Every finding on record at Monmouth Rehab and Nursing

Based on Observation, Interview and Record Review, the facility failed to identify, thoroughly investigate and document multiple staff to resident allegations of verbal and mental abuse, protect residents from the alleged abuser, and implement measures to provide safety and prevent further abuse after allegations were made for four of six residents (R1, R4, R5, R6) reviewed for Abuse in the sample of six. This failure resulted in multiple undocumented and uninvestigated abuse allegations regarding V16 (Certified Nursing Assistant) and allowed V16 continued access to the alleged victims, R1, R4, R5 and R6 after each resident voiced allegations of Abuse against V16, allowed V16 to enter into R4 and R6's rooms to address the allegations, and resulted in R4, R5 and R6 experiencing mental anguish and physical symptoms of fear with V16's continued care interactions.Findings include:The facility's Resident Right to Freedom from Abuse, Neglect and Exploitation policy, dated 10/16/23, documents The facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in this policy. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This policy applies to any and all owners, directors, officers, clinical staff, employee, independent contractors, consultants, and others currently or potentially working for the facility. This policy also documents The facility will investigate any allegations made alleging abuse, neglect, and exploitation of residents and misappropriation of resident property. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility shall: Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment of resident property, are reported in the proper timeframe pursuant to this policy. Have evidence that all alleged violations are thoroughly investigated. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrative or his or her designated representative and to other officials in accordance with state law, including to the state survey agency, within five working days of the incident, and if the alleged violation is verified, appropriation corrective action must be taken.The facility's Certified Nursing Assistant Job Description (undated), documents The primary purpose of your job is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors. Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift. Report all complaints and grievances made by the resident. Assist residents with bathing functions as directed. Change bed linens at least weekly and when soiled. Keep linens smooth and wrinkle free while under the resident. Assist resident with bowel and bladder functions (such as; take to bathroom, offer bedpan/urinal, portable commode etcetera). Keep incontinent residents clean and dry. Ensure that you treat all residents fairly, and with kindness, dignity, and respect.The facility's Director of Nursing Job Description (undated), documents The primary purpose of your job description is to plan, organize, develop and direct the overall operation of our Nursing Services department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. This job description also documents a function of the Director of Nursing includes to Report and investigate all allegations of resident abuse and/or misappropriation of resident property in accordance with regulation policies and procedures.The facility's Social Service Job Description (undated), documents The primary purpose of your job position is to assist in planning, organizing, implementing, evaluating, and directing the overall operation of the social services department. This would include being in compliance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. This job description also documents a function of Social Service includes to Review complaints and grievances made by the resident and make a written/oral report to the Administrator indicating what action(s) were taken to resolve the complaint or grievances that indicates the action taken to resolve the complaint or grievance. Follow facility's' established procedures. Maintain a written record of the resident's concerns, and/or grievances that indicates the action taken to resolve the concern and the current status of concern.1. R1's Care Plan, dated 7/8/26, documents R1 admitted to the facility on [DATE] and has diagnoses including Major Depressive Disorder, Chronic Kidney Disease, Weakness, Chronic Pain and Congestive Heart Failure.R1's Minimum Data Set assessment (MDS), dated [DATE], documents R1 requires maximal assistance of staff for activities of daily living (ADLs) and R1's cognition is intact.On 8/11/26 at 9:30 AM, R1 stated that V16 (CNA) is very rough and jerks you around when she takes care of you. R1 stated (V16) is very loud and will yell at me in the mornings. I have also heard her yell down the hall that a resident shit themselves and she needs help cleaning them up. R1 stated she has told many staff her concerns about (V16) including V2 (DON).R1's current electronic medical record does not document any allegations, social service notes, abuse investigations, progress notes or care plan interventions related to facility employees, V16 (CNA) or R1's risk for abuse.2. R4's Care Plan dated 8/6/26, documents R4 was admitted to the facility on [DATE] and has diagnoses of Major Depressive Disorder, Unsteadiness of Feet, and Diabetes Mellitus with Diabetic Neuropathy.R4's MDS assessment, dated 7/1/26, documents R4 requires substantial maximal assistance