Potassium Chloride 20 meq, and Lantus 100 unit/ml (10 units) ordered to be administered at 8:00 pm, documented as administered at 10:16 PM.10/07/25- Lyrica 50 mg, Potassium Chloride 20 meq, Glyburide 5 mg, Jardiance 25 mg, Tradjenta 5 mg, Metformin 500 mg, Levothyroxine 50 mcg, and Furosemide 20 mg ordered to be administered at 8:00 AM documented as administered at 10:48 AM.10/10/25- Lantus 100 unit/ml (10 units) ordered to be administered at 8:00 PM, documented as administered at 10:37 PM.10/15/25 - Lantus 100 unit/ml (10 units) ordered to be administered at 8:00 PM, documented as administered at 9:44 PM. Lyrica 50 mg ordered to be administered at 8:00 PM, documented as administered at 11:57 PM.10/18/25- Lyrica 50 mg ordered to be administered at 8:00 AM documented as administered at 10:54 AM.10/19/25- Potassium Chloride 20 meq, glyburide 5 mg, metformin 500 mg, tradjenta 5 mg, Jardiance 25 mg, levothyroxine 50 mcg, and furosemide 20 mg ordered to be administered at 8:00 AM, documented as administered at 9:21 AM. Potassium Chloride 20 meq, Lyrica 50 mg, and Lantus 100 unit/ml (10 units) ordered to be administered at 8:00 PM, documented as administered at 10:35 PM.On 10/20/25 at 11:34 AM, R5 stated she is a diabetic and takes insulin. When asked if her medications were ever administered late, R5 stated, Yes, all medications are late when the agency nurse is working. R5 stated she sometimes doesn't get her medications that are due at 8:00 PM until 11:00 PM, including her insulin.2(b). R19's admission Record with a print date of 10/22/25 documents R19 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction, diabetes, dementia, and hypertension.R19's MDS dated [DATE] documents a BIMS score of 07, indicating a severe cognitive deficit.R19's current Care Plan documents a Focus area of, (R19) has Diabetes Mellitus Date Initiated: 05/17/2022. This Focus area includes the following intervention, Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Date Initiated: 05/17/2022.R19's Order Summary Report dated 10/01/2025 includes the following physician orders: Humalog Inject 10 unit subcutaneously with meals for Hyperglycemia and Lantus Inject 12 unit subcutaneously at bedtime for elevated blood glucose.R19's Medication Admin Audit Report dated 9/1/25 to 10/23/25 documents the following medications were administered late:9/11/25-Humalog 10 units ordered to be administered at 8 AM, documented as administered at 9:25 AM.9/26/25 - Humalog 10 units ordered to be administered at 12:00 PM, documented as administered at 1:45 PM.10/04/25 Humalog 10 units ordered to be administered at 8:00 AM, documented as administered at 9:37 AM.10/18/25 - Humalog 10 units ordered to be administered at 8:00 AM, documented as administered at 11:08 AM.10/18/25 - Lantus 12 units ordered to be administered at 8:00 PM, documented as administered at 9:30 PM.2(c). R35's admission Record with a print date of 10/22/25 documents R35 was admitted to the facility on [DATE] with diagnoses that include repeated falls, chronic obstructive pulmonary disease, chronic kidney disease, and obstructive sleep apnea.R35's MDS dated [DATE] documents a BIMS score of 14, indicating R35 is cognitively intact.R35's current Care Plan does not document a Focus area with interventions that include medication administration.R35's Order Summary Report dated 10/22/25 includes the following physician orders: Gabapentin Oral Capsule Give 1 capsule by mouth two times a day for nerve pain with an order date of 9/17/2025 and Quetiapine Fumarate Tablet 25 mg (Seroquel) give 1 tablet by mouth at bedtime for Insomnia with an order date of 09/17/2025.R35's Medication Admin Audit Report dated 10/1/25 to 10/20/25 documents the following medications were administered late.10/04/25 - gabapentin 100 mg ordered to be administered at 8:00 AM, documented as administered at 11:19 AM.10/06/25 - gabapentin 100 mg ordered to be administered at 8:00 AM, documented as administered at 10:19 AM.10/07/25 - gabapentin 100 mg ordered to be administered at 8:00 AM, documented as administered at 10:59 AM.10/12/25 - gabapentin 100 mg ordered to be administered at 8:00 AM, documented as administered at 11:32 AM.10/15/25 - gabapentin 100 mg and Seroquel 25 mg ordered to be administered at 8:00 PM, documented as administered at 9:34 PM.On 10/22/25 at 12:28 PM, V33 (RN/Registered Nurse) stated she is late administering medications at times because she will pause her medication pass to feed residents.On 10/22/25 at 12:23 PM, when asked why she administered medications late to the residents at times, V49 (RN) stated she was an agency nurse and she had to make sure she was administering the correct medication to the correct resident, and she also had to stop her medication pass at times and provide care to the residents.On 10/20/25 at 12:54 PM, V32 (LPN/Licensed Practical Nurse) stated he can administer his medications timely.On 10/22/25 at 1:13 PM, V70 (RN) stated medications were administered late at times in part due to the workload. V70 stated when you have so many medications to give including patches, eye drops, and nasal sprays, it gets delayed. V70 stated when you have 35 residents to administer medications to and multiple things that need to be done and you give the residents the attention they need, medication administration is late.On 10/22/25 at 2:01 PM, V71 (RN) stated she is very late administering medications at times. V71 stated it has happened more than once but not every time she administers medications. V71 stated unusual weather causes the computer to shut down and that impacts medication administration times. V71 stated she also spends a lot of time trying to locate missing items including medications and that causes her medication administration to be late. V71 stated the residents on the hall she usually works on are a higher level of care and that causes her medication administration to be late. V71 stated she only worked at the facility as needed and that could also be part of the reason the medications were administered late.On 10/22/25 at 4:56 PM, V53 (LPN) stated she was able to pass her medications timely if everything went ok but if something happened the medications would be administered late. V53 stated she administers medications to approximately 40 residents each shift.On 10/21/25 at 2:38 PM, V2 (Director of Nurses) stated she didn't know why medications were administered late. V2 stated she administers medications at the facility, and she can administer them timely unless there was another issue. V2 stated if a resident falls or she had to send someone to the hospital then timely medication administration would be an issue.On 10/22/25 at 3:23 PM, V1 (Administrator) stated she would expect medications to be administered according to the current guidelines. V1 stated medications should be administered within one of before or after the times the medications were ordered.On 10/28/25 at 12:27 PM, when asked about medications being administered late, V74 (Nurse Practitioner) she had talked with staff about administering insulin as ordered. V74 stated she is at the facility every week. V74 stated every morning blood sugar tells her what the nighttime dose of insulin is doing. V74 stated giving that insulin late really affects things. When asked about the effect late administration has on a resident, V74 stated, as a prescriber, I don't know that it is given late. V74 stated she then adjusts the dosage of their insulins, so the worst-case scenario is hypoglycemia. V74 stated the residents blood sugar is going to bottom out. V74 stated she was very frustrated with the facility and wasn't sure why they weren't prioritizing resident care. This surveyor reviewed with V74 other medications that were administered late and V74 stated if a diuretic isn't administered until noon the onset of action would be 4-5 pm. That is when someone with Sundowner's would start exhibiting symptoms and could fall attempting to take themselves to the bathroom.The (name of regional pharmacy) Policy and Procedure Manual 2024 (dated July 2024) documents in section 5.1: Drug Administration--General Guidelines procedure step 8 Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered precisely as ordered. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. 3(a). R35's admission Record with a print date of 10/22/25 documents R35 was admitted to the facility on [DATE] with diagnoses that include fractures, repeated falls, and muscle weakness.R35's MDS dated [DATE] documents a BIMS score of 14, indicating R35 is cognitively intact.R35's current Care Plan does not document a Focus area related to self-administration of medication.On 10/15/25 at 10:42 AM, R35 stated she hadn't seen nursing staff leave medications on the medication cart unattended, but they did at times leave them in her room on her table for her to take them independently. R35 stated she didn't think they were supposed to do that.3(b). R45's admission Record with a print date of 11/5/25 documents R45 was admitted to the facility on [DATE] with diagnoses that include metabolic encephalopathy, muscle weakness, cognitive communication deficit, hypertension, atrial fibrillation, weakness, and adult failure to thrive.R45's MDS dated [DATE] documents a BIMS score of 13, indicating R45 is cognitively intact.On 10/20/25 at 1:04 PM, V66 (Agency LPN) gave R45 her sodium chloride 1000mg tablet in the dining room, V66 set the cup down on the table and told R45 it was her medication. R45 was in the middle of eating her cookie, R45 said ok and started setting her cookie down, V66 told R45, go ahead and finish your cookie and take it after then V66 left the medication cup sitting on the dining room table in front of R45 and walked out of the dining room.On 10/20/25 at 2:51 PM, V66 (Agency LPN) stated she didn't remember sitting medications down on a table and walking away during the noon medication pass. V66 stated if she did, she didn't mean to.On 10/15/25 at 7:24 PM, V47 (CNA) stated she reported meds being prepped in advance and left on the top of the med cart unattended. V47 stated it was V85 (Registered Nurse/Agency) who left them out.On 10/15/25 at 10:44 PM, V61 (CNA) stated he hadn't seen nursing staff leave medications unattended on top of the medication cart, but they leave them unattended in residents rooms. V61 stated when he sees them, he always takes them to a nurse because he doesn't want another resident to take them.On 10/16/25 at 2:56 PM, V51 (CNA) stated he didn't know V85 (Agency RN) but V56 (LPN) and V53 (LPN) leave medications unattended on top of the medication cart and in resident rooms.On 10/20/25 at 11:44 AM, V62 (CNA) stated nursing staff leave medication on residents bedside tables for the resident to take. V62 stated the pills just sit unattended on the table.On 10/21/25 at 2:38 PM, V2 (Director of Nurses) stated it was not acceptable for medications to be left unattended.The (name of regional pharmacy) Policy and Procedure Manual 2024 (dated July 2024) documents in section 5.1: Drug Administration--General Guidelines procedure step 14 During routine administration of medications, the medication cart is kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on the top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Under Tips for Safe Medication Administration documents 1. Maintain security of provided medications. A. Cart must always be visible to nurse administering medications.C. Never leave a medication in a resident's room without orders to do so.The facility undated Medication Administration Policy for Senior Living documents, Adherence to this Medication Administration Policy is essential to ensure the well-being and safety of our residents. All staff members are expected to follow these guidelines strictly and to report any issues or deviations from the policy.S. Residents who self-administer must have a profile only MAR which lists their medications & indicates that they self-administer.1. Medications should be stored in a secure, locked area with restricted access to authorized personnel only.3. Medications should be administered according to the five rights of medication use: right resident, right drug, right time, right dose, and the right route. 4. Staff members must ensure that residents have swallowed or otherwise received the medication properly. S. Self-administration of medications will be supported for those who have written orders from an authorized healthcare provider and can demonstrate that they are capable of safely administering their medications through a self-administration evaluation upon admission, every 6 months, and as needed.

A. Based on observation, interview and record review the facility failed to provide assistance in a manner to prevent falls for 2 (R5 and R10) of 6 residents reviewed for falls in a sample of 16. This failure resulted in R10 sustaining a large intracranial hematoma, left eyebrow laceration and a left periorbital hematoma and R5 sustaining a skin tear to right shin and right shoulder along with a forehead laceration requiring 4 sutures. Findings include: 1. R10's Admission Record documents an admitted [DATE] with diagnoses including: acute cystitis without hematuria, unspecified Escherichia coli as the cause of diseases classified elsewhere, encephalopathy, hemiplegia affecting left non-dominant side, history of transient ischemic attack and cerebral infarction without residual deficits, osteoarthritis right shoulder, cerebral infarction, other abnormalities of gait and mobility, other lack of coordination, blepharoconjunctivitis of the left eye, third nerve palsy of left eye, history of covid-19, anxiety disorder, schizophrenia, aphasia following cerebral infarction, other symptoms and signs involving cognitive functions following other cerebrovascular disease, dysarthria following other cerebrovascular disease, muscle weakness, repeated falls, other symptoms and signs involving the nervous system, disorientation, altered mental status, restlessness and agitation, weakness, history of malignant neoplasm of the brain, and epilepsy. R10's Minimum data Set (MDS) quarterly review dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 14 indicating R10 is cognitively intact. R10's eating assistance is documented as: setup or clean-up assistance, oral hygiene as: supervision or touching assistance, upper body dressing as: substantial/maximal assistance and roll to right or left as: dependent. R10's Fall risk data collection form dated [DATE] documents a score of 29 indicating R10 was a high risk for falls. R10's hospital's discharge summary with an admitted [DATE] and a discharge date of [DATE] documents: Hospital Course: Patient (R10) is [AGE] year-old with past medical history of brain tumor, seizure disorder, dementia, hyperlipidemia and hypothyroidism. She had a recent episode of nonresponsiveness at a SNF (Skilled Nursing Facility) unit and was sent in for altered mental status. Patient's (R10) baseline is that she is unable to ambulate and is wheelchair-bound. ER (emergency room ) evaluation included CT (computed tomography) of the brain and CT brain perfusion with no evidence of ischemia chest x-ray no acute process CTA (computed tomography angiography) head neck indicated acute ischemia to the left anterior cerebral artery distribution could not be excluded. Her blood glucose was initially 60 (milligrams/deciliter) and she was given D10 (dextrose 10%) patient was admitted to the hospitalist service and neurology was consulted. She was also found to have a UTI (urinary tract infection) and antibiotics were started. MRI (magnetic resonance imaging) of the brain recommended by neurology showed no acute abnormalities, EEG (electroencephalography) showed generalized slowing, echo indicated normal LV (left ventricular) size with an EF (ejection fraction) of ,d+[DATE] (%). Neurology felt patient was suffering from encephalopathy related to covid infection. Feeding tube was placed due to continual failure of swallowing eval. She is to have a video swallow eval today. Patient had trouble with hyponatremia but that has improved with fluid restriction and urea sodium after hypertonic NICU (neonatal intensive care unit). She was transition to p.o. (per oral) Cortef . Pts (patient's) sodium is normalized. Video swallow evaluation revealed no aspiration. Diet recommendations in dc (discharge) summary. Pt will transition back to snf. R10's MDS significant change review dated [DATE] documents a BIMS of 05 indicating severely impaired. R10's eating assistance is documented as: dependent, oral hygiene as: dependent, upper body dressing as: dependent and roll to right or left as: dependent. R10's Care Plan documents a focus area of: R10 is at risk for falls with a date initiated of [DATE]. Interventions included: dated [DATE] of anti-slip mat in seat of wheelchair and dated [DATE] of do not leave resident alone when sitting on the side of the bed. R10's care plan documents a focus area of: R10 has a history of CVA (cardiovascular accident) with a date initiated of [DATE] and interventions including: monitor/document communication skills, document baseline if resident is presenting problems with cognitive function and communication, obtain order for speech therapy consult to evaluate and treat dated [DATE], monitor/document residents abilities for ADLs (activities of daily living) and assist resident as needed. Encourage resident to do what he/she is capable of doing for self dated [DATE], and monitor/document/report to MD (medical doctor) PRN (as needed)) for neurological deficits: level of consciousness, visual function changes, aphasia, dizziness, weakness, and restlessness dated [DATE]. R10's care plan documents a focus area of: R10 has left hemiplegia/hemiparesis related to stroke with an initiated date of [DATE] and interventions of: give medications as ordered, monitor/document for side effects and effectiveness dated [DATE], obtain and monitor lab/diagnostic work as ordered, report results to MD and follow up as indicated dated [DATE], pain management as needed, see MD order, provide alterative comfort measures PRN dated [DATE], and PT, (physical therapy) OT (occupational therapy), ST (speech therapy) evaluate and treat as ordered dated [DATE]. New interventions added [DATE] include, resident is working with therapy in tilt/reclining chair with anti-skid mat in place, dated [DATE] of will reassess for safety upon resident's return from the hospital, and dated [DATE] of: keep resident's tilt/recline chair in reclined position until staff is ready to assist with meals. Interventions also included: dated [DATE] of anti-slip mat in seat of wheelchair and dated [DATE] of do not leave resident alone when sitting on the side of the bed. R10's final investigation report submitted to IDPH (Illinois Department of Public Health) dated [DATE] documents: (R10) age 55 with diagnoses of Cerebral infarction, hemiplegia affecting left side, encephalopathy, personal history of TIA (transient ischemic attack), osteoarthritis of right shoulder, epilepsy, major depressive disorder, aphasia, schizophrenia, and personal history of malignant neoplasm of the brain. On [DATE] R10 sustained a fall when she sat forward in her tilt/recline chair and fell to the floor. Licensed staff initiated a head-to-toe assessment. The resident voiced complaints of pain to her face and head. Logged rolled to her back to monitor airway. Laceration noted to forehead. First aid administered. No loss of consciousness. Resident left in position d/t (due to) potential for FX (fracture). V31 (Medical Director) notified and an order received to send to ER for evaluation. POA (power of attorney) notified of occurrence and pending transfer. Resident transferred per ambulance to ER for evaluation and treatment. Resident admitted to hospital with DX (diagnosis) of intracranial hematoma without loss of consciousness. Returned to facility on [DATE] with hospice referral. Laceration above left eyebrow closed with steri -strips. Care plan reviewed and updated On [DATE] at 8:24 AM, V22 (Certified Nurse Aide) stated, R10 could sit up, she had head and neck control, she would also scoot herself forward in her chair. V22 stated, on the day R10 fell out of her wheelchair ([DATE]) everyone was in the dining room. V22 stated she pushed R10 up to the table and positioned her up so that she could eat without choking. V22 stated she was up at the kitchen window getting R10's food so she could assist her and she heard R10 fall. V22 stated, she thought R10 fell sideways out of her chair because she didn't hit the table and the way she was laying on the floor. V22 stated, there were other CNAs in the dining room, but no one right next to R10. V22 stated, when R10 came back after, she believes she had a stroke, she was not as good, she was more confused, her speech was more slurred, she would fall asleep when they were assisting her to eat and she was switched to a thickened liquid and puree diet. V22 stated, she was educated after R10 fell to have her food in front of her before she puts her in the upright position. On [DATE] at 4:05 PM, V6 (Physical Therapy) stated she would expect someone to be there when R10's chair was in the fully inclined position. V6 stated R10 returned to the facility after her last stroke on [DATE] with multiple declines, she had low motivation to bend forward also. On [DATE] at 9:56 AM, V4 (Director of Rehabilitation) stated prior to [DATE] when R10 had her last fall, speech language was working with R10 due to her decline after her last stroke. R10 was lethargic and they changed her diet to honey thick liquids and puree food. R10 could support her head and trunk to a degree. On [DATE] at 10:10 AM, V25 (Therapy) stated she had evaluated R10 on [DATE]. R10 would ebb and flow and sometimes she could be lethargic and obstinate during mealtime. She would expect her to have her food and then be put in the upright position in her wheelchair. They were currently working on core strength and reaching abilities with her. V25 stated R10 had recently been hospitalized just prior to her fall and she had more limited abilities. R10 was out for over 10 days, her wheelchair was changed to a wheelchair that looks like a recliner on wheels that the feet platform does not raise, her swallow function changed, she was no longer the same after the hospital stay. After the hospital stay she was deconditioned, she was very different than she was prior to her hospital stay from the stroke. R10's therapy note dated [DATE] documents: patient (R10) demonstrates L (left) lateral lean, sacral sitting, occasional anterior leaning forward in w/c (wheelchair) increasing fall risk. R10 presents with decreased alertness and does not respond to verbal cures for adjusting self in w/c, therapist can readjust and as day progresses R10 will have to have multiple repositioning in standard w/c. Provided R10 with tilt in space w/c and feature of recline back. R10 has foot board to provide support for BLE (both lower extremities) in neutral position. Staff education provided on patient