or is dependent for ADLs and R4's cognition is intact.On 8/11/26 at 9:45 AM, R4 stated that V16 works third shift and is very rough with me and will come in my room in the mornings and yell at me for not having my clothes laid out. R4 further stated that V16 will scream in her ear during cares and stated she has told everyone about her issues with V16 and has requested more than once that V16 not take care of her, but she still does.R4's Grievance Communication Form, dated 6/9/26 and completed by V11 (SSD), documents (V16) spoke to (R4) rudely, raising her voice at her and argued with her. (R4) does not want (V16) to be in her room or complete her care. This grievance documents V2 (DON) handled the grievance and documents Steps taken to investigate: discussed with (V16) her tone of voice on 6/10/26. (V16) she has a very gruff voice and apologized to the resident. (R4) stated (V16) did come in her room and apologize. No further action needed. Corrective action: No follow up needed.R4's current electronic medical record does not document any social service notes, abuse investigations, progress notes or care plan interventions related to facility employees, V16 (CNA) or R4's risk for abuse.3. R5's Care Plan, dated 7/8/26, documents R5 was admitted to the facility on [DATE] with diagnoses of Generalized Anxiety, Type Two Diabetes Mellitus, Seizures, Extrapyramidal and Movement disorder, Insomnia, Bipolar Disorder, Parkinson's Disease with Dyskinesia, Depression, and Abnormalities of Gait and Mobility.R5's MDS assessment, dated 5/20/26, documents R5 requires supervision and touch assistance with hygiene and showers and R5's cognition is intact.On 8/11/26 at 9:45 AM, R5 was sitting in her room in a chair. R5's hands and legs began visibly shaking when talking about V16 (CNA). R5 stated I have had issues with (V16). I am scared to shower because she is not nice and is mean to me. She won't let me take my walker into the shower room. Other aides let me, without a problem. She won't let me and makes me leave it outside of the room. But the floor isn't very safe and I don't feel safe. I asked her for a hand and she yelled at me we're not supposed to help you! If I ask her to hand me the soap she is mad or put out. I talked to (V3, Assistant Director of Nursing) a while ago about her yelling and being rude. After that she still took care of me. I know I talked to (V3) and (V11, SSD). I get really nervous and scared and I shake when I know she is going to be the one giving me a shower. Just talking about it makes me shake.R5's current electronic medical record does not document any allegations, social service notes, abuse investigations, progress notes or care plan interventions related to facility employees, V16 (CNA) or R5's risk for abuse.4. R6's care plan, dated 7/8/26, documents R6 was admitted to the facility on [DATE], and has diagnoses of Adult Failure to Thrive, Disorder of Kidney and Ureter, Nocturia (frequently urinating at night), Hypertension, Morbid Obesity, and Transient Cerebral Ischemic Attack.R6's MDS assessment, dated 6/14/26, documents R6 requires full dependence of staff for toileting and R6's cognition is intact.On 8/11/26 at 10:40 AM, R6 was sitting in her wheelchair, and self-propelled her wheelchair into a empty quiet room where she requested to shut the door to speak about incidents she's experienced with V16. R6 stated she had an incident with V16 where she spilt the contents of her bedpan and then left her bed pads and blankets wet. R6 stated (V16) told me they would clean me up in the morning and left the wet blankets and a pile of them on my bedside table. When the CNA (V19) came in the next morning she said what's this? (V19, CNA) then stated it was pee, not water and she could tell by the smell. Now when (V16) takes care of me she won't turn on the light in my room. I use the bedpan a lot through the night. I can hear when she's coming from her stomping down the hall and I just think oh boy, here we go. I think she doesn't turn on the light so that I don't know it's her and then she doesn't say much. After the incident with the bedpan, the next time she took care of me she said I had spilt water and made it look like she left me wet. I asked her what her name was and she yelled back at me Santa Clause. I just worry about retaliation. I know what goes on in nursing homes and I keep my pillows up by my head. I told my family that if something happens to me to question my death. I think I talked to social service director (V11). I can't remember who all knows about it. It made the other CNA (V19) very upset though and she was going to go with me to talk to (V1, Administrator) but I know she got busy and we didn't get to go. When (V16) comes in my room now you can just feel the tension, she doesn't turn on the light and it's uncomfortable for me.R6's current electronic medical record does not document any allegations, social service notes, abuse investigations, progress notes or care plan interventions related to facility employees, V16 (CNA) or R6's risk for abuse.On 8/10/26 at 2:00 PM, V1 (Administrator) stated the facility does not have any abuse reports or abuse investigations from 5/10/26 through 8/10/26.On 8/10/26 at 2:25 PM, V11 (Social Services) confirmed that R4, R5 and R6 have brought concerns to her related to V16 (Certified Nursing Assistant). V11 confirmed she is the one who helped R4 write a grievance and stated I don't know who the abuse coordinator is. Maybe I am supposed to be the abuse coordinator, I really don't know. V11 stated she handed the grievance for R4 to the Director of Nursing (V2) but did not notify anyone else or conduct any interviews or investigation. V11 then stated (R5) complained to me about feeling rushed with showers and that she was afraid of (V16, CNA). (R5) didn't want me to fill out a grievance form. I think she was afraid of retaliation. V11 went on to state (R6) has also complained that (V16) spilt her bedpan overnight. (V16) told her it was close enough to dayshift and they'd clean her up. Then, after nursing was made aware, (V16) came back into (R6's) room and told (R6) she knew it didn't happen and that she (R6) just spilt water to make it seem like pee. (R6) did not want a grievance filed but I know nursing was made aware and it was also discussed in our (facility department head) morning meetings. V11 confirmed that she did not document any of the concerns brought to her from R5 or R6, did not interview or further investigate the allegations and stated she did not report any of the concerns with R4, R5 or R6 to V1 (Administrator) but confirmed V1 is present in morning meetings when those concerns were discussed.On 8/11/26 at 12:25 PM, V3 (Registered Nurse/ Assistant Director of Nursing) confirmed being aware of some complaints related to V16 (CNA). V3 stated If I get a complaint about a staff member then I go to the resident and talk to them. If it's something that requires education then I, along with V2 (DON), provide education to the facility staff. With (R6), she complained about an issue with her bedpan and then said it was spilt on her bed. She also said that (V16) came in the next day and told her it was water that she had spilt and not urine. But when we looked at the schedule, V16 didn't work the next day. I did not document any interviews, and I do not have a record of the incident. I don't recall (R5) saying anything specific about (V16). I do remember her complaining that staff don't want to help her with getting a shower in the mornings. I assured her that she can get a shower and if anyone gives her an issue she can talk to the nurse on duty. I don't have any documentation about that conversation though. I don't have any documentation of any complaints related to (V16). V3 confirmed that V1 is the abuse coordinator and allegations of potential abuse should be reported to V1 so that an investigation can be conducted. V3 also confirmed that complaints voiced by R1, R4, R5 and R6 would have been discussed during morning meetings with V2 and V1.On 8/11/26 at 12:43 PM, V2 (Director of Nursing) confirmed she has been made aware of concerns with V16 over the past couple of months. V2 stated With (V16), there was a concern with a possible spilt bedpan. That was on the 23rd or 24th of July. Social services (V11) said that (V16) went into (R6's) room the next morning and told (R6) it was just water. (V16) didn't work that next morning. I do not have any documentation of an interview with (R6) or (V16). I did not talk to (V16) about that. V2 then confirmed the grievance filled by R4 was handled by her and was documented, reported to V1 or investigated as potential abuse. V2 stated I talked to (V16) and (R4) after (R4) filed a grievance on 6/9/26. I don't remember if the grievance was given to me or if we just talked about it in the morning meeting. (V16) said she went in and apologized to (R4). I was not in there when she apologized. I don't have any other documentation than what is in the grievance form. (V1) gets a copy of the grievance forms too. (V16) has not been suspended and we have not done any abuse investigation or reports in relation to these incidents. Technically with any allegation I talk to everyone involved. If it is actual abuse, we then file an abuse report to the state and complete an investigation. If it's just tone of voice or a customer service allegation, then we don't consider that abuse and don't file a report. If a person says I've been abused then we do an investigation, otherwise we interview the resident and if it's not determined to be abuse then we just in-service staff.The facility's CNA schedule dated 6/10/26-8/12/26, documents V16 worked in the facility three to five nights per week from 10:00 PM to 6:00 AM for a total of 37 shifts, where she had access and provided care to R1, R4, R5 and R6.On 8/12/26 at 9:40 AM, V1 (Administrator) stated he started as the facility's administrator in March of 2026, confirmed he is the facility's abuse coordinator, and stated he does not have documentation of abuse investigations related to V16 and residents. V1 stated I am aware of the customer service complaints from (R6) towards (V16). I was under the impression that (V16) just speaks loudly and that it wasn't an abuse concern. I am aware that (R4) has made complaints about (V16's) loud voice. I was not aware of (R5) voicing complaints and I was not aware of (R6's) incident with the bedpan until yesterday. I expect any allegations of abuse to be reported to me but if it's handled as customer service and not abuse then I don't see the issue. When I report abuse to the state agency it is because we have substantiated abuse. I was not aware that every allegation that could be potential abuse needed reported to me or to the state agency. V1 confirmed he did not complete investigations for R1, R4, R5 or R6 because he saw them as customer service complaints when looked at individually.