to be tilted back when not in line of sight, when R10 is at mealtime, or in line of sight, may be placed in a neutral position. Provided nonskid mat under bottom in order to prevent sliding forward with chair having an anti thrust cushion feature in chair. Response to session interventions: presented with decreased alertness, not following verbal cues or tactile cues. R10's progress note dated [DATE] at 5:20 PM documents: staff heard a loud crash and found resident laying on the floor face down. Chair had been reclined back in main dining room awaiting meal but when staff turned around chair was straight up. R10's progress note dated [DATE] at 5:30 PM documents: EMS (emergency medical services) here to transport resident to ER for evaluation and treatment for fall. R10's progress note dated [DATE] at 12:38 AM documents: called ER and spoke with nurse on update of resident. ER nurse reports resident is being admitted to the unit due to a brain bleed. R10's progress note dated [DATE] at 6:29 AM documents: spoke with ICU (intensive care unit) nurse. Resident admitted with intracranial hematoma without loss of consciousness. R10's hospital daily progress note dated [DATE] documents: subjective: has had some headaches but no new neurologic deficits from her baseline. Summary: [AGE] year old female with remote history of right temporal lobe tumor resection, previous stroke with residual speech and cognitive deficit, residual left-sided weakness, seizure disorder, dysphagia on modified diet, recently hospitalized with encephalophy in setting of covid infection, hyponatremia, UTI (urinary tract infection) found to have adrenal insufficiency, presenting back from nursing facility after sustaining a traumatic fall with noted large intracranial hematoma, along with left eyebrow laceration, and a left periorbital hematoma, Laceration repair in ED (emergency department). (R10's) aspirin and Plavix was stopped. (R10) was given platelets and DDAVP (desmopressin) following initial presentation. Neurosurgery consulted. Monitored further with serial neuro (neurological) checks. Follow-up CT (computed tomography) head appeared stable. R10's neurosurgery consultation dated, [DATE] at 7:21 AM documents: the patient (R10) is a 55 y.o. (year old) female who presented to the ED (emergency department) on ,d+[DATE] after she fell out of a chair in her nursing home striking her head. She has a neurosurgical history that is significant for prior brain tumor resection, though no records are available and no family is at bedside to provide further information and she is a very poor historian. She apparently resides in a nursing home due to chronic left hemiparesis and cognitive difficulty. She fell from a chair to the floor at her facility, striking her head and sustaining a laceration. She was brought to the ED where a CT revealed intracranial hemorrhage, prompting neurosurgical consultation. She has been observed overnight in the ED due to a lack of beds in the ICU. She currently endorses headaches, however she has delayed speech and difficulty expressing herself at baseline. She will follow commands in all extremities with baseline left-sided weakness. Records from the nursing home state she takes ASA (acetylsalicylic acid (aspirin)) and Plavix, though the reasons are unclear. She was given Platelets and DDAVP in the ED. R10's progress note dated [DATE] at 5:41 PM documents, Res (resident) back from hospital and nonverbal. EMS said res had not said a word the whole transport. Res v/s (vital signs) wnl (within normal limits). Left eyebrow laceration dried blood noted and bruised face and eye with left eye swollen shut. Res to have hospice consult and DNR. Noted DNR signed by her sister and not her POA. Res made comfortable in bed. R10's progress note dated [DATE] documents: EMS here to transport resident to hospice center. On [DATE] at 2:08 PM, V27 (Family) stated, R10 was diagnosed with Covid and a UTI and they had got her back to the facility and she fell in the dining room. They (the family) decided to send her to hospice in another state due to brain bleed causing seizures. On [DATE] at 3:06 PM, V1 (Administrator) stated when R10 fell in the dining room on [DATE] she was put in the upright position for eating and then the staff went to get her food from the window and she fell . V1 stated, she would have expected them to get her food, come back, and then put her in the upright position. R10's Death Certificate documents R10 died on [DATE] with the cause of death listed as intracranial hemorrhage. Other significant condtions contributing to death include: temporal lobe tumor, cerebrovascular accident with sided residual weakness and seizer disorder. The manner of death is marked as natural. On [DATE] at 11:38 PM, V30 (Nurse Practitioner) stated, her and V31 (Medical Director) had looked at R10's diagnoses and medical history extensively prior to taking R10 on as a patient. R10 has had a couple brain bleeds prior to the fall on [DATE]. R10 had CVA residual affects from how the body heals and reroutes, therefore it was likely that she would have another CVA. R10 had CVA's prior. V30 stated, no she does not believe the fall on [DATE] hastened or exacerbated R10's death. R10 had a personal history of brain cancer, CVA's, and schizophrenia and that would probably lead R10 to have another cerebral infarction. Another CVA would cause her to fall. After her last hospital visit her and V31 were going to discuss with R10's family hospice care for R10. There is no way she would say the fall hastened or caused her death. R10's brain neoplasm was affecting her ocular nerve. Based on her history and disease process there is no way she can say that fall caused her death. Due to her past diagnoses with her current prognoses and the recent encephalopathy due to covid they can not say what all that would cause and would affect. There are many different variables with covid and how it has affected systems and exacerbated disease processes. V30 stated based on R10's history, disease processes and recent diagnoses there is no way she can say that event (the fall) caused her death her diagnoses and disease process was an affecting factor. 2. R5's Admission Record documents an admitted [DATE] with diagnoses including: dementia, xerosis cutis, other atrophic disorders of skin, muscle weakness, acute kidney failure, full incontinence of feces, lack of coordination, urinary incontinence, altered mental status, and cognitive communication deficit. R5's MDS dated [DATE] documents a BIMS score of 00 indicating severe impairment. R5's care plan documents a focus area of: R5 has an ADL self care performance dated [DATE] with interventions to include: Bed Mobility: the resident requires 1 staff participation to reposition and turn in bed with date initiated of [DATE], Transfer: The resident requires 1 staff participation with transfers with date initiated [DATE]. A new intervention dated [DATE] included Side rails: quarter rails up as per V31's order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN to avoid injury. R5's care plan documents a focus area of R5 is at risk for falls and has had an actual fall d/t generalized weakness, poor nutritional status, incontinence, history of falls with a date initiated of [DATE] and an intervention of: place quarter rails to bed that can be placed in upright position during cares to prevent falls from air mattress. Until bedrails placed two CNAs at a time when giving incontinence care with a date of [DATE]. R5's Care plan also lists a focus are, (R5) has limited physical mobility date initiated [DATE]. Interventions included, Mobility: the resident requires 1 staff participation for mobility with date initiated [DATE]. R5's final report to IDPH dated [DATE] documents: On [DATE]th approximately 1850 (6:50 PM) the C.N.A was assisting the resident with incontinence care, the resident scooted to the side of the bed and rolled off and hit her head. The C.N.A called for the nurse. The resident was noted with a cut to her right forehead, skin tear to right shin and right shoulder. The resident denied any other pain or discomfort, ROM (range of motion) assessed and was WNL (within normal limits). MD/POA informed. Orders to have resident evaluated in ER. The resident returned from ER with four sutures to her forehead. Orders to remove sutures in ,d+[DATE] days. Follow up with left ovarian mass. Investigation: The resident was seen in ER as stated above and returned to facility. During ER visit a CT scan of head, spine and pelvis was completed and was negative for any acute intercranial abnormality. CT of spine was negative for any acute cervical fracture. CT scan of pelvis incidentally showed an ovarian mass and constipation. Orders received to remove sutures in ,d+[DATE] days, order placed to remove on [DATE]. The resident has had a pain level of ,d+[DATE] and denied need for any PRN (as needed) medications. Bruising is noted to forehead and beneath eye fading in color. The resident did have a BM (bowel movement) on [DATE]. The resident has resumed her normal activities. The resident prefers to stay in bed and receive her meals and care in her room. The DON (Director of Nursing) had a discussion with the POA regarding the air mattress and changing her mother to a regular pressure reduction mattress, POA did not want to change mattress due to age and weight to prevent any skin issues. The DON offered quartered side rails up during provision of care. POA/daughter agreeable to quarter side rails. Bed kept in low position and call light in reach. Care plan updated with interventions. On [DATE] at 1:57 PM, V8 (Certified Nurse Aide/CNA) stated, she was providing care for R5 when she fell out of bed. V8 stated, R5 was in the middle of the bed and she rolled R5 onto her side, she is little and has never moved when providing care for R5 until she got these sores on her bottom. Previously when she would wipe her she would twitch or grunt but never move much. The day when she fell she was wiping her bottom because she had a bowel movement and she jerked and moved and rolled off of the bed. She would never roll before when providing care. R5 had always been a one person assist when providing care. After R5 fell , a second person would always go in to assist when providing care until she got her siderails. R5 can hold on to the side rails fine while providing care. R5's sores on her bottom have healed a lot so she does not jerk or twitch while providing care anymore. R5's bed is raised higher than the 18 inches or so off the floor when providing care, she would guess the bed would be approximately 2.5 feet off the ground. On [DATE] at 2:20 PM, V8 demonstrated to this surveyor the height of the bed when care would be provided, which was approximately 2.5 feet off the ground. On [DATE] at 2:20 PM, R5 was laying in the center of her bed she had approximately seven inches from her shoulders to the edge of the bed. On [DATE] at 4:25 PM, V9 (CNA) stated she had provided care for R5 before, and she had never moved before while providing care but she would swat at you on occasion. R5 did not have any sores when she had provided care for her. R5's progress note dated [DATE] at 6:50 PM documents: resident (R5) had rolled off the bed while CNA providing incont (incontinence) care, resident has laceration to R (right) forehead, skin tear to R shin, and skin tear to R shoulder. R5's hospital note dated [DATE] at 10:36 PM documents: CT of the head was negative for any acute intracranial abnormality. CT of the chest was negative for anything acute. CT of the cervical spine was negative for any acute cervical spine fracture. CT of the abdomen pelvis did show a left ovarian mass and constipation as well. Laceration to the right forehead was repaired. Patient will be discharged back to the nursing home. Sutures should be removed in 5 to 7 days. Will advise nursing home staff of constipation and left ovarian mass as well. Patient will be discharged shortly in stable condition. R5's hospital note dated [DATE] at 1:45 AM documents: subjective: history of present illness: [AGE] year old patient who presents to the emergency department status post fall. The patient is unable to give any history. It is reported that the patient fell from bed. She was lying in bed at (the facility) and fell approximately 2 feet onto the floor. No LOC (loss of consciousness) reported. The patient has a bandage on her head. R5's progress note dated [DATE] at 1:25 AM documents: resident (R5) returned to facility with orders to remove sutures in 5 -7 days. Follow up with left ovarian mass. R5's progress note dated [DATE] at 3:33 PM documents: left message for (family) regarding the need to order side rails. Informed (her) that two CNAs will provide incontinence care for safety until quarter side rails placed. On [DATE] at 3:06 PM, V1 stated she was not at the facility when R5 fell from her bed, therefore she did not do the investigation. V1 stated she would not expect residents to fall out of bed during care. V1 stated, they put an intervention in of two CNAs to provide care for R5 until she was evaluated and received the siderails. The undated facility policy titled, Fall Prevention documents: the facility shall ensure that a fall management program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety A fall is the unintentional coming to rest on the ground, floor, or other lower level. If a resident loses balance and would have otherwise fallen if not for someone intervening is considered a fall, includes witnessed and unwitnessed falls, includes with or without injury. Serious injury includes but not limited to: fracture, laceration requiring sutures, any falls related to injury requiring an evaluation in the emergency room or admission to the hospital. B. Based on interview, observation, and record review the facility failed to provide adequate supervision to prevent elopement for 1 (R6) of 3 residents reviewed for elopement in a sample of 16. Findings include: R6's Admission record documents an admitted [DATE] with diagnoses including: dementia, cerebral ischemia, generalized anxiety disorder, muscle weakness, lack of coordination, difficulty in walking, and cognitive communication deficit. R6's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 07 indicating cognition is severely impaired. R6's Care plan contains a focus area date initiated [DATE] documenting: R6 is an elopement risk/wanderer AEB (As Evidenced by) due to anger with placement within the facility. Interventions include distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: sitting in her room with her husband, also church activities dated [DATE] and wander alert device # model ,d+[DATE] dated [DATE]. A recent intervention includes: assist R6 to ambulate to her room or the common area in her hallway after meals in main dining room to prevent attempts of elopement dated [DATE]. R6's elopement assessment dated [DATE] documents: section: 1. Elopement Risk: a. is the resident cognitively impaired and independently mobile (with or without a device)? with yes marked. 'History of Elopement': b1. Does the resident have; with 1. A history of elopement, 2. A desire to leave the facility, and 4. Wandering activity all marked. 'Elopement Risk Factors': b2. Does the resident 6. Have a diagnosis of Alzheimer's disease or dementia marked. C. documents 'yes' for is the resident at risk for elopement, d. documents: 1. Application of electronic monitoring bracelet 3. Picture in elopement book for: 'what interventions were put in place to prevent resident from eloping. The area 'Elopement Needs' area documents: focus: R6 is an elopement risk/wanderer AEB (As Evidenced by) due to anger with placement within the facility. The resident is an elopement risk/wanderer AEB with Goals marked as R6 will not leave facility unattended through the review date and R6's safety will be maintained through the review date, 'intervention' distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers sitting in her room with her husband, also church activities; intervention of wander alert and intervention of elopement/wandering risk, anger with placement within the facility. Intervention: 1. Offer to turn the tv to a station that R6 likes 2. Offer to sit and talk with R6 and see if you are able to calm her down 3. Call V26 (family) to talk with R6 to calm her down. R6's incident report dated [DATE] documents: The resident (R6) was last seen by staff approximately ,d+[DATE] ( 6:00 PM - 6:10 PM) in the main dining area. The resident did not mention leaving the facility to staff. The staff working with the resident were all interviewed, and statements obtained and reviewed. Unable to interview roommate as roommate has Alzheimer's diagnosis. Approximately 1800 -1810 on [DATE]th was the last time staff was able to state they saw the resident in the dining room. The temperature was approximately ,d+[DATE] degrees and clear with a breeze per weather service at 6pm on the 28th. The resident was wearing a short-sleeved t-shift, a wind breaker type jacket, pants, socks and her rainbow crocs. She was also carrying a blanket on her rollator walker. The resident was located by a staff members spouse less than 100 feet from the facility walking with her rollator near the adjacent business. The staff member's spouse called the staff member who was working at the facility at the time and notified her that he is with a resident from the facility, and he is next door. The staff member's spouse stayed with the resident until staff came out to assist her back to the facility. At approximately 1844 (6:44 PM), the staff went out to assist the resident back to the facility. The resident's wander guard went off when re-entering the facility. 100% head count was completed. All doors in the facility were checked by staff who verified that alarms were working. Elopement education was initiated immediately. The resident (R6) was unable to state which door she may have gone through to leave the facility. During investigation the resident's blanket was found on the picnic table just outside the breakroom door. A nurse leaving the facility at approximately 1838 noted the blanket on the table. The call to inform the facility of the resident outside was at approximately 1844 (6:44 PM). A 100% audit of all elopement assessments was completed and 100% of the residents were reassessed for elopement and care plans were updated as needed. The elopement books at each nurse station were reviewed for accuracy and a new picture of the resident placed in book. 100% of the wander guards were checked and verified for function. 100% of staff were in-serviced on the elopement policy, where the elopement binders are kept and how to react to an alarm sounding. A care plan was scheduled on ,d+[DATE] at 2pm with the POA but she was unable to make it to care plan meeting during this busy time of year. The medical director was updated regarding the investigation results. An elopement drill was completed on [DATE]. R6's progress note dated [DATE] at 6:40 PM documents: this nurse (V16, Licensed Practical Nurse) was notified by CNA (V15,Certified Nurse Aide) that (R6) was outside at storage facility next door. When I got outside (R6) was standing by the storage facility with 3 CNAs (V13, V14, V21) and 2 kitchen (Dietary) staff (V26 and V28). (R6) has been refusing to walk back to the facility with CNA's. I was able to talk R6 into coming back to facility. It was about 70 degrees outside still and resident was wearing a t-shirt, jacket, pants, slipper socks and shoes. She had a blanket at the picnic table and her walker with her. Once back in the building R6 went to bed. (R6's) wander device is on and working. A skin assessment was completed with no issues noted. On [DATE] at 11:05 AM the door R6 exited to the location where R6 was located was observed and was approximately 65 feet with no hazards observed. On [DATE] at 10:55 AM, V5 (Dietary) stated she received a call from V24 (Family of Employee) at 6:28 PM stating R6 was outside of the facility on the side of the storage units with him. V5 stated she asked V24 to stay with her and she would let staff know. On [DATE] at 10:58 AM, V24 (Family of Employee) stated he was over at the storage units on [DATE] at just after 6:00 PM when he came out of his unit at approximately 6:25 PM and saw R6. V24 then stated he called V5 at 6:28 PM to tell her R6 was with him and to let staff know. V24 stated he waited by the tree with R6 and staff came out minutes later to get R6 and convince her to go back inside. On [DATE] at 8:14 PM, V23 (CNA) stated she was working the day R6 eloped, she stated the last time she saw R6 was approximately between 6:15 and 6:30 PM she believes. One of the kitchen staff came out of the kitchen and said R6 was outside. R6 went out the double doors towards the breakroom is what she was told. V23 stated, she was in a room assisting another resident when R6 got out. They brought R6 back in the same way she went out and she thinks the alarm sounded, she does not specifically remember. V23 stated, usually there is a nurse by that nurse's station around that time. V [TRUNCATED]