Based on Observation, Interview and Record Review, the facility failed to recognize and immediately report multiple allegations of staff to resident verbal and mental abuse to the facility's Abuse Coordinator and the State Agency for four of six residents (R1, R4, R5, R6) reviewed for Abuse in the sample of six. This failure resulted in multiple allegations of staff to resident mental and verbal abuse going unreported and left R4, R5 and R6 feeling mentally and physically upset and in fear of retaliation for reporting allegations themselves.Findings include:The facility's Elder Justice Act and Reporting Suspected Crimes Against Residents policy, dated 10/1/23, documents It is the policy of the facility to empower and enable any and all owners, operators, employees, agents or contractors of the facility to make reports to the relevant authorities pursuant to the provision of the Elder Justice Act and CMS (Center for Medicare Services) regulations. Alleged violation is defined as a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. An alleged violation can be observed or reported by staff, resident, relative, visitor, another health care provider, or others. An individual (resident, visitor, facility staff) who reports an alleged violation to the facility staff does not have to explicitly characterize the situation as abuse, neglect, mistreatment, or exploitation in order to trigger reporting requirements. Rather, if the facility staff could reasonably conclude that the potential exists for noncompliance with the federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property, then it would be considered reportable. This policy also documents Alleged violations, covered individuals must report the alleged violation, whether it was oral or in writing, to the administrator or other designated facility representative and the facility must report the alleged violations to the state survey agency. Reporting requirements under this policy are based on real (clock) time, not business hours. Alleged violations (reporting), immediately for alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, but not later than: two hours if the alleged violation involves abuse or results in serious bodily injury; 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility shall: Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment of resident property, are reported in the proper timeframe pursuant to this policy. Have evidence that all alleged violations are thoroughly investigated. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrative or his or her designated representative and to other officials in accordance with state law, including to the state survey agency, within five working days of the incident, and if the alleged violation is verified, appropriation corrective action must be taken.The facility's Certified Nursing Assistant Job Description (undated), documents Report all complaints and grievances made by the resident. Ensure that you treat all residents fairly, and with kindness, dignity, and respect. Report all grievances/ concerns/ complaints made by the resident to the charge nurse/nurse supervisor. Report all allegations of resident abuse and/or misappropriation of resident property.The facility's Social Service Job Description (undated), documents a function of Social Service includes to Review complaints and grievances made by the resident and make a written/oral report to the Administrator indicating what action(s) were taken to resolve the complaint or grievances that indicates the action taken to resolve the complaint or grievance. Follow facility's' established procedures.The facility's Director of Nursing Job Description (undated), documents a function of the Director of Nursing includes to Report and investigate all allegations of resident abuse and/or misappropriation of resident property in accordance with regulation policies and procedures.1. R1's Minimum Data Set assessment (MDS), dated [DATE], documents R1 requires maximal assistance of staff for activities of daily living (ADLs) and R1's cognition is intact.On 8/11/26 at 9:30 AM, R1 stated that V16 (Certified Nursing Assistant, CNA) is very rough and jerks you around when she takes care of you. R1 stated (V16) is very loud and will yell at me in the mornings. I have also heard her yell down the hall that a resident shit themselves and she (V16) needs help cleaning them up. R1 stated she has told many staff her concerns about (V16) including V2 (Director of Nursing).2. R4's MDS assessment, dated 7/1/26, documents R4 requires substantial maximal assistance or is dependent for ADLs and R4's cognition is intact.On 8/11/26 at 9:45 AM, R4 stated that V16 works third shift and is very rough with me and will come in my room in the mornings and yell at me for not having my clothes laid out. R4 further stated that V16 will scream in her ear during cares and stated she has told everyone about her issues with V16 and has requested more than once that V16 not take care of her, but she still does.3. R5's MDS assessment, dated 5/20/26, documents R5 requires supervision and touch assistance with hygiene and showers and R5's cognition is intact.On 8/11/26 at 9:45 AM, R5 was sitting in her room in a chair. R5's hands and legs began visibly shaking when talking about V16 (CNA). R5 stated I have had issues with (V16). I am scared to shower because she is not nice and is mean to me. She won't let me take my walker into the shower room. Other aides let me, without a problem. She won't let me and makes me leave it outside of the room. But the floor isn't very safe and I don't feel safe. I asked her for a hand and she yelled at me we're not supposed to help you! If I ask her to hand me the soap she is mad or put out. I talked to (V3, Assistant Director of Nursing) a while ago about her yelling and being rude. After that she still took care of me. I know I talked to (V3) and (V11, SSD). I get really nervous and scared and I shake when I know she is going to be the one giving me a shower. Just talking about it makes me shake.4. R6's MDS assessment, dated 6/14/26, documents R6 requires full dependence of staff for toileting and R6's cognition is intact.On 8/11/26 at 10:40 AM, R6 was sitting in her wheelchair, and self-propelled her wheelchair into a empty quiet room where she requested to shut the door to speak about incidents she's experienced with V16. R6 stated she had an incident with V16 where she spilt the contents of her bedpan and then left her bed pads and blankets wet. R6 stated (V16) told me they would clean me up in the morning and left the wet blankets and a pile of them on my bedside table. When the CNA (V19) came in the next morning she said what's this? (V19, CNA) then stated it was pee, not water and she could tell by the smell. Now when (V16) takes care of me she won't turn on the light in my room. I use the bedpan a lot through the night. I can hear when she's coming from her stomping down the hall and I just think oh boy, here we go. I think she doesn't turn on the light so that I don't know it's her and then she doesn't say much. After the incident with the bedpan, the next time she took care of me she said I had spilt water and made it look like she left me wet. I asked her what her name was and she yelled back at me Santa Clause. I just worry about retaliation. I know what goes on in nursing homes and I keep my pillows up by my head. I told my family that if something happens to me to question my death. I think I talked to social service director (V11). I can't remember who all knows about it. It made the other CNA (V19) very upset though and she was going to go with me to talk to (V1, Administrator) but I know she got busy and we didn't get to go. When (V16) comes in my room now you can just feel the tension, she doesn't turn on the light and it's uncomfortable for me.On 8/10/26 at 2:00 PM, V1 (Administrator) stated the facility does not have any abuse reports or abuse investigations from 5/10/26 through 8/10/26.On 8/10/26 at 2:25 PM, V11 (Social Services) provided a grievance from 6/9/26 for R4 which alleged that V16 (CNA) Spoke to (R4) rudely, raising her voice at her and argued with her. This grievance documents, and V11 confirmed, that R4 does not want V16 in her room or to give her care again. V11 stated I don't know who the abuse coordinator is. Maybe I am supposed to be the abuse coordinator, I really don't know. V11 stated she handed the grievance to the Director of nursing (V2) but did not notify anyone else. V11 then confirmed she is aware of other residents having issues with V16, including R5 and R6. V11 stated These concerns were discussed during morning meetings, but I worried that maybe I was breaking confidentiality since the residents didn't want to file written complaints. They (residents) are afraid of retaliation. V11 then confirmed she did not report any of the concerns with R4, R5 or R6 to V1 (Administrator) but confirmed that he is present in morning meetings when these concerns were discussed.On 8/11/26 at 1:20 PM, V19 (CNA) stated I am aware of (V16) having several complaints against her. V19 confirmed she is the CNA who took care of R6 the morning after the bedpan incident when R6's bedpan urine was spilt on her bed. V19 stated (V16) told (R6) that someone would be in at seven to get her cleaned up. This happened around five in the morning. (V16) left her with urine soaked blankets until I came in for dayshift. I told (R6) that I would go with her to talk to (V1, Administrator) that day. I got really busy and didn't get the chance to take her down to talk to (V1). (R6) was afraid of revenge from this CNA and said she didn't want to get anyone in trouble. I don't think I told anyone else that day. V19 then stated This isn't the first time (V16) has been talked to or questioned about her behavior with residents. I am not sure who the Abuse coordinator is. On 8/11/26 at 12:25 PM, V3 (Registered Nurse/ Assistant Director of Nursing) confirmed being aware of resident complaints related to V16 (CNA) including R6's bedpan being spilt in her bed, R1 and R4's complaints about V16 being rude and yelling and R5 stating she was having issues with her showers. V3 that complaints voiced by R1, R4, R5 and R6 would have been discussed during morning meetings but that she did not document or report any of the incidents as potential abuse allegations to V1. On 8/11/26 at 12:43 PM, V2 (DON) confirmed having knowledge about R4 and R6's complaints against V16 and confirmed she did not report them as Abuse to V1. V2 stated Technically with any allegation I talk to everyone involved. If it is an actual abuse, we then file an abuse report to the state and complete an investigation. If it's just tone of voice or a customer service allegation then we don't consider that abuse and don't file a report. If a person says I've been abused then we do an investigation, otherwise we do an investigation and if it's not determined to be abuse then we will just in-service staff.On 8/12/26 at 9:40 AM, V1 (Administrator) stated he started as the facility's administrator in March of 2026, confirmed he is the facility's abuse coordinator, and stated he has not reported any allegations to the state agency of alleged staff to resident abuse. V1 stated I am aware of the customer service complaints from (R6) towards (V16). I was under the impression that (V16) just speaks loudly and that it wasn't an abuse concern. I am aware that (R4) has made complaints about (V16's) loud voice. I was not aware of (R5) voicing complaints and I was not aware of (R6's) incident with the bedpan until yesterday. I expect any allegations of abuse to be reported to me but if it's handled as customer service and not abuse then I don't see the issue. When I report abuse to the state agency it is because we have substantiated abuse. I was not aware that every allegation that could be abuse needed reported to me or to the state agency.