Based on interview and record review the facility failed to provide peritoneal dialysis treatments for 1 of 2 residents (R1) reviewed for dialysis in a sample of 7. This failure resulted in R1 presenting with a change in condition of confusion and being admitted to the hospital with lethargy and receivng hemodialysis during R1's hospital stay. Findings include: R1's Admission Record documents R1's initial admitted to the facility as 03/25/24. The same document lists diagnoses for R1 including but not limited to: End Stage Renal Disease, Dependence on Renal Dialysis, Syncope and Collapse, Muscle Weakness (Generalized), Other Lack of Coordination, and Type 2 Diabetes Mellitus Without Complications. R1's current care plan, with an initiation and revision date of 4/16/24, documents a need of hemodialysis related to renal failure. There was no documentation of the need for peritoneal dialysis prior to this date upon request. R1's Minimum Data Set (MDS) dated [DATE] documents in section C, a Brief Interview for Mental Status (BIMS) score of 13, indicating that R1 is cognitively intact. The same MDS documented in section G, that R1 requires partial to moderate assistance, with rolling left to right, sitting to lying, lying to sitting on a bed, sit to stand, chair to bed transfer, indicating the helper would do less than half the effort. The same MDS documented in section O, Special Treatments, Programs and Procedures, that R1 receives dialysis upon admission and while a resident at the facility. R1's Discharge Planning Summary from the local hospital documents an entry on 3/22/2024 at 3:44 PM, that R1 was informed that this facility can meet her needs and that R1 wanted to talk to her family about her options. This same document has an entry dated 3/25/2024 at 10:22 AM that Patient (R1) was agreeable to rehab and referral sent to facility. An entry dated 3/25/2024 at 12:10 PM, documents (V3-Admission Coordinator) accepted patient (R1) to facility with orders prior for peritoneal dialysis prior to (R1) transferring to ensure they can get the equipment prior to patient arrival. This same document dated 3/28/2024 at 9:01am has a late entry note on 3/25/2024 at 2:00pm stating that (R1) was agreeable to bringing her peritoneal dialysis equipment and 2 days' worth of fluids with her to facility while V9 (Family Member) was at bedside and V3 (Admission Coordinator) agreeable to R1 going to the facility today. R1's Electronic Health Record (EHR) has no documentation of peritoneal dialysis orders received upon admission. R1's Nurse's Note dated 3/26/2024 at 6:05 PM, by V16 (Registered Nurse/RN), documents called and notified (V17 Nurse Practitioner/NP) that (R1) wouldn't be getting her peritoneal dialysis tonight due to not having all supplies available. Resident (R1) was supposed to bring 2 days supplies but forgot the fluids needed. Resident (R1) vital signs stable and will continue to monitor resident throughout the night. R1's Nurse's Note dated 3/27/2024 at 2:08 PM, documents V10 (Registered Nurse/RN) contacted V8 (Dialysis Registered Nurse) at R1's current dialysis provider regarding peritoneal dialysis orders. V8, states that resident is to use dialysis cycler to run 2 6-liter bags over 9-hour period every night. V10, notified R1 who can provide own dialysis treatment. R1's Nurse's Note dated 3/27/2024 at 8:18 PM documents, (R1) is experiencing a change in condition related to (R1) being confused and needing dialysis. R1's Nurse's Note dated 3/27/2024 at 8:46 PM documents, (V10 RN) notified (V17 Nurse Practitioner) that (R1) was having periods of confusion and unable to set up her peritoneal dialysis treatment. (V10) received orders from (V17) to send (R1) to (out of state) emergency room . (V10) attempted to notify family. On 5/03/2024 at 10:56 AM, V3 (Admissions Coordinator) stated she arranged admission to the facility with the discharging hospital and was aware R1 needed peritoneal dialysis. V3 stated it was understood by the discharging hospital that R1 would need to complete peritoneal dialysis independently while in the facility and would wait to be discharged to the facility until peritoneal dialysis supplies could be ordered and in the facility for R1. V3 stated the hospital case management arranged with R1 and R1's family to have a family member stop at R1's house to pick up the peritoneal dialysis machine with supplies and then bring the patient and supplies to the facility. V3 stated R1 arrived at the facility without her supplies and machine. V3 stated they have had a handful of patients receiving peritoneal dialysis over the years and could not confirm if staff were currently trained to assist R1 with her peritoneal dialysis. On 5/03/2024 at 12:10 AM, V5 (Director of Nursing/DON) stated that she has taken care of R1. V5 stated, her understanding was R1 missed one day of dialysis when she arrived at the facility because she did not have her supplies. V5 stated, R1's medical provider was notified of R1 not having her supplies and R1 was monitored through the night. V5 stated that V2 (Social Services Director) went the next day to meet family to pick up R1's supplies and dialysis machine. On 5/07/2024 at 11:08 am, V5 stated she was the educator for the peritoneal dialysis training for the facility. V5 stated that she used a power point to educate nursing staff. V5 stated she is not aware that a dialysis center staff came to the facility to train the staff and the staff did not have a peritoneal dialysis machine to demonstrate/practice on. On 5/03/2024 at 1:21pm, V2 (Social Services Director) stated he was asked to go meet R1's family at her home to get R1's peritoneal dialysis supplies and machine. V2 stated he did get the supplies and returned to the facility with them but cannot recall what day. V2 stated that R1 did review her dialysis orders with V10 (RN). On 5/03/2024 at 1:45 PM, V7 (Administrator of local Dialysis Company) and V8 (Nurse of local Dialysis Company) both stated, that R1 has been a peritoneal dialysis patient since April 2020 and was completing her treatments independently at home prior to her hospital admission at the end of March. V7 and V8 both stated, R1 would not be able to complete her treatments independently with R1 having a decrease in her physical abilities. On 5/07/2024 at 9:34am, V9 (Family Member) stated that she brought R1 to the facility after stopping at R1's house to retrieve her supplies to complete dialysis in the facility. V9 stated she was notified the next day that they forget the solution. V9 stated she was unable to get the solution to the facility until the next day. V9 stated that V2 did come to meet her at R1's house to pick up the solution on the third day of R1's admission. On 5/3/2024 at 9:39AM, V1 (Administrator) stated that R1 arrived at the facility without her peritoneal dialysis supplies. V1 stated that V3 (Admissions Coordinator) discussed with the hospital prior to discharging R1 to the facility that R1 would have to be able to complete the peritoneal dialysis, independently, and would need all supplies brought to the facility upon arrival. V1 stated that R1 arrived at the facility without her supplies. V1 stated that R1 was monitored through the night and then V2 (Social Services Director) went to meet R1's family at R1's home to get the peritoneal dialysis machine and supplies the next day. V1 stated that once the machine and supplies were brought to the facility, R1 could not complete the steps to start her dialysis. V1 stated R1's medical provider was notified and R1 was sent to the hospital for evaluation. V1 stated if they knew she was not bringing her supplies, they would not have accepted R1. V1 stated there was an issue with V9's (family member) car when she was notified the next day, they needed her to bring R1's solutions to the facility. On 5/07/2024 at 11:43 am, V10 (Registered Nurse/RN) stated she had direct patient care with R1. V10 stated she cared for R1 on day shift, 3/26/2024, after R1 arrived at the facility. V10 stated, that R1 arrived late the prior evening without her dialysis supplies and the facility was in contact with the family the next day to arrange getting the supplies. V10 stated on the third day, V10 and R1 set up the supplies and machine in R1's room. V10 stated she was under the impression that R1 was going to direct the staff on how to use the dialysis machine, however that evening when V16 (RN) went to help R1, R1 was not able to direct staff on how to assist. V10 stated, R1 was then sent out to the hospital since she had been without a dialysis treatment for 3 days. V10 stated that she did have peritoneal dialysis training a year ago by the facility staff, however, could not remember the exact date. V10 stated, she does not feel comfortable assisting with peritoneal dialysis and does not recall being trained by a dialysis facility faculty. On 5/08/2024 at 6:51 AM, V16 (RN) stated that she had direct patient care with R1. V16 stated she was the nurse that took care of R1 when she arrived at the facility her first night around 11:30 pm. V16 stated that R1 had a lot of bags with her dialysis equipment with her, however, R1 refused to set up the equipment and stated she did not need dialysis that evening. V16 stated she came in to work the next night and was told that R1's family was notified that R1 forgot her solution at home to complete her treatments and V9 (family member) was contacted to bring the solution to the facility. V16 stated that V9 notified the facility that her car was broken down and had no transportation to bring the solution to the facility however someone from the facility is welcome to go to her house and pick up the solution. V16 stated she notified V17 (Nurse Practitioner) of R1 missing her treatments because of no solution and was showing no signs of distress. V16 stated she received orders to monitor R1 for any signs of symptoms of distress. V16 stated when she arrived at the facility for the third night in a row, R1 had her supplies to complete her treatment. V16 stated that someone from the facility went to R1's home that day to get her solution. V16 stated R1 was physically unable to complete her dialysis treatment on her own and staff were supposed to assist by giving directions on what solutions to be used and buttons to be pushed on the machine. V16 stated R1's peritoneal dialysis order was received by the day shift nurse from the dialysis company on 3/27/2024 around 2:00pm. V16 stated the day shift nurse and R1 set up all supplies and her machine that day in R1's room. V16 stated around 7:00 pm, she went into R1's room to assist with dialysis and R1 was unable to give directions on how to set up and start treatments. V16 stated she notified the V17 (Nurse Practitioner) and sent R1 to the hospital. V16 stated she attended the peritoneal dialysis training instructed by V5 sometime in 2023. V16 stated she cannot recall if she was trained on a peritoneal dialysis machine during that training. V16 stated, she has not been trained on peritoneal dialysis by a certified dialysis staff member. V16 stated she feels comfortable assisting residents with peritoneal dialysis when they can give directions on their set up, solutions to use, etcetera. On 5/07/2024 at 1:27 pm, V11 (Physician) stated that R1 was his resident completing peritoneal dialysis treatments at home, independently. V11 stated he was notified after R1 was discharged from the hospital to this rehab facility. V11 stated he expects a nursing home facility to have supplies and proper training prior to accepting a peritoneal dialysis resident. V11 stated he would expect if R1 arrived at the facility without her supplies then the facility should have sent her back to the hospital to receive treatment or R1 to her home to get all her supplies to complete her treatment. On 5/08/2024 at 9:24 AM, V17 (Nurse Practitioner/NP) stated R1 arrived at the facility on 3/25/2024 without her dialysis supplies to complete her treatment. V17 stated she was notified the next evening when R1 still had not received her supplies at the facility. V17 stated when she was contacted by the nurse that R1 was unable to complete her treatments the next evening (day 3), she had R1 sent out to the emergency room for evaluation. V17 stated the understanding upon admission to the facility was that R1 was able to complete her dialysis treatments independently, however, R1 was unable to complete the steps or direct the staff on what was needed to initiate the peritoneal dialysis treatment. The facility's Inservice Education Signature Sheet for peritoneal training by V5 (Director of Nursing/DON) with Peritoneal Dialysis (Continuous Ambulatory) procedure was reviewed and had V10 (Registered Nurse/RN) and V16 (Registered Nurse/RN) signatures as having attended the training . R1's Hospital Discharge Summary from an out of state hospital dated 4/3/2024 documents that R1 was admitted to the hospital on 3/27/24 with a chief complaint of no dialysis in 2 days. The Cumulative Hospital Course and Treatment documents that R1 has End Stage Renal Disease (ESRD) and is on Peritoneal Dialysis (PD) and presented to the emergency room from the rehab center due to lethargy and R1 had not received peritoneal dialysis in at least 2 days. R1 was new to the rehab center, and they were not made aware of her peritoneal dialysis needs. R1 was admitted to the hospital with nephrology consult where a decision was made to change dialysis modality to hemodialysis (HD) and a permcatheter was placed. R1 completed a hemodialysis treatment on 4/03/2024 and was discharged in stable condition to the rehab facility. R1 was to continue hemodialysis treatments, 3 days a week. The same discharge summary documents under Discharge Problem List a principal problem of ESRD needing dialysis and active problems of Lives in a long-term custodial care facility, acute kidney injury, and acute post-hemorrhagic anemia.

Based on interview and record review, the facility failed to safely transport a resident in a wheelchair to prevent an accident for 1 of 3 residents (R1) reviewed for accidents in the sample of 6. This failure resulted in R1 receiving an 8 cm (centimeter) laceration over his right eye requiring 10 staples. The findings include: R1's face sheet documents R1 was admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies, Parkinson's Disease with dyskinesia, with fluctuations, and repeated falls. R1's Minimum Data Set (MDS) dated [DATE] documents in section C, Cognitive Patterns, a Brief Interview of Mental Status (BIMS) score of 01, indicating that R1 has severe cognitive impairment. Section GG, Functional Abilities and Goals, of the same MDS documents that R1 uses a wheelchair as a mobility device, R1 requires partial/moderate assistance (helper does less than half the effort) with sit to stand, walking 10 feet, and walking 50 feet with two turns. The same section documents that R1 requires supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) with wheeling 50 feet in a wheelchair with 2 turns and requires partial/moderate assistance to wheel 150 feet in a wheelchair. R1's Fall Risk Data Collection dated 1/19/24 documents a score of 32 and documents high risk for the category. R1's Fall Incident Report in the Electronic Health Record dated 3/3/24 documents under Incident Description that at approx. (approximately) 1945 (7:45 PM) resident (R1) was being wheeled up the hall in wheelchair towards his room when the nurse witnessed resident lean forward and fall to floor hitting his head. Obvious laceration noted. Staff directed to not move resident. Under Immediate Action Taken it documents Obvious laceration to right side of head noted. New orders received to send to ER (emergency room ) for eval and treat. The intervention documented is have leg rests on while being pushed in his w/c (wheelchair). R1's Patient Health Summary from the local hospital dated 3/3/24 documents a chief complaint of head laceration and stated complaint of .presents to the ER (emergency room ) from local nursing home after he apparently fell forward out of his wheelchair striking his head on the ground resulting in a laceration over the right. The same document under Physical Exam stated laceration over the right eye. It is stellate on the medial side almost in a Y-shaped. The 2 arms are 1cm (centimeter) and then the rest of the laceration is 6cm. Extending through the subcutaneous tissue. No visible bone. Under Laceration/Wound Repair it documents the wound length is 8 cm and the wound was repaired with 10 staples. Physician Progress Note on the same document states that a CT (Computerized tomography) head, maxillofacial and cervical were all negative for acute fractures or findings. R1's Care Plan documents that R1 is at risk for falls and documents an intervention of Leg rests to be on the wheelchair when pushing residents with an initiation date of 3/3/24. On 3/7/24 at 2:15pm, V10 (CNA) said she was pushing R1 when he fell . V10 said she takes R1 with her in the wheelchair so she can watch him since he is always trying to get up. V10 said she parked R1 in his wheelchair outside of the room she had to go in. V10 said she was going to answer a call light and the nurse was at her medication cart. V10 said the nurse motioned to her that someone was trying to get up. V10 said she was about 6 doors down. V10 said she didn't pay attention and began pushing him. V10 said she didn't realize that R1 had scooted forward in his wheelchair and put his feet down causing R1 to fall face first on the floor. V10 said she did not have foot pedals on the wheelchair. V10 said they are using foot pedals now with R1 and he won't keep his feet on the pedals. On 3/7/24 at 3:00pm, V1 (Administrator) said she was aware of the foot rests not being on, but was not aware of R1 sitting at the edge of the wheelchair when being pushed. V1 said they implemented the intervention of ensuring the foot rests were on the wheelchair after he fell on [DATE]. The facility policy titled Fall Policy (revision date 9/17/19) documents that the the facility shall ensure that a Fall management Program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety.

Based on interview and record review, the facility failed to ensure a resident's wheelchair had foot rests in place when transporting a resident outside of the facility for 1 (R1) of 7 residents reviewed for accidents. This failure resulted in R1's foot dropping and pulling back under the wheelchair resulting in a closed fracture of distal end of the right tibia. This past non-compliance occurred between 10/12/23 and 10/18/23. The findings include: R1's Admission record documents an admitted to the facility of 4/13/18 with diagnoses including bipolar disorder, sepsis, unspecified organism, orthostatic hypotension, unspecified osteoarthritis, unspecified site. Additional diagnoses include displaced spiral fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing dated 10/12/23. R1's MDS (Minimum Data Set) section C, dated 10/12/23, note that R1 has a BIMS (Brief Interview of Mental Status) of 12 indicating R1 has moderate cognitive impairment. The same MDS section GG documents that R1 has impairment in both sides of lower extremities (hip, knee, ankle foot) and uses a wheelchair as a mobility device. R1's care plan documents a focus area of The resident has limited physical mobility with a documented goal of the resident will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall related injury through the next review date. Documented interventions include the resident uses a wheelchair for locomotion and the resident requires 1 staff participation for mobility. R1's fall risk assessment dated [DATE] note a score of 8 which indicates that R1 was a low risk for falls. The Facility Incident Log, with an incident date of 10/12/23, documents the final investigation as R1 was exiting the transportation bus off the ramp being pushed by transport staff (V8/transport staff) when her right leg was caught on the end of the ramp and entangled under her wheelchair. The Facility Incident Log further documents At that time, R1 was being transported to wound care appointment at a local out of state hospital. On the night of 10/12/23, R1 complained of pain to bilateral hips and feet. Pain medication was administered. Complaints of pain continued on 10/13/23. Registered Nurse (RN) began to question resident about her foot and hip pain and R1 stated at that time that she feels like it occurred during her wound care appointment. R1 was immediately sent to local out of state emergency room for evaluation. The Facility Incident Log documents that R1 was transferred to a local out of state emergency roiagnom on [DATE] due to complaints of right leg pain. R1 was noted to have a closed fracture of distal end of right tibia. A splint was applied in the emergency room . R1 was placed on non-weightbearing status and given recommendations to follow up with local orthopedic group next week. The hospital ED (Emergency Department) Provider Notes dated 10/13/23, document R1 was discharged with a closed fracture of distal end of right tibia, unspecified fracture morphology, initial encounter. The same note documents that the emergency room physician discussed case with an on-call orthopedic surgeon who recommended posterior splint with non-weightbearing status. Plan to follow up outpatient in clinic next week. On 10/27/23 at 10:15 am, R1 said that they loaded her up in the wheelchair and put her on the transport bus. R1 said V8 was driving the bus and V9 (CNA/Certified Nurse Assistant) was helping her. R1 said they went to get her out and her leg went underneath her. R1 said that they did not put any foot rests on the wheelchair. R1 said that it started hurting later that night and they sent her to the emergency room . R1 said she did follow up with Orthopedics and said she has to wear the cast on her foot for 6 weeks. On 10/31/23 at 9:15 am, V8 (transport staff) said that he was pushing R1 off the lift and told her to keep her legs up. V8 said he guesses she could not hold them up or she dropped her leg. V8 said he is not sure if possibly her sock got caught in the lift. V8 said they had not made it off of the lift yet and R1 said ouch and when she said ouch, he stopped and got her foot up. V8 said that V9 was at the foot of the ramp to assist with R1 and go in the hospital with her. V8 said that R1 never complained of any pain other than saying ouch. V8 said he went back to get R1 from the hospital and R1 never complained of any pain. V8 said he does not transfer any residents, all he does is transport. V8 said he has been in-serviced on using leg rests while transporting a resident out of the facility. V8 said that now, no one gets on his bus unless they have their foot rests on. On 10/31/23 at 9:45 am, V9 (CNA) said she went out on transport to take R1 to the hospital for a wound care visit. V9 said that R1's foot basically drug back when she was being pushed off the ramp of the bus. V9 said that after V8 pulled back on the wheelchair, she got R1's foot up and all R1 said was ouch. V9 said they went in for her appointment and R1 never complained of pain. V9 said that the doctor in wound care lifted her foot up and R1 never said anything- no ouch, that hurts or nothing. V9 said she has been in-serviced on using footrests when transporting a resident out of the facility. On 10/27/23 at 10:15 am, V1 (Administrator) said that they were not aware R1 had an injury to her foot. They realized it on 10/13/23 when she began complaining of pain and was sent to the emergency room . V1 said she immediately began an investigation. On 10/31/23, V1 provided their QAPI (Quality Assurance Performance Improvement) form where they discussed past non-compliance related to facility reported incident with R1. Prior to this survey date, the facility took the following actions to correct the non-compliance: 1. Immediate Corrective Action: All approved transportation staff were educated by the DON/Director of Nurses that all residents that require a wheelchair and are being transported via facility staff should have wheelchair legs attached to the wheelchair during transport. 2. Systemic Changes to Ensure Compliance: All transportation staff were educated on ensuring that all residents have leg rest prior to facility transport, QAPI meeting with Medical Director was held on 10/18/23. 3. System Maintenance: DON or designee will do random checks of 3 appointments per week for 2 weeks to ensure leg rest was attached prior to transport, Universal leg rest were provided to the transport staff to ensure compliance with every transport. 4. Other Residents with the Potential to be Affected: All residents have the potential to be affected by the alleged deficient practice. R1's Facilities Past non-compliance packet contained the random checks for footrests dated 10/18/23, 10/19/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/30/23 and 10/31/23.