Based on observation, interview, and record review, the facility failed to prevent pressure ulcer development and failed to provide treatment and implement pressure-relieving interventions of pressure ulcers for one (R1) of three resident reviewed for pressure ulcers in the sample list of six. This failure resulted in R1 having an untreated pressure injury to the coccyx with two new painful open areas and placed R1 at risk for further skin breakdown and delayed healing. Findings include:The facility's Skin Prevention, Assessment and Treatment Policy, revised May 1, 2026, documents the purpose of the policy was to implement appropriate interventions to prevent the development of clinically avoidable wounds and promote a systematic approach and monitoring process for residents with existing wounds and those at risk for skin breakdown. The policy further documents that residents' care plans should ensure appropriate interventions are implemented to manage identified risk factors and promote healing of existing pressure ulcers. R1's Census line documents R1 admitted to the facility on [DATE]. R1's Minimum Data Set (MDS) dated [DATE] documents R1 did not have a pressure ulcer. The same MDS documents R1 is cognitively intact. R1's Braden assessment dated [DATE] documented R1 was at risk for skin impairment. R1's Wound Log dated 7/22/26 documented a new area on the left buttock measuring 0.4 centimeters (cm) in length, 0.6 cm in width, and 0.1 cm in depth. This wound log documents an order to cleanse the wound and apply collagen (moisture wicking dressing) and wound gel (keeps wound bed moist) daily. R1's Wound Log dated 7/22/26 also documents a wound to the right buttock, identified as acquired on 7/13/26, measuring 0.6 cm in length, 0.5 cm in width, and 0.1 cm in depth. The same dressing treatment was documented. R1's Physician Orders documents an order for wounds to the right and left buttocks: cleanse with wound cleanser, pat dry, mix equal parts collagen powder (moisture wicking dressing) and wound gel (keeps wound bed moist), apply to the wound bed, and cover with a foam dressing daily and as needed every day shift for wound care. The order had a start date of 7/23/26 and a discontinuation date of 8/6/26. R1's Physician Progress Note dated 8/6/26 at 10:54 AM, signed by V8 (Nurse Practitioner/NP), documents V8 observed a chronic pressure injury to R1's buttock/sacral region. The note documents the wound was clean and healing, without erythema, warmth, purulence, or odor suggestive of infection. The note further documented healing was limited by R1's continuous sitting in a recliner and intolerance of side-lying. The 8/6/26 physician progress note documented pressure-relieving interventions, including a pressure-redistributing cushion for R1's recliner and a pressure-redistributing mattress/overlay for the bed. The note also recommended repositioning, including spending at least two hours in bed with pillow-supported 30-degree lateral positioning and alternating hips rather than full side-lying. The same 8/6/26 note documents that R1 spent the majority of her time in a recliner, including at night, because she did not like lying in bed. The note further documented that R1 did not have a pressure-redistributing cushion or mattress overlay and that side-lying was uncomfortable and poorly tolerated. On 8/10/26 at 11:25 AM, V6 (Registered Nurse/RN) stated V6 completed R1's weekly wound assessment on 8/6/26 and documented that R1's coccyx wound had healed. V6 stated she healed the wound out in the electronic system because there were no open areas at that time. V6 confirmed she did not put ongoing preventive treatment in place. R1's wound log dated 8/6/26 at 1:30 PM, signed by V6 documents Wounds to R1's right and left coccyx are healed. R1's Physician Orders document the wound treatment order for the bilateral buttocks was discontinued on 8/6/26. No subsequent treatment order for R1's coccyx wound was documented in R1's medical record. R1's current care plan does not contain pressure relieving interventions for R1's coccyx wound. On 8/10/26 at 9:45 AM, R1 stated she had a large sore on her bottom and that staff did not take care of it every day. R1 stated that sometimes, if she complained enough, staff would put a bandage on it. R1 stated the area was very sore. R1 stood with assistance from V5 (Licensed Practical Nurse/LPN). V5 pulled down R1's pants and the coccyx area was observed to have a very large bright red area on right and left side of coccyx with two pinpoint open areas. R1 stated the area was very painful. V5 confirmed R1 had a large red area with two open areas, approximately the size of a pencil tip, on her coccyx and V5 identified the area as a pressure ulcer. V5 further confirmed there was no treatment being provided for the area. On 8/10/26 at 1:15 PM, R1's bed and recliner did not contain the pressure-relieving devices ordered/recommended by V8 on 8/6/26. R1's bed did not have a pressure-redistributing mattress overlay or low-air-loss mattress, and R1's recliner did not have the ordered pressure-redistributing cushion. On 8/10/26 at 1:30 PM, V2 (Director of Nursing/DON) stated R1 was to lay in bed for at least two hours each day. V2 stated she was not aware why the ordered interventions from V8 on 8/6/26 had not been implemented and was not aware that R1's wound treatment had been discontinued. On 8/10/26 at 3:30 PM, V8 (Nurse Practitioner/NP) stated she saw R1 in her office on 8/6/26 and performed a physical assessment, including examination of R1's coccyx after R1 reported having a painful sore. V8 stated R1's bottom was very bright red, and she considered the area to be a Stage 1 pressure ulcer at that time. V8 stated she did not give the facility an order to discontinue R1's wound treatment, but to continue with ordered treatment and implement additional interventions to keep R1's coccyx wound from worsening. V8 further stated that if the facility was not providing treatment and did not implement the pressure-relieving interventions she ordered, R1's wound could quickly worsen given her history. R1's Nurse Progress Note dated 8/12/26 at 10:01 AM, signed by V6 (Registered Nurse/Wound Nurse) documents R1 has a small Stage II pressure injury noted to the right buttock, measuring 1.2 cm x 1.0 cm x 0.1 cm. Resident denied pain or tenderness with palpation of the discolored area but reported pain/tenderness with direct pressure to the Stage II pressure injury.

Based on observation, interview, and record review the facility failed to ensure a reliable operating nurse call light system to alert staff in the event of an emergency or if a resident needs assistance. This has the potential to affect all 37 residents residing at the facility. Findings include:The facility's Matrix (CMS 802) dated 3/17/26 documents there are 37 residents residing at the facility.The facility Resident Call Bells Policy dated 11/5/2025 documents The facility will be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, toilet and bathing facilities. Calls for assistance shall be answered timely.Procedure:The communication system shall be checked regularly to ensure operability and that it can be reached by the resident.A tap bell supply/hand bells will be available to be used in the case of communication system malfunction. In the event the primary communication system malfunctions, a tap/hand bell shall be issued to each resident to call for assistance with and shall serve as the new communication system until the primary communication system is functioning again.The facility's undated Maintenance Director job description documents duties include assure proper maintenance and running condition of all equipment including all nurses' call station systems.The facility's Grievance Log entry dated 11/21/25 documents Call lights not working. Working on getting quotes and a repair plan.On 3/18/2026 at 10:00 AM during the facility Resident Council meeting V10 (Ombudsman) reports the facility has a ghost light system meaning one call light when activated may trigger other call lights on or if one call light is turned off it will turn them all off so then staff have to go room to room. R20 reports she has been woken up in the night by staff asking her if it was her call light on because they do not know which call light is on. On 3/18/2026 from 11:15 AM through 11:17 AM, room [ROOM NUMBER], 16, and 20's bathroom call lights were observed to be blinking quickly and audibly alarming. There were not any residents in the rooms.On 3/18/2026 at 11:18 AM, V8 (Registered Nurse) stated I have heard that when the shower room's emergency light is turned on, it also turns on those other rooms (14, 16 and 20).On 3/18/2026 at 11:23 AM, V9 (Maintenance Director) stated he was aware of the call-lights in room [ROOM NUMBER], 16 and 20 turning on when the front hall shower room emergency light is activated. V9 stated the call light system needs to be replaced and the corporation had an estimate done for a replacement system a couple of months ago.On 3/18/2026 between 1:00 PM and 1:30 PM Call lights for each room and bathroom were checked and verified by V12 (RN). V12 reports there have been problems with the call light system. Findings included:room [ROOM NUMBER]'s room call light was activated and the call light indicator outside of rooms [ROOM NUMBERS] lit up.The emergency call light in the bathroom shared by rooms [ROOM NUMBERS] was activated and the indicator light outside of the room did not light up.room [ROOM NUMBER]'s room call light was activated and the call light indicators outside of the room and on the call light board at the nurses station did not light up.The shower room's emergency call light was activated and the indicator light outside of the room.On 3/18/2026 at 1:55 PM the call light board at the nurses station was sounding, but there were no lights lit up to indicate which call light was on. V13 (CNA) went to each hallway and verified there were no call light indicator lights outside of any resident room lit up. V13 reports the call light system has not been working correctly for a while and when this happens she has to go to each room and check the call light on the wall in each room. V13 verified it was the call light in room [ROOM NUMBER] that was on.On 3/18/2026 at 2:55 PM V9 (Maintenance Director) reports he had two electronic companies come to the facility and report the call light system needs replaced and there was an estimate given to the corporate office to replace the call light system. V9 reports he does not conduct an audit of the call light system. V9 stated, I might if I had a functioning system.On 3/19/2026 at 9:00 AM V15 (Regional Director of Plant Services) reports the corporation uses a work order system for any maintenance notifications of malfunctioning equipment and audits. V15 reports the work order system has a module that is to be used to inspect call lights and it is to be done monthly.On 3/19/2026 at 8:42 AM V14 (CNA) reports the call light in the shower room sometimes works and sometimes it doesn't. V14 reports when the call board system is sounding but there is not a light lit up on the board or outside of a room it is usually on the front hall, but it has happened on the back hall as well.On 3/19/2026 at 8:46 AM V16 (CNA) reports when the shower room call light is activated multiple call light indicators outside of the rooms will light up. V16 reports when the call system only sounds the staff split up and go to different hallways to find the call light that is on.