Based on interview and record review, the facility failed to apply a gait belt while transferring and ambulating 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure resulted in R1 falling to the floor which resulted in a fracture of the L2 vertebrae. Findings include: R1's Admission Record in the medical record documents that R1 admitted to facility on 6/08/2022 with a diagnosis of cerebral infarction, unspecified. R1's Minimum Data Set (MDS) assessment dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating that R1 is cognitively intact. Section G, Functional Status documents Limited assistance with one-person physical assist with bed mobility, transfers, ambulating, dressing, toilet use, and personal hygiene. R1's Care Plan documents under Focus that R1 is at risk for falls with an initiation date of 6/09/2022 and revision date of 12/13/2022. Under the section Goal it documents that R1 will be free from falls through the review date with an initiation date of 6/09/2022 and revision date of 12/20/2022 and target date of 5/08/2023. Interventions documented include: be sure the resident's call light is within reach and encourage the resident to use it for assistance with an initiation date of 6/09/2022 and revision date of 6/20/2022, ensure personal items are within reach with an initiation date of 6/09/2022, ensure that the resident is wearing appropriate footwear ambulating or mobilizing in wheelchair with an initiation date of 8/31/2022 and revision date of 9/19/2022. R1's Fall Risk assessment dated [DATE] documents score: 9 (Low Risk). R1's Progress Notes dated 5/27/2023, documents It was reported to V4 (Licensed Practical Nurse) by (R1) that (R1) had experienced a fall last night, (R1) has a deep purple bruise on coccyx and (V4) noted (R1) is having problems transferring, (R1) stated It only hurts when they try and stand up. (R1) explained that she was using rollator (wheeled walker) with (V5-Certified Nurse Aide), (V5) went to pull blankets back for (R1) to get in bed, (R1) lost balance and landed on buttocks. (V9-Nurse Practitioner) notified and ordered (R1) to emergency room for evaluation. Family made aware. R1's Emergency Department Provider Notes dated 5/27/2023, documents in part .(R1) is a [AGE] year-old white female present to the emergency room with complain of low back pain .(R1) had a fall yesterday .person did not support her back and (R1) fell on the floor on her buttocks .(R1) has a bruise on her lower buttocks and low back .Final Impression, 1. Closed compression fracture of L2 lumbar vertebra, initial encounter. On 6/13/2023, at 9:00 a.m. V1 (Administrator) stated that it was reported that R1 experienced a fall on 5/26/2023 and V5 (CNA) was assisting R1 back from the bathroom and went to pull her bedding back and R1 lost her balance and landed on her buttocks. V1 stated that V5 was educated to follow R1's plan of care and to use a gait belt when transferring or ambulating a resident that requires assistance with transfers and ambulation. On 6/12/2023, at 11:25 a.m., V4 (Licensed Practical Nurse), stated that she was working on 5/27/2023 and was notified by the CNA that R1 was having difficulty transferring and she had noticed a bruise on her coccyx area. V4 stated she went in to assess R1 and observed a deep purple bruise to her coccyx and right buttock area. V4 stated that R1 told her she had fallen the night before. V4 stated she asked R1 if she was having pain and R1 told her she was having a little pain. V4 stated she offered R1 some pain medication at that time and notified the primary physician and made family aware. V4 stated the primary physician ordered for R1 to be sent out to the emergency department for an evaluation and treatment. V4 stated that R1 was sent out to the local hospital and returned with a fracture to her lower back. V4 stated that R1 normally transfers with assistance of one person with a gait belt and ambulates with a rollator walker. On 6/13/2023, at 10:00 a.m., V5 (Certified Nurse Aide) stated he was working the evening of 5/26/2023 and was helping R1 get ready for bed. V5 stated he helped R1 go to the bathroom and when R1 was coming out of the bathroom, he went over to her bed to pull down the bedding and when he turned around R1 had fallen to the floor on her buttocks. V5 stated R1 told him she was fine. V5 stated he notified V8 (Agency LPN), and she came in to look at R1. V5 stated that after V8 looked her over, he helped R1 get up and put her into bed. V5 stated that he did not have a gait belt on R1 when he was helping R1 to and from the bathroom. On 6/13/2023, at 10:15 a.m., V8 (Agency LPN) stated that she was working the evening of 5/26/2023 and was notified by V5 (CNA) that R1 had fallen to the floor while coming back from the bathroom. V8 stated she went into R1's room and assessed R1. V8 stated that R1 did not have any complaints of pain or discomfort at that time and R1 was able to move her extremities with no problems and denied hitting her head. V8 stated that R1 was assisted up and put back to bed with no problems noted. On 6/12/2023, at 10:00 a.m., R1 stated she had a fall recently. R1 stated she was walking back from the bathroom with her walker and V5 (Certified Nurse Aide/CNA) was over at her bed pulling down the bedding on her bed to help assist her get ready for bed. R1 stated she lost her balance and fell into her closet and sat down to the floor. R1 stated that the nursing staff usually have a gait belt on her and walk with her when she is walking with her walker. R1 stated that V5 did not put a gait belt on her at that time. R1 stated she did not have any sudden pain until she got up the next morning and noticed her back was sore. R1 stated that she told the nurse she had back pain and had fallen the night before. R1 stated the nurse checked her out and noticed a bruise on her lower back/bottom. R1 stated she was sent out to the hospital and was told her lower back had a fracture in it. R1 stated she was brought back to the facility after her hospital visit. The facility's Final Report dated 5/27/2023 documents in parts . Staff were educated in the use of a gait belt, the proper way to complete the transfer and the task of preventing any incidents in the future .

Based on observation, interview, and record review the facility failed to ensure pressure ulcers were assessed, treated, and interventions were implemented timely for 1 of 3 (R66) residents reviewed for pressure ulcers in the sample of 36. This failure resulted in R66 developing a Stage 3 Pressure Ulcer to R66's coccyx which was up to 1 week old before it was assessed and treated. Findings Include: R66's facility Admission Record with a print date of 5/24/23 documents R66 was admitted to the facility on [DATE] with diagnoses of fracture of femur, cirrhosis of liver, fracture of ribs, neurocognitive disorder, diabetes, and fracture of vertebra. R66's MDS (Minimum Data Set) dated 4/23/23 documents a BIMS (Brief Interview for Mental Status) score of 02, which indicates R66 has a severe cognitive deficit. This same MDS documents R66 is dependent on staff for bed mobility and toilet use and requires extensive assistance with transfers. This same MDS documents under Section M, R66 is at risk for developing pressure ulcers, has a Stage 2 pressure ulcer, and has the following interventions: pressure reducing device for chair, pressure reducing device for bed, nutrition/hydration intervention, and pressure ulcer/injury care. R66's Braden Scale for Predicting Pressure Sore Risk assessments document a score of 17 on 4/17/23 and a score of 15 on 4/24, 5/1, and 5/8/23. This indicates R66 is at risk for skin breakdown. On 05/24/23 at 9:25 AM, V4 (Registered Nurse/Wound Nurse) was observed administering treatments to the pressure ulcers located on R66's buttocks and coccyx. The area to R66's left buttock was red and opened with the surrounding tissue being red and inflamed. The area to R66's coccyx was covered with yellow slough with the surrounding tissue being red and inflamed. V4 stated R66 came to the facility with the small area on his left buttock and then developed the Stage 3 pressure ulcer to his coccyx after admission. V4 cleaned the areas with wound cleanser and applied calcium alginate to the pressure ulcer on R66's left buttock and applied Santyl, Adaptec, and silicone foam to the pressure area on R66's coccyx. V4 performed hand hygiene per current standards of practice. R66's weekly skin checks document on 4/24/23 there was a pressure ulcer to R66's left buttock with no assessments or measurements notes. R66's weekly skin check dated 5/8/23 documents a pressure ulcer to R66's coccyx and left buttock with no assessments or measurements notes. R66's weekly skin checks dated 5/1, 5/16, and 5/23/23 do not document assessments of pressure areas. R66's progress notes were reviewed from 4/17/23 to 5/24/23 and did not document assessments of pressure areas including measurements, classifications, and/or descriptions. R66's Skin and Wound Evaluation dated 4/18/23 documents a Stage 2 pressure ulcer to left buttock, present on admission to the facility. The assessment documents the pressure ulcer measures 3.1 cm x 2.3 cm x 0.1 cm with no undermining or tunneling. Under Notes the assessment documents, Stage 2 pressure ulcer to left buttock present on admission. Turn/reposition frequently. Arginaid to promote healing. R66's Skin and Wound Evaluation dated 5/8/23 documents the Stage 2 pressure ulcer to R66's left buttock that measures 2.9 cm x 1.1 cm x 0.1 cm. Under Notes the assessment documents, Stage 2 pressure area to buttock stable. Calcium Alginate continues to wound bed covered by silicone bordered foam daily. This indicates the pressure area to R66's left buttock was not assessed from 4/18/23 until 5/8/23. R66's Skin and Wound Evaluation dated 5/15/23 documents the Stage 2 pressure ulcer to R66's left buttock measures 1.2 cm x 0.6 cm x 0.1 cm with no undermining or tunneling. Under Notes the assessment documents, Stage 2 pressure area to left buttock has improved in size. Will continue calcium alginate to wound bed cover with silicone bordered foam daily. R66's Skin and Wound Evaluation dated 5/22/23 documents a Stage 2 pressure ulcer to left gluteus that was present on admission that measures 0.7 cm x 0.3 cm. x 0.1 cm. The assessment documents a light amount of exudate, no odor, attached edges, no pain, no swelling, and normal in color. Under Notes the assessment documents, Stage 2 pressure ulcer to left buttock continues to show improvement. Will continue calcium alginate to wound bed and cover with silicone bordered foam daily. Arginaid daily to promote wound healing. R66's Skin and Wound Evaluation dated 5/8/23 documents a Stage 3 pressure ulcer on R66's coccyx, acquired in house within the last week. The pressure ulcer is measured at 2.1 cm x 0.7 cm x 0.2 cm. Under Notes the assessment documents, Stage 3 pressure area noted to coccyx. 50% yellow slough. 50% granulation tissue noted to wound bed. New order for honey absorbing sheet to wound bed covered by silicone bordered foam daily. Arginaid added to promote wound healing. R66's Skin and Wound Evaluation dated 5/15/23 documents a Stage 3 pressure ulcer on R66's coccyx measured as 3.5 cm x 1.7 cm x 0.2 cm. Under Notes the assessment documents, Stage 3 pressure area to coccyx has deteriorated. Larger in size with 90% yellow slough noted to wound bed. 10% granulation tissue. Honey absorbing sheet to wound bed covered by silicone bordered foam daily. Arginaid daily to promote wound healing. R66's Skin and Wound Evaluation dated 5/22/23 documents a Stage 3 pressure ulcer to coccyx that was acquired in house, approximately one week ago. The assessment documents the area measures 3.0 cm x 1.0 cm x 0.2 cm with no undermining or tunneling. The assessment of the area is documented as no evidence of infection, moderate serous exudate, no odor, attached edges, no swelling, and normal peri-wound temperature. Additional care is documented as turning/repositioning program with no other interventions documented on this assessment. Under Notes the assessment documents, Stage 3 pressure area to coccyx stable. 90% yellow slough noted to wound bed. 10% granulation tissue. New order to apply Santyl ointment to wound bed covered with Adaptec and silicone bordered foam daily. Arginaid daily to promote wound healing. R66's Order Summary Report dated 5/24/23 includes the following physician orders Cleanse stage 2 pressure area to left buttock with wound cleanser. Pat dry. Apply calcium alginate to wound bed. Cover with silicone bordered foam dressing daily and prn (as needed) for soiling or dislodgement until healed. Every night shift for wound healing. Start date: 4/23/23, and Santyl External Ointment 250 unit/gm(gram) (Collagenase) Apply to stage 3 coccyx topically every night shift for wound care apply nickel thick layer Santyl to wound bed. Cover with Adaptec and silicone bordered foam daily. Start date: 5/22/23. This same Order Summary Report documents an order that was discontinued 5/22/23 to cleanse Stage 3 pressure ulcer to coccyx with wound cleanser, apply honey absorbing sheet to wound bed and cover with silicone bordered gauze daily with a start date of 5/8/23. This indicates there was no physician order for treatment of the Stage 2 pressure ulcer on R66's left buttock from 4/17/23 until 4/23/23. R66's Treatment Administration Record (TAR) dated 4/1/23 to 4/30/23 documents an order to Cleanse Stage 2 pressure area to left buttock with wound cleanser. Pat dry. Apply calcium alginate to wound bed. Cover with silicone bordered foam dressing daily and prn (as needed) for soiling or dislodgement until healed. Start date: 4/23/2023. The treatments are signed as being administered as ordered. R66's TAR dated 5/1/23 to 5/31/23 documents an order to Cleanse Stage 2 pressure area to left buttock with wound cleanser. Pat dry. Apply calcium alginate to wound bed. Cover with silicone bordered foam dressing daily and prn for soiling or dislodgement until healed. Every night shift for wound healing. Start Date: 4/23/2023. This TAR documents signatures for all dates except 5/11, 5/14, and 5/20/23, which indicates treatments were administered as ordered on every day except 5/11, 5/14, and 5/20/23. R66's TAR dated 5/1/23 to 5/31/23 documents an order for Santyl External Ointment 250 unit/gm (Collagenase) Apply to Stage 3 coccyx topically every night shift for Wound Care. Apply nickel thick layer Santyl to wound bed. Cover with Adaptec and silicone bordered foam daily. Start Date: 5/22/23. This TAR documents signatures indicating treatments were administered as ordered. This same TAR documents an order to cleanse the Stage 3 pressure ulcer to coccyx with wound cleanser, apply honey absorbing sheet to wound wound bed and cover with silicone, with a start date of 5/8/23 and discontinue date of 5/22/23. This TAR documents signatures on each day indicating the treatments were administered as ordered except on 5/11, 5/14, and 5/20/23. R66 Care Plan dated prior to 5/24/23 did not contain an area related to potential skin breakdown or a pressure ulcer care area. On 05/24/23 at 10:12 AM, this surveyor reviewed R66's care plan with V4 (RN/Wound Nurse) and she confirmed R66 did not have a potential for skin breakdown or pressure ulcer care area on his current care plan. When asked how to tell what, if any interventions were in place to prevent skin breakdown V4 stated she didn't have a good answer for me at that time. R66's current Care Plan documents a Focus area of (R66) has potential/actual impairment to skin integrity r/t (related to) decreased mobility. Left Gluteus, Coccyx, Date Initiated: 5/24/23. The interventions documented for this care area dated 5/24/23 are, Administer medications as ordered. Monitor/document for side effects and effectiveness .Administer treatments as ordered and monitor for effectiveness Document location of wound, amt (amount) of drainage, peri-wound area, pain, edema, and circumference measurements .Encourage good nutrition and hydration in order to promote healthier skin .Evaluate wound for: Size, Depth, Margins, peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated .Inform the resident/family/caregivers of any new area of skin breakdown .Monitor dressing when providing care to ensure it is intact and adhering. Report lose dressing to nurse .Monitor pressure areas for changes in color, sensation, temperature, and report any change to nurse .Pressure redistributing mattress on bed .The resident needs pressure redistributing cushion to protect the skin while up in chair. This indicates there was no care plan implemented related to skin breakdown from 4/24/23 when the Stage 2 pressure ulcer was identified until 5/24/23. On 05/24/23 at 3:22 PM, V9 (Certified Nursing Assistant/CNA) stated the facility staff rotate R66 every two hours and use pillows to keep him off his bottom. V9 stated they keep R66 clean and dry. V9 stated they have been implementing those interventions since R66 was admitted to the facility. On 05/24/23 at 3:24 PM, V15 (LPN/Licensed Practical Nurse) stated R66 didn't have a cushion in his wheelchair. V15 stated R66 was non-weight bearing when he was first admitted to the facility and wasn't up in his wheelchair. V15 stated they had to order a cushion to fit his wheelchair and it hasn't come in yet. V15 stated they keep R66 clean and dry, float his heels, and turn and reposition him every two hours and they implemented those interventions when R66 was admitted . V15 stated R66 had the pressure ulcer to his buttock when he was admitted and the one on his coccyx developed after admission. On 05/25/23 at 10:00 AM, V4 (RN/Wound Nurse) stated R66 should have had a skin breakdown/pressure ulcer care plan in place. V4 stated if the care plan wasn't present the staff would just use standard nursing practice for interventions such as turn and reposition, intake, hydration. V4 stated there is no documented assessment of the Stage 2 pressure ulcer to R66's left buttock until 5/8/23. On 05/25/23 at 10:25 AM, V2 (Director of Nurses) stated she put the physician order for the treatment to the pressure ulcer on R66's buttock in on 4/23/23 and the pressure ulcer was documented on the 4/24/23 weekly skin check. V2 stated she didn't have measurements, or an assessment of the area documented until 5/8/23. V2 stated the pressure ulcer should have been assessed weekly and she knows it was measured but she failed to document the measurements. V2 stated there was no care plan documented and the interventions to prevent the pressure ulcer from worsening was to turn and position at least every two hours, observe the area with treatments, and if it was worsening to put new interventions in place. This surveyor reviewed R66's TAR and asked her why there were some days with no signatures, V2 stated she believes the nurses did the treatments but just failed to document them. When asked how they monitored the pressure ulcer on R66's left buttock to ensure it wasn't worsening, V2 stated they did it with the dressing changes. V2 stated she didn't administer every treatment and the same nurse did not administer every treatment. When asked if she had different nurses doing the treatments with no assessments of the area documented, then how would the nurse know if the area worsened or improved, V2 stated, They can only go off what they have seen prior. When asked if there were any new interventions implemented after R66 developed a Stage 3 pressure ulcer on his coccyx, V2 stated there were dietary interventions implemented to promote healing. V2 stated a cushion was also placed in R66's chair. This surveyor reviewed with V2, R66 didn't have cushion in his chair and V2 stated, Ok. When asked if she had a resident who had a Stage 2 and developed a Stage 3 pressure ulcer if she would expect new interventions to be implemented other than dietary changes, V2 stated, Yes. On 05/25/23 at 2:15 PM, V1 (Administrator) stated she would expect staff to assess, obtain treatment orders, and implement new interventions for residents with pressure ulcers. V1 stated she couldn't find an order to treat the Stage 2 pressure ulcer to R66's left buttock prior to 4/23/23. On 05/25/23 at 2:23 PM, V17 (Nurse Practitioner/NP) stated he wasn't aware R66 had pressure ulcers. V17 stated with R66's condition he doesn't think the pressure ulcers would be avoidable. V17 stated he would expect the facility staff to assess and document assessments so they could monitor if the areas are improving or declining. V17 stated if the facility had notified him of the areas, he would have given the order to refer R66 to wound care. V17 stated he hasn't seen the pressure areas but has seen R66 three times since he was admitted to the facility. V17 stated every time he had seen him, R66 has been up in his wheelchair except when R66 was in isolation. V17 stated he has no documentation he was notified of the areas and/or gave orders to treat the areas. On 5/25/23 at 2:35 PM, V4 (RN/Wound Nurse) stated she thinks V17 (NP) gave her the orders for the treatments to R66's pressure ulcers. The facility Pressure Ulcer/Pressure Injury Prevention (PUP) policy dated 4/2018 documents, Prevention of Pressure Ulcers/Injuries; A pressure ulcer/injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must: Identify whether the resident is at risk for developing or has a PU/PI upon admission and thereafter; Evaluate resident specific risk factors and changes in the resident's condition that may impact the development and/or healing of a PU/PI; Implement, monitor, and modify interventions to attempt to stabilize, reduce, or remove underlying risk factors; and If a PU/PI is present, provide treatment to heal it and prevent the development of additional PU/PI's 1. Assessment: A standardized pressure ulcer/pressure injury risk assessment (Braden Scale) will be used to identify residents who are at risk for the development of pressure ulcer/pressure injury 2. Planning: An individual plan of prevention will be developed to meet the needs of the resident. It will include the consideration of mechanical support surfaces, nutrition, hydration, positioning, mobility, continence, skin condition and overall clinical condition of the resident as well as the risk factors as they apply to each individual .3. Implementation: Interventions for the prevention of pressure ulcer/pressure injury will be individualized to meet the specific needs of the resident 4. Evaluation and Reassessment: The facility's Care Management System committee will review program components to evaluate the effectiveness of the prevention program and facility systems. Findings and recommendations will be reviewed with the QA Clinical Committee. Based on evaluation, the need for reassessment and further changes to the individual resident's plan of care will be determined and acted upon.

Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 3 (R2) residents reviewed for abuse in the sample of 6. This failure resulted in R2 being hit by V3 (Registered Nurse) resulting in bruising and scratches on R2's face and neck. Findings Include: R2's facility admission record documents R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility final report not dated, regarding R2, documents under Complete Description of Occurrence, Alleged Physical Abuse. On 10/03/21 at 1:50 AM V3 (Registered Nurse/RN) was suspended pending investigation for physical abuse. Employee refused drug screening. (local) Police, family, MD (physician), and Administrator/Abuse Coordinator were notified of occurrence. Complete body assessment performed on resident with injures documented. Facility abuse policy and procedures initiated. Midnight staff interviewed. Resident safety questionnaire completed on five alert residents without any safety concerns voiced. 100% skin audit performed on all residents with no abnormal bruising or injuries noted. All staff inserviced on abuse policy, residents rights, and how to cope with job related stress and burnout. Social service performed follow up interview with resident. Due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . After completion of investigation, it was determined that the physical abuse allegation was substantiated and employee will be terminated. Resident's family has decided to pursue criminal charges and are working with local law enforcement. R2's resident notes history dated 10/03/21, regarding incident with V3, documents under Nurse's Note, Nurse (V3) reports that she attempted to redirect resident because he was being destructive to property. She (V3) reports that he (R2) began scratching her (V3) arms and ramming his (R2) wheelchair into her (V3) and continued coming toward her (V3) when she (V3) attempted to back away. Nurse reports that she (V3) pushed his (R2) wheelchair away to end the conflict. Under resident statement it documents, Resident (R2) stated that this lady came up from behind and started hitting my neck. Then she hit my ear and then my eye. He reports that he was striking back at her in attempt to get her to stop wailing on me. Under witness statement it documents, V7 (Certified Nursing Assistant) was in a room providing care when she heard resident yelling out for help. States that she entered the hallway and witnessed the RN (V3) holding resident by the back of his neck and witnessed her strike the resident in the right eye. She states that she told the RN (V3) that the behavior was unacceptable and at that time the RN (V3) shoved residents wheelchair with force causing it to propel down the hall and almost tip. V7 (CNA) took resident to the other nurse in the building and the abuse policy was initiated. Under immediate action it documents, Alleged perpetrator removed from direct care and suspended pending investigation. Complete body assessment performed. The facility resident (R2) injury history dated 10/03/21 documents the following injury descriptions, left side of neck-superficial scratches, right side of neck- superficial scratches, right eye- redness to corner of eye. R2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .o (year old) male was seen at the nursing facility today for medical evaluation after reports of abuse. Facility reports over the weekend staff member evidently grabbed the resident by the back of the neck leaving scratch marks. The resident does have underlying dementia and is a poor historian. He does not recall the event and is not showing any signs of aggression or signs of post traumatic stress at this point. Under physical examination the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/13/2021 at 11:10 AM this surveyor attempted to interview R2. He was sitting in bed with lower extremities covered. There were no obvious injuries observed to R2's face. Attempted to view R2's neck but R2 did not want me to look at the back of it so this surveyor was unable to determine if the injuries were still visible. R2 was not interviewable. R2 did not appear agitated or afraid during these observations. On 10/13/21 at 11:27 AM, V7 (CNA) stated she was working the night the incident occurred. V7 sated R2 had been up and roaming about the facility pleasant and not agitated since about 10:00 PM that night. V7 stated V3 (RN) came up and insisted R2 go to bed and swung his wheelchair around and took R2's shoes off. V7 stated she (V7) took R2 to bed and within a short time R2 was observed crawling out of his room and into the hallway so V7 assisted R2 into his wheelchair. V7 stated she (V7) was doing bed checks so she (V7) pushed R2's wheelchair close to where she (V7) was working and went into a room to complete a bed check. V7 stated while in the room she heard R2 yell, Help me granddaughter. She's beating me. V7 stated she dropped what she was doing and ran into the hallway where she (V7) observed V3 hitting R2 with the flat side of her (V3) fist. V7 stated she (V7) yelled at V3 to stop and turn him (R2) loose. V7 stated V3 was holding the wheelchair and hit R2 in the eye with her (V3) other hand. V7 stated V3 then shoved R2's wheelchair down the hall so fast that when V7 caught him R2 was almost falling out of the chair. V7 stated she ran to the other nurse's station and told the other nurse (V13/RN) what happened. V7 stated V13 called V2 (Interim Director of Nurses) and V2 arrived to the facility in about 7 minutes and V3 was removed from the facility at that time. V7 stated R2 was with staff until V7 was removed from the facility. V7 stated R2 had marks on his ear, his eye was red and puffy, and there were marks on his neck. V7 stated the local police were called and arrived to the facility within about ten minutes. On 10/14/21 at 9:55 AM V10 (CNA) stated he was working the night of the incident but did not witness it. V10 stated he was at the nurse's station when V7 came running up and said V3 had hit R2. V10 stated R2 very clearly talked about what had occurred. V10 stated R2 described how he was battered on his back, side of his shoulder, side of his head and then on his face across the nose, and onto the eye socket. V10 stated V13 (RN) assessed R2 and you could clearly see the areas he had been hit. On 10/14/21 at 10:58 AM V13 (RN) stated she was working the night the incident occurred. V13 stated all of a sudden V7 (CNA) came running up the hall, she was crying, and said V3 hit R2. V13 stated R2 had some redness around his right eye and on his neck and kept saying she (V3) had hit him. V13 stated she stayed with R2 after the incident was reported to her and V2 arrived to the facility in less than 10 minutes. V13 stated R2 was upset and talked about it for hours after it happened. On 10/13/21 at 11:13 AM V6 (housekeeping/laundry) stated she spoke with R2 the day after the incident occurred (10/4/2021) V6 stated R2 was fired up because she (V3) had hit him. V6 stated R2 was trying to hit a peer and was talking about what had occurred. V6 stated R2 told her she (V3) hit him upside the head. On 10/14/21 at 9:45 AM V12 (CNA) stated she provided care to R2 the day after the incident occurred (10/4/2021). When asked how R2 appeared on 10/4/21 V12 stated R2 was very aggressive. V12 stated R2 thought his roommate was trying to beat him up all day so they moved R2 down the hall to a different room. When asked how R2 did after the move V12 stated R2 wasn't happy and he was talking aggressively. V12 stated R2 kept showing them his pinky finger that had blood around it and his left ear was red. When asked if it was normal for R2 to have aggressive behaviors V12 stated he did when he first moved to the facility but he had not had any recently. V12 stated R2 was in better spirits now than he was the day after the incident occurred. On 10/14/21 at 10:19 AM V2 (RN) stated her title at the time the incident occurred was Interim Director of Nurses. V2 stated she got a call from V13 about 2:00 AM who reported the incident. V2 stated when she got to the facility approximately 10 minutes later V13, V7 and R2 were all together and V3 was outside smoking. V2 sated she met V3 as she was coming into the facility and informed her of the allegation of abuse and that she would be removed from direct care. V3 stated they walked together, counted the narcotics, and then went to her office where she called the local police. V2 stated V3 kept holding her arms out and saying look what he did to me and V2 observed superficial scratches on V3's arms. V2 stated V3 said she was trying to get a baby monitor from R2 and she was trying to protect herself when she shoved his wheelchair away from her. V2 stated V3 was very upset and belligerent. V2 stated after they were finished with the local police they did a thorough skin check on R2 and observed two red areas with scratches on each side of his neck and a slight red mark on his right eye that quickly went away. V2 stated they started the investigation which included interviewing staff and residents, doing skin checks on all of the residents to ensure there were no injuries of unknown origin, and training all staff. V2 stated after they completed their investigation they determined the allegation of abuse was founded so they called V3 and let her know she was terminated. On 10/14/21 at 11:14 AM V14 (family member) stated she was notified by the facility of the incident. V14 stated she saw R2 on the Friday after the incident (10/8/21) and he had some red spotted blood pooled under the skin. V14 stated it looked like bruises/scratched or scraped marks. V14 stated the facility terminated V3 and called the police and she didn't have any concerns with the way the facility handled the incident. V14 stated she had spoke with the police and charges were being filed against V3. On 10/14/21 at 1:45 PM V1 (Administrator) stated she was out of town when the incident occurred and V2 was responsible for investigating the incident. V1 stated V2 notified her of the incident on 10/3/21 at approximately 2:30 AM. V1 stated V3 was trained on abuse and neglect prior to the incident and all staff have been re-trained after the incident. The local police report dated 10/03/21 documents On 10/03/21, at approximately 2:42 AM, the (name of police department) responded to (facility) in regards to staff abuse to a resident. On my arrival, I saw two females standing in front of the entrance to the facility. One of the females approached me and advised she was the Director of Nurses (V2) and was mandated to report the incident. V2 stated she received a call from one of the CNA's, informing her about the incident. Before my arrival, V2 had removed a female .(V3), who was the registered nurse involved in the incident V2 then stated that a CNA (V7) witnessed the end of the altercation and confronted V3 We first spoke with the Victim (R2) who is a resident When R2 was asked about the altercation he went into detail. R2 stated he was sitting at the kitchen table when he confronted a lady who used to work for him. R2 then stated the woman struck him in the back of his neck, struck him in the ear, and then struck him multiple times in the left eye. I observed visible injuries to R2's neck. While describing the actions of the event, R2 was using hand gestures of the motion of someone hitting him in the face. R2 then stated, she whooped my butt. After R2 was finished describing the incident, he was given an orientation test. R2 was asked what year it was currently and who the current President of the United States was? R2 answered the first question with 2000. He answered the second question with yea I don't like the man, he used to work for me We spoke with V7, the CNA who witnessed the incident. V7 stated she was in room . checking on R2's roommate when she heard a male voice yelling form the hall. When she got out in the hall, she witnessed the charge nurse (V3) strike R2 in the face with an open hand. V7 stated that R2 was trying to grab and push V3 away from him. V7 stated she confronted V3 and V3 advised V7 that R2 had hit her first. V7 stated she told V3 to turn R2 loose and with a running start, V3 shoved R2's wheelchair down the hall. V7 advised the wheelchair rolled down the hall, swerving from side to side. V7 stated she grabbed the handle of the chair to stop him and noticed R2 had nearly slipped out of the wheelchair. V7 stated she pushed R2 to the nearest split in the hallway, where R2 was in the open view while V7 went to the nearest nurses station to report what happened. A charge nurse from another hall called and reported the incident to V2, the Director of Nursing . The local police report documents V3 did not want to speak with them without an attorney present and that V14 wished to pressed charges against V3. Located within the local police report is an affidavit of probable cause dated 10/03/2021 that indicates there is sufficient facts to support a determination that V3 probably committed the crimes of aggravated battery and elderly abuse. The facility Abuse, Prevention and Prohibition Policy dated 11/2018 documents under statement of intent, Each resident has the right to be free from abuse, corporal punishment, and involuntary inclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Under Policy it documents, This facility prohibits mistreatment, neglect or abuse of residents .

Based on interview, and record review, the facility failed to accurately identify, assess, treat, and document wounds, report a decline to the physician, and seek timely medical treatment for 2 (R10 and R11) of 3 residents reviewed for wounds in the sample of 27. These failures resulted in an immediate jeopardy, which was identified to have begun on [DATE] when the facility failed to accurately identify and assess a wound and seek timely medical treatment. These failures resulted in R11 developing [CONDITION(S)] of her left foot, causing R11 to be hospitalized on [DATE], and R11's subsequent death from staph bacteremia on [DATE]. This has the potential to affect all 49 residents living in the facility. While the Immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2 as the facility continues to educate staff as needed and evaluate the effectiveness of their interventions. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 11:44 AM. The surveyors confirmed by observations, record review, and interview, that the Immediate Jeopardy was removed on [DATE] but non-compliance remains at Level Two because additional time is needed to evaluate the implementation, and effectiveness of In-service training. Findings Include: 1) R11's admission record with a print date of [DATE] documents R11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's wound weekly evaluation non-pressure assessment dated [DATE] documents an area to R11's left great toe as healed. There are no wound weekly evaluation non-pressure assessments documented after [DATE]. R11's skin check weekly and PRN assessment dated [DATE] documents other to the top of R11's left and right foot. R11's medical record does not document weekly skin assessments after [DATE]. V1 (Administrator) confirmed in email on [DATE] at 6:25 PM the facility did not complete weekly skin assessments on R11 after [DATE]. R11's progress notes document on [DATE] a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's medical record does not document assessment of the area, physician notification, and/or family notification. R11's order summary report dated [DATE] -[DATE] documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's treatment administration record dated [DATE]-[DATE] documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's progress notes document on [DATE] the area to R11's left great toe and left 2nd toe have healed. R11's progress notes document the following; [DATE], .Top of left foot red and painful for resident to wear shoes or socks. Will follow up with MD (physician) in am to report changes in left foot. [DATE], .Resident's top of left foot is red and skin is open. This nurse applied TAO (triple antibiotic ointment) with bordered gauze. Resident's second toe on left foot is not receiving blood flow. Toe is pale and cold to touch. Blood blisters noted underneath toe in crease. Resident states I have a sore toe when observing. Left foot has been wrapped with Kerlix to protect toe from further harm. Will be contacted (sic) MD. R11's telemedicine progress note dated [DATE] documents R11 was seen by V9 (Nurse Practitioner) via telemedicine for a persistent papular rash on her abdomen and back. The telemedicine progress note does not document V9 was notified of the area on R11's left foot and/or an assessment of R11's left foot was completed. On [DATE] at 11:52 AM V9 (Nurse Practitioner) confirmed in interview he had a telemed visit with R11 on [DATE] and had assessed her for a rash. V9 stated there was no documentation in his notes that he was made aware of a wound on R11's foot at the time of the visit. R11's order summary report dated [DATE]-[DATE] does not document an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's progress notes do not document assessment, treatment, physician notification or family notification of the area on R11's left foot until [DATE] (6 days after being identified) when the following notes are documented: [DATE] at 5:10 AM .Residents bandage fell off of her left foot. Top of residents foot has slough with redness. Residents second toe has necrotic tissue on the distal end and purulent drainage near the proximal end [DATE] at 2:14 PM, .Notified by staff that resident's left second toe was black. Second toe with areas of necrosis that extends past base of toe. Some open area on lateral sides. Small amt (amount) bloody drainage noted on bed. Resident's foot is red and edematous. Call placed to V14's (Physician) office. Awaiting return call. Resident asleep while foot examined and remained asleep throughout. [DATE] 2:30 PM, .Resident left foot and toe assessed by this nurse. Necrotic tissue and purulent drainage noted to 2nd toe. Redness to top of left foot noted. Wound care nurse notified. MD notified. No new orders at this time [DATE] 2:54 PM, .This nurse assessed left foot and toe. Necrotic tissue noted to second toe. Redness to top of left foot noted. Wound care nurse notified. MD notified. Resident to be sent to (name of regional hospital) to be evaluated per MD (physician). Ambulance called at 1450. Family notified. [DATE] 9:46 PM, Resident admitted to (name of regional hospital) for [CONDITION(S)] of foot. R11's SBAR (situation background assessment recommendation) communication and progress note dated [DATE] documents R11 has a wound to the left foot and toe that started on [DATE]. R11's transfer form dated [DATE] documents R11 was being transferred to the hospital for abnormal kidney function. This transfer form does not document any skin assessment, concerns, or issues. R11's regional hospital record dated [DATE], documents under history and physical, This is a 90 yr (year) old lady with hx (history) of dementia, dm (diabetes mellitus) type 2, cad (coronary artery disease) who presented to the ed (emergency department) with necrotic appearing left 2nd toe with [CONDITION(S)] and warmth of the foot. She is unable to provide hx but nursing staff at the ED reported the nursing home reported this happened overnight. R11's regional hospital record dated [DATE], documents under imaging results, .findings suggest [CONDITION(S)] of the distal phalanx of the second toe. R11's regional hospital podiatry note dated [DATE] documents, .Patient (R11) is apparently a resident of long term care facility and was sent to the emergency department with necrotic appearing left second toe with [CONDITION(S)] and warmth of the foot; nursing home apparently reported that this event happened overnight. Daughter notes that she was told by nursing facility staff that they have been dressing wound for last 2 weeks with antibiotic ointment. R11's regional hospital notes dated [DATE] document under assessment/plan, Given findings of [CONDITION(S)], options include amputation of second digit versus partial ray amputation vs. TMA (trans metatarsal amputation). Given patients (R11) age, significant dementia, and comorbid conditions patient would likely benefit from conservative measures at this time including antibiotic therapy and local wound care. Also discussed palliative care measures with daughter and she was agreeable. Under hospital course R11's regional hospital record discharge summary documents, The patient is a 90 y. o. (year old) female who presented to (name of regional hospital) with left foot with [CONDITION(S)] and necrosis. Family have ultimately decided upon comfort/hospice care and decline surgery and further antgbx (antibiotic)---only want comfort care for their family. R11's facility progress notes dated [DATE] document R11 returned to the facility on [DATE] under hospice care. R11's progress notes document R11 passed away on [DATE] at 12:59 PM. R11's death certificate dated [DATE] documents cause of death as staph/bacteremia. On [DATE] at 12:45 PM V17 (family) stated R11 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . V17 stated the family was unable to visit due to covid restrictions, so she would call the facility for updates. V17 stated the facility did not mention the area on R11's left foot until R11 was sent to the hospital on [DATE]. V17 stated the toe looked horrible and the physician said there was no way it could have happened overnight. V17 stated they did not think R11 could withstand a surgery, so they decided to put her on hospice. V17 stated R11 passed away the next day. On [DATE] at 11:00 AM V5 (Licensed Practical Nurse/LPN) stated she remembered the area on R11's left foot. V5 stated she contacted the physician on [DATE] and sent R11 to the hospital. V5 stated that was the first day she was aware of the area to R11's left foot. When asked to explain the process when a new area is found, V5 stated, a skin assessment is done, the physician, wound nurse, and director of nurses is notified. V5 stated any new orders from the physician should be put on the treatment administration record. On [DATE] at 3:34 PM V4 (LPN) stated she had communicated on the log there was something going on with R11's left foot. V4 stated R11 declined quickly. When asked what quickly meant. V4 stated within a couple of weeks. When asked about the dressing that was on her foot and the triple antibiotic ointment that was used. V4 stated if there was an area and no order for it the nursing staff would cover it with a dressing until an order could be obtained. V4 stated she would pass the information on to day shift for them to get a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if she remembered the area on R11's left foot, V4 stated R11's foot was red and then black and during that time she declined, stopped eating, and just wasn't doing well. On [DATE] at 1:18 PM V3 (Assistant Director of Nurses) stated R11 always had issues with her left toe. V3 stated the physician always thought it was gout. V3 stated she had worked a midnight shift and made a note about the top of R11's left foot turning red on [DATE]. When asked if the physician was notified V3 stated she gave the information to the day nurse. V3 was unable to find documentation in R11's medical record the physician was notified. V3 stated she was not involved in R11's care from [DATE] until she was transferred to the hospital on [DATE]. On [DATE] at 2:26 PM V12 (LPN) stated she remembered the area on R11's left foot and would have contacted the physician by phone or fax. V12 stated she doesn't remember anything being changed after that and would only have charted notifying the physician if he had made changes. V12 stated she believed they were still using triple antibiotic ointment on the area. When asked if the triple antibiotic ointment should have been documented on the treatment administration record, V12 stated she believed someone had put it on there. On [DATE] V13 (Registered Nurse/Wound nurse) stated she was first made aware of the area on R11's left foot on [DATE]. V13 stated when she was made aware of it, she requested R11 be sent to the emergency room for evaluation because it was obviously something beyond the scope the facility could handle. On [DATE] at 2:55 PM reviewed R11's history with V2 (Director of Nurses). When asked if the areas that were present on R11's left foot at admission had healed prior to [DATE], V2 stated she believed so. When asked if the physician and/or family were notified after R11's left foot became red again on [DATE], V2 was unable to find in R11's medical record the physician and/or family had been notified. V2 was unable to locate in R11's medical record that the physician was notified, and that orders were given for the triple antibiotic ointment used as a treatment to R11's left foot on [DATE]. When asked if she would expect the staff to get a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if she would expect the staff to notify the physician and family when they found a new area V2 stated she would. On [DATE] at 12:14 PM V14 (physician) stated he was not notified on [DATE] of R11's foot being found red and painful, nor was he notified on [DATE] it had become open and triple antibiotic ointment was being applied. V14 stated he was not made aware of any issues until [DATE] when R11 was sent to the emergency department for evaluation. When asked if he had been notified on [DATE] when R11's foot was red and painful, if he would have treated it, V14 stated he would have. V14 stated it was possible the outcome could have been different for R11 if he had been notified on [DATE] and treatment started. When asked if the facilities failure to notify him on [DATE] and again on [DATE] for treatment to begin had led to R11's hospitalization and subsequent death V14 stated That is a fair assessment. V14 confirmed the staph bacteremia listed as the cause of death on R11's death certificate was caused by [CONDITION(S)] of R11's left foot. 2) R10's facility admission record dated [DATE] documents R10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's MDS (Minimum Data Set) dated [DATE] documents under section C, R10 has a severe cognitive impairment and requires extensive assistance with activities of daily living. R10's progress notes document on [DATE] R10 was admitted to the facility on hospice for end of life support. R10's skin check weekly and PRN (as needed) dated [DATE] documents blisters opened to inner thighs, hospice made aware during the day and applied tx (treatment). This assessment documents the blisters are on R10's bilateral inner thighs. R10's progress notes document on [DATE], Resident (R10) continues in hospice care .2 raised fluid filled blisters on left leg inner thigh, bandaged (sic) applied to area, hospice notified . R10's medical record included a telephone order signed by V16 (Physician) on [DATE] with an order date of [DATE]. The order documents, clean wound with cleaner and apply TAO (triple antibiotic ointment), cover with dry dressing daily and PRN (as needed) . This order does not document what wound this treatment is for. R10's treatment administration records dated [DATE]-[DATE] and [DATE]-[DATE] do not document a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's progress notes document on [DATE] .padding applied to areas of water blisters on inner thigh, and on [DATE], water blisters noted to inner thigh. R10's progress notes do not document any further assessment or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's skin check weekly and PRN dated [DATE] documents water blisters and sores to bilateral inner thighs. R10's skin check weekly and PRN dated, [DATE], [DATE], and [DATE] document water blisters to bilateral thighs. R10's skin check assessments do not document treatment, family notification, and/or physician notification of the blisters to R10's inner thighs. R10's pressure ulcer weekly wound evaluations dated [DATE] through [DATE] do not document blisters to R10's thighs. R10's wound weekly evaluation non-pressure assessments dated [DATE] and [DATE] do not document blisters to R10's thighs. R10's medical record does not document assessment or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's medical record does not document if and/or when the blisters to R10's thighs healed. On [DATE] at 11:00 AM V5 (Licensed Practical Nurse/LPN) stated she remembered blisters on R10's thighs and speaking with hospice concerning them but she does not remember being given any treatment orders for the blisters. V5 stated it should be documented in R10's progress notes. On [DATE] at 2:26 PM V12 (LPN) stated she remembered blisters on R10's thighs that came and went a little bit but was unable to recall if there was a treatment being done. On [DATE] at 2:02 PM V13 (Registered Nurse/Wound nurse) stated she did not remember the blisters on R10's thighs. V13 stated she was not involved in getting or changing treatment orders for R10. On [DATE] at 2:55 PM V2 (Director of Nurses) stated she was unable to locate in R10's record, R10's family being made aware of the blisters on R10's thighs. When asked if she would expect to see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 confirmed she would also expect to see assessment of the blisters to R10's thighs in R10's medical record. On [DATE] at 5:01 PM V16 (Physician) stated he remembered R10 having wounds but was unable to recall specific details about the blisters on R10's thighs. V16 stated any orders he would have written would be part of R10's facility record. V16 stated R10 was being provided end of life care and any wounds R10 had would not have been preventable. On [DATE] at 2:55 PM after reviewing the order from [DATE] and R10's ,d+[DATE] and ,d+[DATE] treatment administration records, V1 (Administrator) stated she was unable to locate documentation R10's treatment order for triple antibiotic ointment was administered. The facility wound assessment policy dated ,d+[DATE] documents, It is the policy of the facility to assess each wound initially either at the time of admission or at the time the wound is identified. Each wound will be assessed weekly thereafter or with any significant change noted in the wound. Under procedure the wound assessment policy documents, The designated Wound Care Nurse will assess each wound using the guidelines established below and will document the findings. The guidelines listed include potential etiology, classification of wound, anatomic location, size, drainage, pain, peri wound skin condition, and odor. The facility significant condition change and notification policy (not dated) documents the purpose of the policy is to ensure the resident's family and medical practitioner are notified of resident changes such as new wounds, bruises or skin tears .onset of swelling .skin discoloration. Under procedure the policy documents, .Calls will be made to the resident's representative until they are reached .The medical practitioner will be contacted immediately for any emergencies .Non-emergency notification may be made the next morning if the situation occurs on the late evening or night shift Each attempt will be charged as to the time the call was made, who was spoken to, and what information was given to the medical practitioner .If after two attempts, there is no response to the calls, the medical director will be contacted. The facility significant condition change and notification policy (not dated) documents under Documentation .Charting will be done each shift for residents with change of condition until condition is controlled resolved or the resident is transferred or discharged . Charting will include a complete assessment of the resident's current status as it relates to the change in condition and will include observations of the resident for pain or discomfort. An Immediate Jeopardy was identified to have begun on [DATE] when R11 developed redness, and pain to the top of the left foot, and timely medical treatment was not obtained, ultimately resulting in R11's death from staph bacteremia. V1, Administrator was notified of the Immediate Jeopardy on [DATE] at 11:44 am. On [DATE] the surveyor confirmed through observation, interview, and record review, that the facility took the following actions to remove the Immediacy: The Administrator and the DON have initiated training of all nursing staff on the identification, assessment, notification, documentation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] CNA's will observe for changes in skin integrity while providing cares and report to the charge nurse. Nurses will complete weekly skin checks. Any identified areas will be assessed, documented and the provider notified for any newly identified areas or changes or decline in existing areas. Anytime there is a newly identified area or change in skin integrity, the provider will be notified of the assessment change and documented. Documentation of assessment to be completed by the nurse for identified changes in skin integrity Treatment orders obtained for all skin conditions and placed on TAR for nurses to complete treatments Friday [DATE] 100% completed No staff will be, or have been allowed to work without being educated. Education in above items was based on enforcement of current policies and procedures. No revisions or new policies and procedures were implemented. The facility nurse managers have initiated on [DATE] a 100% audit of all resident's skin to ensure that all areas have been identified. Any newly identified areas will be assessed and called to the provider and orders obtained. This audit was completed on [DATE] The facility nurse managers will complete a 100% audit of all orders to ensure that all identified areas have an order in place. This audit was completed [DATE] A special QAPI Meeting will be scheduled immediately with the facility Medical Director to review this issue and the plan of action for correction of this deficiency. This is scheduled for [DATE] at 4:00 PM. Date of final Completion - [DATE] @ 5:00 p.m. Ongoing: Nursing management will review documentation daily to ensure any identified areas of skin concerns have been assessed and called to the provider and orders obtained. Nursing management will review weekly skin checks for any newly identified skin conditions or changes in existing skin condition to ensure assessment completed, provider notified, documentation completed and treatment in place. Nursing management team will review all residents with wounds at least weekly to ensure appropriate identification, assessment and treatment completion. This review will occur in the Care Management Systems Meeting.

Based on observation, interview, and record review the facility failed to identify, notify the physician timely, treat appropriately, isolate, and prevent the spread of an infestation of scabies for 5 of 5 (R2, R3, R5, R6, and R13, ) residents reviewed for infection control in the sample of 27. These failures resulted in psychosocial harm for R5, in that, a reasonable person would react with inability to sleep, agitation, anxiety, frustration, and restlessness when having a rash that was characterized by intense itching that is often worse at night that goes untreated. Findings Include: 1. R5's facility admission record dated 8/24/2020 documents an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's MDS (minimum data set) dated 8/18/2020 documents a BIMS (brief interview for mental status) score of 10, which indicates a moderate cognitive impairment. R5's progress notes document; 6/27/2020 Resident c/o (complains of) itching on right side. Skin rash noted to right side on ABD (abdomen). [MEDICATION(S)] cream applied. Resident stated cream did give her some relief. Resident denies pain at this time. Will continue to monitor. 7/4/2020 Resident is continuously yelling that her sides and back are itching. This nurse has applied half a tube of [MEDICATION(S)] cream to resident and gave resident Benedryl (sic). Resident continues to yell at this nurse while in the room applying cream. 7/6/2020 Notified MD (physician) of resident's rash and request to treat with [MEDICATION(S)] cream. New order received. 7/8/2020 Resident treated with [MEDICATION(S)] cream last night for rash to body. Was given a shower today and bed sanitized and cleaned. Will continue to monitor progress of rash. 7/14/2020 [MEDICATION(S)] cream applied this shift to resident from neck to soles of feet. Resident tolerated tx (treatment) well. Will continue to monitor. R5's skin check weekly and PRN dated 7/11/2020 documents rash to upper body and treatment applied. R5's medication review report dated 6/1/2020 to 6/30/2020 does not document physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] R5's medication and treatment administration records dated 6/1/2020 to 6/30/2020 does not document physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] R5's care plan with a print date of 8/24/2020 does not document a focus area of rash. R5's medical record does not document R5's physician was notified of the rash and itching from 6/27/2020 until 7/6/2020 when orders for [MEDICATION(S)] cream were obtained. R5's medication review report dated 7/1/2020 to 7/31/2020 documents orders for [MEDICATION(S)] cream 5% apply one time with start dates of 7/7/2020 and 7/14/2020, [MEDICATION(S)] injection one time only with a start date of 7/21/2020, and [MEDICATION(S)] lotion apply to areas for itching with a start date of 7/29/2020. R5's 7/1/2020 to 7/31/2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's progress notes document; 8/3/2020 Small open areas noted to resident's chest on left side from scratching d/t (due to) itchiness. Some blood drainage noted. Areas cleansed and TAO (triple antibiotic ointment) applied . 8/6/2020 Resident c/o (complained of) itching under neck this morning. [MEDICATION(S)] cream applied. Resident stated relief of itching at this time. No complaints from resident at this time. Will continue to monitor. 8/10/2020 .She has had a rash on her chest but we have been putting cream on it to help it heal Overall her mood has been doing well besides some itching from the rash she had on her chest. 8/12/2020 Resident c/o itching on left upper chest and neck area this shift. [MEDICATION(S)] cream applied. No complaints from resident at this time. Will continue to monitor. On 8/14/2020 R5 was observed in her bed with V5 (Licensed Practical Nurse) and V11 (Certified Nursing Assistant) present. R5 was observed to have scratch marks with bumps on her upper arms and chest area. R5 stated the areas itched very badly. R5's medication review report dated 8/1/2020 to 8/31/2020 does not document physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's 8/1/2020 to 8/31/2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's medication administration and treatment administration records do not document any other orders for a rash/itching skin in the month of 8/2020. R5's skin check weekly and PRN dated 8/22/2020 documents scabbed over bumps on chest and left upper arm. On 8/21/2020 at 11:00 AM V5 (Licensed Practical Nurse) stated she had provided care to R5 over the past couple of weeks and R5 had little open areas she had complained of itching and been scratching. Reviewed R5's progress notes that document R5 complained of itching and [MEDICATION(S)] cream was used from 8/6/2020 and 8/13/2020. When asked if R5's physician had been notified R5 was continuing to itch and if there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V5 stated R5's doctor requires V2 or V3 contact them. When asked if she remembered reporting to either V2 or V3, R5 was continuing to itch, V5 stated she had reported it to V3 (Assistant Director of Nurses) and she believed R5 had gotten a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/21/2020 at 1:18 PM V3 (Assistant Director of Nurses) stated she had not been involved in the care of R5's rash. R5 stated she had not taken any orders from R5's physician and the nurses would be the ones who would get orders. On 8/20/2020 at 2:26 PM V12 (Licensed Practical Nurse) stated she was not aware of R5's physician being notified the rash continued and if new treatment orders had been obtained. On 8/21/2020 at 2:55 PM V2 (Director of Nurses) stated she would expect the physician to be notified and an order received and put in the system for [MEDICATION(S)] and for the [MEDICATION(S)] cream. When told R5 was observed scratching V2 stated she had observed R5 and did not see a rash. When asked if the physician had been notified of the continued itching V2 stated she did not see where the physician had been notified. On 8/25/2020 at 11:52 AM V9 (Nurse Practitioner) stated he had seen R5 in person a few weeks ago. V9 stated he would expect to be notified prior to the facility administering [MEDICATION(S)] cream and/or [MEDICATION(S)]. V9 stated those are over the counter medications however in the long term care world they would need a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V9 stated he was reviewing notes and he did not see that he had been notified of a rash or itching skin. When asked if he would expect the facility to notify him if the treatment was not working V9 stated, Yes. On 8/28/2020 at 9:34 AM V21 (family member) stated she was told R5 had scabies by a facility nurse (not named). V21 stated she visited with R5 every night from the dining room window and could see her mom was scratching and it was driving her nuts. V21 stated R5 had extreme intense itching and itching in places she couldn't scratch. V21 stated R5 now has scars on her neck and her chest from scratching. V21 stated the itching was keeping R5 awake at night and R5 suffers from anxiety anyway and the itching was stressing R5 out. 2. R13's facility admission record dated 8/24/2020 documents R13 was admitted to the facility on [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's MDS (Minimum Data Set) dated 8/4/2020 documents R13 has a BIMS (Brief Interview for Mental Status) score of 5, which indicates R13 has a severe cognitive impairment. R13's progress notes dated 6/24/2020 documents; 5:10 AM, Resident came to nurses station scratching at his abdomen intensely. Took resident to his room to assess him. Resident has very flat red rash to his groin, abdomen, arms, neck, and back. Applied [MEDICATION(S)] cream to all areas listed. MD (physician) made aware via fax, will continue to monitor. 11:07 AM, Skin assessment on resident. Flat red rash noted to ABD (abdomen), lower back, groin, and arms bilaterally. Resident complaining of itching. [MEDICATION(S)] cream applied. MD notified via fax. No new orders at this time. Will continue to monitor. R13's skin check weekly and PRN (as needed) dated 6/26/2020 documents flat red spots with redness surrounding area on R13's chest, vertebrae, and bilateral arms. This assessment documents the areas are not new, there was no documentation if an order was obtained to treat the areas and no documentation of physician and/or family notification on this assessment. R13's progress notes dated 6/27/2020 document, skin rash noted to neck, abd (abdomen) and bilateral upper arms. Resident seen itching at areas. [MEDICATION(S)] cream applied. Resident denies pain. Will continue to monitor. R13's treatment administration record and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] R13's progress notes document on 7/1/2020, skin rash noted to bilateral arms, chest and abd. (abdomen) Resident c/o (complains of) itching. [MEDICATION(S)] cream applied. Will continue to monitor. R13's skin check weekly and PRN dated 7/3/2020 documents red raised bumps to face, chest, bilateral arms, abdomen, and groin area with no documentation order was obtained or R13's physician or family were notified. R13's medical record does not document R13's physician was followed up with to ensure orders were obtained after the physician was notified of R13's rash/itching on 6/24/2020 and 6/27/2020, until 7/6/2020. On 7/6/2020 R13's progress notes document R13's physician was notified, and an order was received to treat the rash with [MEDICATION(S)] cream. R13's progress noted dated 7/8/2020 and 7/14/2020 document R13 was treated with [MEDICATION(S)] cream as ordered by the physician. R13's skin check weekly and PRN dated 7/17/2020 does not document an assessment of the red raised areas/rash on R13's upper body. R13's skin check weekly and PRN dated 7/24/2020 documents small red spots to entire body with no documentation related to an order being obtained, physician notification, and/or family notification. R13's skin check weekly and PRN dated 7/25/2020 documents no new changes this week. R13's progress notes dated 7/25/2020 documents, Red raised areas noted to chest and abd on resident this shift. Resident seen itching and resident c/o itching. [MEDICATION(S)] cream applied. Will continue to monitor. R13's progress note dated 7/29/2020 documents, Skin rash noted to bilateral arms and ABD. Resident c/o itching and resident seen scratching areas. [MEDICATION(S)] cream applied. Will continue to monitor. R13's progress notes do not document R13's physician was notified of continued rash and itching. R13's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's treatment administration record dated 7/1/2020-7/31/2020 does not document treatments to the rash/itching on R13's abdomen. R13's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's skin check weekly and PRN dated 8/1/2020 documents continues with rash to entire body with no new orders documented and no notification to physician or family documented on this assessment. R13's medical record does not document R13's physician was notified of the continued rash/itching after R13 was treated with [MEDICATION(S)] cream on 7/14/2020 until 8/1/2020 when R13's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's skin check weekly and PRN dated 8/8/2020 does not document an assessment of the rash. R13's progress note dated 8/12/2020 documents, Resident c/o itching on bilateral arms this shift. [MEDICATION(S)] cream applied and effective. No complaints from resident at this time. Will continue to monitor. R13's skin check weekly and PRN dated 8/15/2020, and 8/22/20 documents an improving rash on R13's chest. R13 was observed on 8/14/2020 at 10:08 AM with V5 (Licensed Practical Nurse/LPN) present. R13 was noted to have small round red areas on his abdomen. R13 stated they itch and began to scratch his abdomen and then his arms. R13 stated he has had the areas for a few weeks now. V5 stated she believed they were treating the areas with [MEDICATION(S)] cream. R13's progress notes document: 8/22/2020 6:00 AM Resident c/o itching of chest and arms while having cath (urinary catheter) changed out. Noted to have red rash on chest and arms. Will notify oncoming shift. 8/22/2020 10:26 AM, Resident c/o itching. Resident was scratching chest and bilateral arms. MD notified via fax along with current medication list at 1026. No new orders at this time. 8/24/2020 10:35 AM Received call from V23's office in regard to resident's rash. New orders received and implemented. R13's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's care plan with an initiation date of 1/8/2020 does not document a focus area of rash/itchy skin. On 8/21/2020 at 11:00 AM V5 (Licensed Practical Nurse) stated R13 had not had a rash lately. When asked if she had seen the red spots on his abdomen and seen him scratching at his arms on 8/14/2020 at 10:08 AM during the observation of his skin. V5 stated she had. When asked if there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V5 stated she faxes the physician and lets them know what she has used to treat the areas and the physician usually faxes back an ok. When asked if she would then put the order on R13's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/20/20 at 3:34 PM V4 (Licensed Practical Nurse) stated she was the one who blew the lid on the rash. V4 stated it started with R10 and then spread to other residents. V4 stated some of the residents were infested. V4 states the facility did clean the rooms and sanitize the beds but they did not do anything with the resident clothes. V4 stated she was not aware of any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/20/2020 at 2:26 PM V12 (Licensed Practical Nurse) stated she was aware of the rash on R13. When asked if she had used [MEDICATION(S)] cream to treat the rash V12 stated she believed she had. When asked where she would have documented that V12 stated she would have put it on the progress notes. When asked if she would document it on the treatment or Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . V12 stated she thought it was a routine thing for residents who were itching to be treated with [MEDICATION(S)] cream. V12 stated there are tubes of the cream in the treatment cart with the resident's names on them. When asked if the tubes had a pharmacy tag on them V12 stated the resident's names are handwritten on the tube in marker. On 8/21/2020 at 1:18 PM V3 (Assistant Director of Nurses) stated on 6/24/2020 R13's physician communication form was sent to R13's physician. When asked if the physician responded on the communication form with new orders, V3 stated she was unable to locate physician a response from the physician with orders. On 8/21/2020 at 2:55 PM V2 (Director of Nurses) stated she did not know why there was a delay in notifying the physician and getting treatment orders for the rash. V2 stated R13 was clear of a rash around the 12th or 13th of August and V2 was not aware R13 had a rash currently and was itching. V2 stated the last physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/25/2020 at 11:21 Am V10 (Nurse Practitioner) stated she was familiar with R13 and the rash. V10 stated R13 was treated on 7/31/2020 with [MEDICATION(S)] cream and the physician office received a fax over the weekend (8/22/20-8/23/20) notifying them R13 was still itching. V10 stated they notified the facility of new orders for R13 on Monday (8/24/20) when they viewed the fax. V10 stated she had been to the facility after R13 had been treated on 7/31/2020 and had been told the rashes had resolved. 3. R2 is a [AGE] year old resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Health Status Note by V4 LPN (Licensed Practical Nurse) dated 6/21/20- 2:20 AM documents physician was notified via fax of a rash to R2's body. No description or location of the rash is given in this note. A Health Status Note dated 6/22/20 2:49 PM by V5, LPN documents a skin rash to R2's abdomen and lower back and physician notified. There was no documentation of physician response and no new orders received from either the 6-21 or 6-22-20 notification. V5 documented on 6/27/20 2:26 PM that R2 had complaints of itching on her abdomen with a skin rash noted to her abdomen and bilateral arms. V5 documented she applied [MEDICATION(S)] cream to the areas and would continue to monitor. R2's June 2020 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8-21-20 at 11:00 AM V5, LPN verified putting [MEDICATION(S)] cream on R2's rash for itching but was unable to verify having obtained or seen a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The next documentation about R2's rash was a 7-3-2020 Skin Check Weekly assessment form documenting a rash on R2's chest, abdomen and bilateral arms. The was no further documentation of a rash until 7/6/2020 when a progress note, documented by V2, DON at 4:34 PM states that the medical doctor was notified of resident's rash and a request for treatment with [MEDICATION(S)] cream was made with an order received for its use. A 7-6-2020 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse progress notes document R2 was treated with the [MEDICATION(S)] cream to her entire body on the evening of 7/7/2020. The next time the record mentions the rash is on a 7-10-20 Skin Check Weekly assessment form which notes a rash to R2's upper body but with no further description and no follow up as to R2's response to the application of the cream for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A 7/14/2020 11:45 PM Health Status Note documents R2 received a 2nd treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . No description of R2's skin or a rash is given at the time of this 2nd treatment. The record notes a physician telephone order dated 7-14-20 where V10 gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The July 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no follow up documentation to R2's response to the [MEDICATION(S)] injection. On 7/17/20 a Skin Check Weekly form documents a 'rash over most of R2's body, again with no actual description. Further weekly skin check assessments document a healing brown rash (on 7-24-20), and small red raised spots on back, sides, chest and arms (on 7-31-20). As of 8-28-2020, no further documentation was noted regarding a rash. V5 stated on 8-21-20 there were 2 residents on her usual wing who were still complaining of some itching but R2 was not one of them and believed R2's rash had resolved. R2 was observed and stated on 8-13-20 at 3:30 PM that she wasn't having any problems with itching or a rash but did have it a month ago and they greased us up like pigs. R2 pulled her sleeve up and stated see, that's where it was and an observation was made of what appeared to be dark colored linear scarring on R2's skin. A 7-7-2020 MDS documents R2 is moderately cognitively impaired. 4. R6 is a [AGE] year old resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Health Status Note entry by V4 LPN (Licensed Practical Nurse) dated 6/21/20 with a time of 2:19 AM documents R6's physician was notified via fax of a rash to R6's body and waiting for a response. V4 documented on 6/24/20 3:13 AM that R6 had woke up at 3 AM complaining of itching and an assessment revealed that R2 still had a rash covering the majority of her body. This note stated the rash was heavily noted on hands, back of bilateral arms, and upper thighs and V4 applied [MEDICATION(S)] cream to R6 and changed her gown and noted that the medical doctor had been made aware of skin issues. On 8-20-2020 3:30 PM, V4 stated that there were tubes of the cream given to the nurses by V2, Director of Nurses and nurses were instructed to use it on the residents with rashes and itching. V4 was unable to verify there was a signed order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no order found on the June 2020 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/24/2020 11:00 AM V5, LPN documented in nurse progress notes R6 was complaining of itching, a rash was noted, and [MEDICATION(S)] cream was applied. There is no documentation of description of or locations of a rash. V5 documented R6 had indicated some relief from itching and the medical doctor was notified via fax with no new orders at that time. V5 verified on 8-21-2020 at 11:00 AM, that she had applied [MEDICATION(S)] cream to R6's rash areas but was unsure of an actual order for R6 but thought maybe it was a standing order that some of the doctors have. A physician notification fax dated 6-24-2020 (no time) by V5 documents V23, Physician was notified of the rash and itching and includes a handwritten, signed order sent back by fax from V23 for a 1 time injection of [MEDICATION(S)] and to start a [MEDICATION(S)] dose pack on 6-26-20. The fax is dated with a receive date of 6-25-20 10:10 AM. These orders were not transferred to the June 2020 POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 stated on 9-2-2020 at 9:00 AM she had been unable to find documentation of these two medications being given. On 6/27/2020 2:27 PM V5 documented in the nurse progress notes that R6 had a skin rash noted to bilateral arms, complaints of itching and [MEDICATION(S)] cream applied with continued monitoring. There was no further update to the physician regarding a rash until 7/6/2020 4:38 PM, when V2, RN documented that V23 was notified of R6's rash with a request to treat with [MEDICATION(S)] cream and noted an order was received. On 7/8/2020 12:56 PM, V4 documented R6 was treated with the [MEDICATION(S)] cream the previous evening around 11 PM. The next nurse progress note related to the rash is a 7/14/2020 11:46 PM note by V4, documenting a 2nd treatment with [MEDICATION(S)] cream applied to R6, however no description of a rash is given. A Skin Check Weekly assessment of 7-10 -20 documents a rash on R6's upper body and a 7-17-2020 skin assessment documents a rash over most of R6's body. As of an 8-28-2020 record review, there was no further mention of a rash in R6's record after the 7-17-20 assessment. On 8-14-2020 at 10:15 AM, R6 was observed standing at the doorway of her room on 200 hall. R6 was asked if she was having any problems with her skin being itchy. R6 stated that she had a previous problem, but it was better now. When asked if the itching had bothered her much, R6 stated it had more at night but not anymore. R6's 7-6-2020 MDS indicates moderate cognitive impairment. 5. An 8-25-2020 MDS assessment notes R3 is an [AGE] year old resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/18/2020 1:55 PM, V5 LPN documented in nurse progress notes R3 was started on a [MEDICATION(S)] dose pack due to a rash and notes a mild rash on R3's abdomen with R3 denying pain. A 6-17-2020 telephone order for the [MEDICATION(S)] medication was noted. There was no additional documentation found in R3's record prior to this describing a rash. A 6-19-2020 hospice note visit documents Skin clean, dry, and intact, rash noted to bilateral arms and abdomen. Pt started on [MEDICATION(S)] Dose Pack on 6/18/20 . There is further documentation of rash being present on 6-21-2020 and 6-23-20 nurse notes, with an order received for the use of [MEDICATION(S)] cream to rash on the 6-23-2020 documentation. A 6-24-20 nurse progress note documents a flat red rash noted to R3's abdomen and lower back with the [MEDICATION(S)] cream applied and continue to monitor. Nurse progress notes from 6-27-20 thru 7-2-20 continue to mention the presence of a rash with no further physician updates until a 7/6/2020 3:53 PM physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse progress notes document the [MEDICATION(S)] cream was applied on the night of 7-7-2020. There is no documentation of a response to the treatment or further mention of a skin rash or of the rash resolving. A 7-14-2020 note documents a second application of the [MEDICATION(S)] cream and again, no further documentation assessing a rash or of the rash having resolved was found in R3's record. R3 was observed on 8-14-2020, 10:20 AM sitting in a reclined, wheeled chair in front of nurse's station on 100 hall. R3's right arm was exposed to above elbow and no evidence a rash was noted. There were no observations of R3 scratching herself. R3's MDS of 6-1-2020 documents R3 as severely cognitively impaired. On 8/21/2020 at 2:55 PM V2 (Director of Nurses) stated the facility had ten or so residents come up with a rash. Not the same rash and none of them were in the room with each other. V2 stated they checked rooms, laundry detergent, shower gels and could not find a common denominator. V2 stated they checked for bed bugs and had three practitioners look at their residents and none of them would give the facility a definitive diagnosis. V2 stated that V10 recommended treating them with [MEDICATION(S)] cream since no one knew what it was. When asked if there was any tracking in place for the rashes, V2 stated it was just on the nurse manager log. When asked if there should have been a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if families were made aware residents were being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/25/2020 at 10:05 AM V1 (Administrator) stated she did not believe the facility had any formal tracking on the rashes. V1 stated they had received a call from the community stating the facility had scabies and they discussed it but did not think it was scabies. V1 stated R11 was the only resident whose roommate had a rash and they didn't have any staff who could or would verify they had been diagnosed with scabies. V1 stated the reason the facility did not follow their infection control policy related to scabies was because they did not think it was scabies. V1 confirmed she would expect staff to follow up with the physicians if they did not get a response back from them and residents were having continued problems. On 9/2/2020 at 4:18 PM V1 (Administrator) confirmed the facility had not washed the linens in hot water, bagged the linens prior to taking them out of the room, ensured the laundry staff wore gloves and gown while washing the linens, and bagged non-washable items for a period of three days. V1 stated they did not follow the policy for scabies because they were unaware it was scabies until the surveyors were in the building and they received documentation back from the nurse practitioner with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/25/2020 at 11:21 AM V10 (Nurse Practitioner) stated she was familiar with the rash several of the residents at the facility had. V10 stated she initially got a faxed message from one of the nurses at the facility on multiple residents. V10 stated she told the facility at that time there was a limited number of things it could be . scabies, bed bugs . V10 stated they ordered a steroid injection and maybe some cream. V10 stated the rash did not resolve so she went to the facility to see the residents and told the facility it was scabies. V10 stated she ordered [MEDICATION(S)] cream and she instructed them on washing all linens in hot water, washing clothes, and putting pillows in the dryer. V10 stated she advised the facility to notify the other physicians so they could treat all the residents at once. V10 states she felt the facility did not want to list it as scabies because it would get reported. V10 stated any resident who is in a room with someone with a rash should be treated. The facility Infection Prevention and Control Manual under General policies dated 2019 documents the following under, Scabies .Human scabies is caused by an infestation of the skin by the human itch mite .The microscopic scabies mite burrows into the upper layer of the skin where it lives and lays its eggs. The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged; skin-to-skin contact with a person who has scabies. Under management of residents the policy documents, If a resident is suspected of having scabies: a. Notify Infection Preventionist or Charge Nurse/Supervisor, b. Contact primary physician, b (sic). Contact precautions with a private room, if possible, until scabies is ruled out or if confirmed until 24 hours after treatment. C. Staff must wear gloves & gown when in direct contact with infested area(s) until 24 hours after treatment. d. If scabies is confirmed and the resident had a roommate, contact roommate's physician for further orders. Under Contact Investigation post confirmation of diagnosis, the poli

Based on record review and interview, the facility failed to notify the physician, residents legal representative and/or interested family member in a timely manner of a change in condition, and/or of a pharmacy consult drug interaction concern for 3 of 15 residents ( R3, R5, R15) reviewed for physician notification in the sample of 15. This failure resulted in R15 being transferred to local hospital. The findings are: 1. R15's Vital Summary for [DATE] for [DATE] at 2:31 AM shows R15's pulse was 56 (irregular-New onset). No documentation could be found that R15's doctor, Power of Attorney or family was made aware of new onset of irregular, low heart rate. R15's Health Status note on [DATE] at 2:30 AM shows resident was having wet sounding cough and complained of hard time breathing and was experiencing chest pain that was continuous and non-radiating and in the center of her chest and held her right hand in a fist over the area at mid-neck line between her breast. R15 stated she felt like she should go to the hospital. Nurse did not send R15 to hospital at that time but gave R15 an antacid and informed R15 that chest pain may subside in a few minutes. R15's documents go on to show that the nurse went back to the nurse station to resume charting. CNA(Certified Nursing Assistant) went back to check on R15 per nurse request and when CNA entered room came back out and summoned nurse. When nurse arrived R15's eyes were open and her gaze was becoming fixed, weak pulse at 2:50 AM CPR(Cardiopulmonary Resuscitation) and chest compressions were started and continued until Emergency Medical Services arrived. This document goes on to state that hospital informed facility of R15's death at 3:44 AM. There was no documentation found in R15's chart regarding making her doctor, Power of Attorney or family aware of changes in condition and her request to go to the hospital. R15's mental assessment done on [DATE] is a 15 out of 15 which makes her capable of making her needs known and making her own decisions for her care. On [DATE] at 11:00 AM Z1(Primary Care Physician) stated the expectation would be that the staff would notify him or someone from his office if there was a change in the resident and/or if there was a change in the normal status of a resident or their condition. Z1 stated the facility will notify him often of different things by fax and call him but could not remember being made aware of R15's irregular 56 heart rate on [DATE]. Z1 stated the notification would not have necessarily changed the outcome of R15 having a [MEDICAL CONDITION] and subsequent death on the early hours of [DATE], because R15 had such a long extensive history of cardiac and [MEDICAL CONDITION] issues. On [DATE] at 4:00 PM, E4(Corporate Nurse) stated the expectation is that if there's a change in condition in a resident then the nurse should be notifying the doctor and the POA(Power of Attorney). E4 stated the nurse that had taken care of R15 in the early morning of [DATE] and [DATE] should have called and made the physician aware of R15's condition. E4 stated she had spoken to the nurse that had taken care of R15 on the night of [DATE] and it was also the same nurse that took care of R15 on [DATE]. E4 stated she had asked the nurse why she had not notified the doctor of R15's irregular pulse on [DATE] and E4 stated the nurse did not have an answer. E4 stated she also asked the nurse if on the early morning of [DATE] had she taken vital signs, assessed her lungs, or if the nurse even did a general assessment or why she did not send R15 to the hospital at that time of her request. E4 stated the nurse could not answer any of those questions's when asked. E4 stated this nurse no longer worked for the facility because she was terminated for not following policies and procedures. 2. R3 is a [AGE] year old resident with [DIAGNOSES REDACTED]. R3's record included 2 documents from the pharmacy, titled Drug Interaction Information, with dates of [DATE] and [DATE]. Both documents indicate that R3 was receiving [MEDICATION NAME] which may interact with another medication- Quetiapine [MEDICATION NAME], that R3 was also taking. The documents indicate that there is a risk for adverse interaction at a Level 2- Severe Interaction, when these two drugs are used concomitantly. As of [DATE], R3 was continuing to receive these two medications at the same dosage as when the pharmacy addressed the concern. There is no indication in the record that Z3, R3's Primary Care Physician was made aware of this risk as recommended by the consulting pharmacy. On [DATE] at 11:00 am, E2-Interim Director of Nurses, verified that Z3 had not been notified of the drug interaction risk, prior to [DATE]. 3. R5's physician's orders [REDACTED]. R5's medical record contains a document dated [DATE] with heading of Omnicare Pharmacies Drug Interaction Information and states the following: R5 is currently receiving Donepezil 10 mg which may interact with the new order for [MEDICATION NAME] 1mg. Severity Level: 2 Severe Interaction : Action is required to reduce the risk of severe adverse reaction. Please review for appropriate action and place this document in the resident's clinical record. After the surveyor made E2 aware of this issue, a Progress Note dated [DATE] at 9:19 am was presented that states, Z1's, (R5's physician) office made aware of the potential medication interaction between [MEDICATION NAME] and [MEDICATION NAME]. Pharmacy recommendations faxed to office for review. Waiting return physician call. R5's Medication Administration Records for the months of March, April, and May, 2016 indicate that R5 is currently receiving both medications and has been since [DATE].

Based on interview and record review the facility failed to educate residents, family and esentatives regarding the Food and Drug Administration (FDA) black box warnings for 2 of 5 residents (R2, R3) reviewed for antipsychotic medications in a sample of 15. In addition, the facility also failed to provide identified nursing services for one resident (R15) reviewed for nursing services in the sample of 15. This failure resulted in R15 being transferred to local hospital. The findings include: 1. According to the Admission Record, R2 is [AGE] years old, indicating she is geriatric, and has [DIAGNOSES REDACTED]. R2 is prescribed [MEDICATION NAME], an antipsychotic, 0.25 milligrams (mg) one tablet BID (twice a day) on [DATE] for a [DIAGNOSES REDACTED]. This medication has a FDA (Federal Drug Administration) Black Box Warning which includes the information that this medication, when used in dementia related [MEDICAL CONDITION] is not an indicated use and is associated with an increased risk of death. R2's Consent for Psychoactive Medication Therapy form for [MEDICATION NAME] 0.25 mg indicates R2's Power of Attorney for Healthcare gave phone verbal approval on [DATE] however, does not list any of the above FDA's Black Box Warning information. There was no education noted in R2's record regarding potential risks/side effects of the use of these medications being discussed with R2's family or R2. E2, Interim Director of Nurses, verified on [DATE] at 10:00 am that there was no evidence that the FDA Black Box Warning education was shared with residents/next of kin/POA or documented on the Consent forms. 2. According to the Admission Record, R3 is [AGE] years old, indicating she is a geriatric, and has [DIAGNOSES REDACTED]. R3 is prescribed [MEDICATION NAME], an antipsychotic, 25 milligrams (mg) one tablet TID (three a day) on [DATE] as noted on R3's Physician order [REDACTED]. This medication has a FDA (Federal Drug Administration) Black Box Warning which includes the information that this medication, when used in dementia related [MEDICAL CONDITION] is not an indicated use and is associated with an increased risk of death. R3's Consent for Psychoactive Medication Therapy form for the [MEDICATION NAME] indicates R3's Power of Attorney for Healthcare gave phone verbal approval on ,[DATE] 2016 however, it does not list any of the above FDA's Black Box Warning information. E2, Interim Director of Nurses, verified on [DATE] at 10:00 am that there was no evidence that the FDA Black Box Warning education was shared with residents/next of kin/POA or documented on the Consent forms. 3.R15's Vital Summary for [DATE] for [DATE] at 2:31 AM shows her pulse was 56 (irregular-New onset). No documentation could be found that R15's doctor, Power of Attorney or family was made aware of new onset of irregular, low heart rate. R15's Health Status note on [DATE] shows at approximately 2:30 AM resident turned on her call light. A CNA(Certified Nursing Assistant) answered the call light immediately. The CNA reported to this nurse that the resident not feeling well. This nurse went in to residents room and discovered resident was lying flat in bed in supine position with her head upon a pillow. Nurse noticed wet sounding cough and resident was holding a trash can and spitting into it. At this time resident was alert and speaking to nurse describing how she felt. Resident reported to nurse that she was having a hard time breathing due to cough. Nurse adjusted resident with the assistance of 2 CNA's who came into the room at this time. HOB (Head of bed) was elevated. Resident described experiencing chest pain that was continuous and non-radiating. She described location in the center of her chest and held her right hand in a fist over the area of mid-neck line between her breast. She stated she felt like she should go to hospital. This nurse went to med.(medication) cart and obtained a antacid and gave it to resident. Nurse instructed resident to chew antacid up in her mouth and swallow it. Resident nodded her head in understanding. Nurse informed resident that her chest pain may subside in a few minutes and that nurse was going to leave the room for just a minute. Resident nodded. Nurse came to nurses station and resumed charting on another resident, nurse also asked CNA at nurse station to go check on resident and to ask her if she was feeling any better. CNA went to resident room and stepped back out into hallway and said, I can't understand her, come like now! Within seconds, nurse was heading to resident's room. Upon arrival, resident had her eyes open and her gaze was becoming fixed. This nurse called out residents name and resident attempted a vocal response. A Weak pulse was noted. Nurses stepped out of room to call 911, and another nurse to aid in CPR if necessary. Continued to get a response from resident. Two nurses met in resident's room and find resident unresponsive to CNA attempts to keep alert. Apnec breathing noted at this time. Sternal rub elicited a response from resident 2 possibly 3 times. Nurses begin CPR with chest compressions starting at 2:50 AM and continued until EMS(Emergency Medical Services) arrived. CNA obtained oxygen and it was started at 4 liters per nasal cannula. Blood sugar was 191. This nurse spoke with local hospital around 4:00 AM and was informed that official time of death was 3:44 AM. On Call nurse notified, as well as family and MD. There was no documentation found in R15's chart indicating that her doctor, Power of Attorney or family were made aware of changes in condition and her request to go to the hospital. R15's mental assessment done on ,[DATE]/ 16 is a 15 out of 15 which makes her capable of making her needs know and making her own decisions for her care. On [DATE] at 11:00 AM Z1(Primary Care Physician) stated the expectation would be that the staff would notify him or someone from his office if there was a change in the resident or if there was a change in a normal status of a resident or their condition. Z1 stated the facility will notify him often of different things by fax and call him but could not remember being made aware of R15's irregular 56 heart rate on [DATE]. Z1 stated the notification would not have necessarily changed the outcome of R15 having a [MEDICAL CONDITION] and subsequent death on the early hours of [DATE] because R15 had such a long extensive history of cardiac and [MEDICAL CONDITION] issues. On [DATE] at 4:00 PM, E4(Corporate Nurse) stated the expectation is that if there's a change in condition of a resident then the nurse should be notifying the doctor and the POA(Power of Attorney). E4 stated the nurse that had taken care of R15 in the early morning of [DATE] and [DATE] should have called and made the physician aware of R15's condition. On [DATE] at 4:00 PM, E4(Corporate Nurse) stated the expectation is that if there's a change in condition of a resident then the nurse should be notifying the doctor and the POA(Power of Attorney). E4 stated the nurse that had taken care of R15 in the early morning of [DATE] and [DATE] should have called and made the physician aware of R15's condition. E4 stated she had spoken to the nurse that had taken care of R15 on the night of [DATE] and it was also the same nurse that took care of R15 on [DATE]. E4 stated she had asked the nurse why she had not notified the doctor of R15's irregular pulse on [DATE] and E4 stated the nurse did not have an answer. E4 stated she also asked the nurse if on the early morning of [DATE] if she had taken vital signs, assessed her lungs, or if the nurse even did a general assessment or why she did not send R15 to the hospital at that time of her request. R15's Brief Mental Health Assessment shows a score of 15 out of 15 and is able to make her own decisions. R15's Medication Review for [DATE] shows she is a full code; orders for [MEDICATION NAME] Solution 0XXX,[DATE].5 (3) mg(milligram)/3 ml(milliliter) ([MEDICATION NAME]-[MEDICATION NAME]) 1 vial inhale orally every 6 hours as needed for congestion; [MEDICATION NAME] tablet sublingual 0.4 mg-Give 1 tablet sublingually every 5 minutes as needed for Chest pain X 3 doses. If no relief , call MD; [MEDICATION NAME] HFA Aerosol Solution ([MEDICATION NAME] HFA)-2 puff inhale orally every six hours as needed for [MEDICAL CONDITION](Cardio [MEDICAL CONDITION] Disease). Review of R15's Medication Administration and progress notes shows she was not sent to the hospital upon her request. R15 was not given [MEDICATION NAME] per physician orders [REDACTED]. On [DATE] at 4:05 PM E4(Corporate Nurse) stated she had questioned the nurse who had taken care of R15 on the early morning shift of [DATE] because there were concerns. E4 stated she was a nurse and she had asked the nurse why the [MEDICATION NAME] or Nebulizer treatments had not been given or why R15 had not been sent to the hospital when request. E4 stated the nurse in question could not provide E4 with any answers to these questions. When asked E4 if the nurse that provided care to R15 on both of these occasion was still working at the facility, E4 stated no. When questioned E4 why the nurse no longer worked at the facility, E4 stated the nurse was terminated for not following facility policy and procedures. E4 stated the nurse should have assessed R15 when she saw her having issues with Shortness of breath. E4 stated it was not the CNA's responsibility to follow up after the nurse had given the antacid and the nurse should have followed up because the CNA's are not qualified to do this. E4 stated if a resident is having problems with shortness of breath then the nurse should listen to their lungs. E4 stated if a resident is complaining of chest pain then a more thorough assessment needs to be done. On [DATE] at 4:10 PM, E13 ADON(Assistant Director of Nursing) stated she had been on call the night/early morning or [DATE] when the nurse on duty had called her to make her aware R15 had been sent to the hospital and expired. E13 stated she had reviewed the incident and stated as a RN(Registered Nurse) she was not sure why R15 had not been sent out or why the [MEDICATION NAME] were not given. E13 stated R15 could tell you what she needed and wanted. Review of R15's pulse summary from [DATE] to [DATE] shows no issues with R15's pulse until [DATE] at 2:30AM of the irregular 56. Review of R15's Respiration Summary from [DATE] to [DATE] shows no issues with R15's respirations being higher than normal until [DATE] at 2:31 AM when it was 24. R15's Plan of Care with initiation date of [DATE] shows resident has altered cardiovascular status related to [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] and the goal is resident will be free from sign/symptoms of complications of cardiac problems through the next review date of [DATE]. Interventions include Assess for shortness of breath and cyanosis every shift; Monitor and report to MD changes in lung sounds on auscultation, shortness of breath; monitor and report to MD as needed any sign/symptom of [MEDICAL CONDITION]: Chest pain or pressure especially with activity, heartburn nausea and vomiting, shortness of breath; monitor pedal pulse to right foot as needed with care and concerns; Vital signs as needed. Notify physician of any abnormal readings. According to same plan of care, R15 had history of asthma and Cardiopulmonary Disease and the goal was resident will display optimal breathing pattern daily. Noted interventions are: Give aerosol or [MEDICATION NAME] as ordered. Monitor/document any side effects and effectiveness; Monitor and report to MD as needed any sign/symptoms of respiratory infection: increase sputum (document the amount, color and consistency), chest pain, increased difficulty breathing, increased coughing and wheezing; Monitor for signs/symptoms of acute respiratory insufficiency: Anxiety, confusion, restlessness, shortness of breath at rest, Cyanosis, Somnolence

Based on record review, and interview the facility failed to have competent staff (E6 and E8)lifting one of one residents (R2) in a mechanical lift from the sample of 5. This failure resulted in a fall with laceration and fractures to R2. Findings include: An occurrence report dated 4-8-11 at 1700 PM, showed that R2 fell out of the lift sling while up in the air. Root cause of the fall was identified as human error. The report identified that R2 sustained head trauma, abrasion to the right eyebrow with open wound of 3 inches long. The recommendation was to re-educate the CNA's on lift transfers, and to have physical therapy educate staff on the way to transfer resident in a safe manner. On 4-13-11, at 1:30 PM, physical therapist E4 stated that he has been training staff on proper lift procedures since 4-11-11. E4 stated that the only way that R2 could have fallen from the lift is if staff hooked the lift on the wrong prongs/hooks or if the loops were not placed completely on the hooks. E4 believed that there was a design flaw because there are two metal hooks on the top that are parallel to the ground and if improperly placed they could slip off. E4 identified that bottom hook is the one that is supposed to be used to loop the sling straps. Review of page 23 of the lift device Owners Operators and Maintenance Manual states to place the straps of the sling over hooks of the swivel bar. Observation on 2-13-11 at 1:30 PM, showed that the swivel bar on the lift was the bottom hook and not the two upper non-swiveled bars. Interview with nurse-E3 on 4-15-11 at 12:50 PM, showed that she came in after the fall of R2. E3 stated that one strap was off the lift, the other three were still strapped on to the lift. The other three were hooked on to the top parallel hooks according to E3. Review of R2's hospital emergency department sheet dated 4-8-11 showed that R2 was admitted with to the hospital with a right [MEDICAL CONDITION], right rib fracture, and right clavicular fracture. Interview with CNA-E8 on 4-15-11 at 2:15 PM, showed that she was orientating E6 on 4-8-11. During application of the lift E8 applied the straps to the hooks on the right side and E6 applied the straps on the left side. E8 confirmed that the straps were applied to the top bars that ran parallel to the ground, and not the swiveled lower hook. E8 stated that E6 had told her that she had been trained on using the lift device. However, review of facility training records (provided by nurse consultant E5 on 4-15-11) showed that E6 and E8 were trained to use a different lift with a manual lift which also was different as it only allowed one option as to the placement of the straps. On 4-15-11 at 12:05 PM, E5 was unable to show surveyor any documentation by a registered nurse to demonstrate that E6 knew how to use the lift device that E6 signed off for or the lift that E5 used with R2 on her first day of work of 4-8-11. E5 confirmed training record of E6 failed to include certification, as E6 had yet tested for certification.

Based on observation, record review and interviews, the facility failed to ensure that nursing staff used 2 persons to assist with a transfer for 1 resident (R1) from the sample of 4. This failure resulted in R1 sustaining a large, deep laceration to the left lower leg which required emergency room treatment. The findings include: Review of the facility incident/accident log for August 2010 thru October 28th 2010 indicated that R1 has had several incidents of bruising and skin tears. The log indicated that on 10/19/2010 at 6:20 AM, R1 sustained a skin laceration. Review of the facility "occurrence report"and the subsequent investigation dated 10/19/2010, described the area as a "5 inch by 3 inch laceration on the left ankle, uneven with tissue missing deeply. Heavy bleeding". The report indicated that on 10/19/2010 at 6:20 AM, E3, certified nurse aide, was transferring R1 from the toilet to her wheelchair by herself when she started seeing "blood everywhere". E3 verified per interview on 10/28/2010 at 1:00 PM that an injury had occurred while she was transferring R1 by herself and that R1 must have gotten her leg caught on the bracket for the wheel chair leg. E3 stated that R3 did not fall but was leaning against the grab bar and toilet paper holder. Further review of the occurrence report indicated that pressure was applied to the area with a pressure dressing and the doctor was notified with orders to send R1 to the emergency room . R1 returned to the facility that evening at 6:30 with several staples to the area and a dressing in place. Orders were to not change the dressing and to call for a follow up appointment with the Doctor for 1 week. Documentation indicates that R1 had a swollen right upper lip when returned from the emergency room as well as bruising to her right shoulder, right hip and left knee. The following day, R1 was noted to have extensive bruising to her sternum, left upper arm, left thigh and left great toe. Investigation indicated that these had occurred as a result of the transfer incident the day before. R1 went to the Doctor and had the dressing changed on 10/27/10 and returned with orders once again to not remove the dressing and to return once again in one week. Further review of the occurrence log indicated that previously, on 8/08/10 at 4:00 AM, R1 fell out of bed while E4, certified nurse aide, was performing incontinence care on R1 by herself. R1 rolled out of the bed into the floor. The report indicated there was no injury identified at the time of the fall but was found with extensive bruising the next day. R1's resident assessment of 8/02/10 indicates that R1 was to be a two person assist with bed mobility. R1's current care plan dated 8/04/10 indicates an extensive history of bruising and skin tears due to very fragile, thin skin. R1's physician orders [REDACTED]. R1 was observed sitting up in a reclining wheeled chair in her room at 10:00 AM on 10/28/10. A large dressing covered the lower left leg and ankle area. When R1 was asked what happened she stated that a tree had fell on it. R1 is assessed with [REDACTED]. This assessment dated [DATE] indicates that R1 requires 2 person assist with bed mobility, transferring and toilet use. E3 stated during the above mentioned interview that she was not aware that R1 was a two person assist at the time of the incident. E1, Administrator was interviewed on 10/28/10 at 12:50 PM regarding the 10/19/10 incident and injury and verified that an investigation was conducted and that the outcome was that an accident had occurred as a result of improper transfer of a resident. E1 stated that there was no suspicion that physical abuse had occurred.