Based on interview, record review, and observation the facility failed to answer call lights in a timely manner. This has the potential to affect all 37 residents residing at the facility.Findings include:The facility's Matrix (CMS 802) dated 3/17/26 documents there are 37 residents residing at the facility.The facility's Resident Call Bells Policy dated 11/05/2025 documents Calls for assistance shall be answered timely. When making beds and tidying resident rooms, the cords for the communication system will be left in a standard place in all rooms. The Nursing Assistant leaving the room must ensure that the communication system is in place regardless of the residents' ability to use it.The facility's Grievance Report Form dated 7/31/25 documents Call lights are not answered timely. It seems they are worse first thing in the morning and at mealtimes.The facility's Suggestion/Complaint/Grievance Communication Form dated 11/21/2025 documents Call lights have been a complaint for some time with several residents. They are not answered timely and are worse early in the morning and at mealtimes. There was a grievance filed on 07/31/2025 in regards to the call light wait times that has not been resolved.The facility's Resident Council Meeting Minutes dated 02/20/2026 documents extended call light times, being told to wait for the next shift when light has been answered due to charting.The facility's Suggestion/Complaint/ Grievance Communication Form dated 02/23/2026 documents Several residents say that the wait times on call lights have gotten extensive. Two different situations residents waited more than an hour to be taken care of.On 3/18/26 at 10:00 AM a Resident Council meeting was held with V10 (Ombudsman), R4, R12, R20, R22, R27, and R39 in attendance. All residents in attendance are alert and cognitively intact. All residents present complained about the call lights not being answered timely. R4 reported she lives in the back hallway of the building and other residents in her hallway will start yelling because staff are not answering their call lights. R4 will then go to the nurses' station which is located in the front of the building to alert staff that a resident in the back hallway needs assistance. V10 confirmed the long wait times for call lights has been an issue for several months.On 3/19/26 at 12:00 PM the bathroom emergency light between rooms was lit up and sounding. V19 (Licensed Practical Nurse) and V20 (Registered Nurse) walked past the emergency light to the front door, turned around and walked back by the emergency light. V19 looked up at the flashing light and both V19 and V20 walked on to the nurses' station. R20 was in the bathroom on the toilet and had turned on the bathroom emergency light for assistance.On 3/20/26 at 9:15 AM V11 (Activity Director) was unable to identify the residents in the grievances that reported they were told to wait until the next shift or the residents that reported waiting over an hour for their call lights to be answered.

Based on interview and record review the facility failed to provide the Resident Council with responses, actions, and rationale taken regarding concerns. This has the potential to affect all 37 residents residing at the facility. Findings include:The facility's Matrix (CMS 802) dated 3/17/26 documents there are 37 residents residing at the facility.The facility's Resident Council Meeting and Agenda Policy revised 3/6/26 documents the purposes of the Resident Council include Residents to have input in the operation of the facility and Discussion of concerns.The facility's Resident and Family Concerns and Grievances Policy and Procedure dated 10/5/2023 documents Purpose: To provide for the prompt resolution of medical and non-medical grievances while maintaining confidentiality. Responses to and Resolution of Grievances: The facility will follow up with resident or their family members, guardian, or representative within 72 hours of the filing of the grievance.The facility's Resident Council Meeting minutes dated 11/25/25 documents Discussed previous months complaints and if those had all been resolved. Three had not. Two from July and one from October.The facility's Resident Council Meeting minutes dated 1/19/26 documents Discussed previous months complaints and if those had been resolved. Four had not. One from July and three from November and December.The facility's Resident Council Meeting minutes dated 2/23/26 documents Discussed previous months complaints and if those had been resolved. Five had not. One from July, three from November and December, and one from January.On 3/17/26 at 9:00 AM R20 stated she used to be the Resident Council President for a long time. R20 said she quit being the president because no matter how many times she brought any concerns up nothing was ever fixed or changed. R20 said We would complain about things and then never hear back anything from them (staff) and the problems would continue. The problems do still continue.On 3/17/26 at 9:55 AM V11 (Activity Director) reports there are not any Resident Council officers because the residents are exercising their rights to do so.On 3/18/26 at 10:00 AM a Resident Council meeting was held with V10 (Ombudsman), R4, R12, R20, R22, R27, and R39 in attendance. All residents in attendance are alert and cognitively intact. All residents present reported they do not get a follow up from the grievances submitted in Resident Council. R12 and R20 both reported that all grievances are filed in Resident Council so that they are anonymous. The facility does not have a Grievance/Suggestion box where grievances can be submitted anonymously. R12 stated he is concerned about retaliation from staff if the grievances are not anonymous.On 3/18/26 at 2:22 PM V11 (Activity Director) reports she gives all grievances and Resident Council Meeting minutes to V1 (Administrator).On 3/19/26 at 11:50 PM V1 (Administrator) reports that the grievances go to the Department Manager that the grievance pertains to and then the Department Manager addresses it with the staff. V1 confirmed there is not a Grievance/ Suggestion box for residents to be able to submit grievances anonymously.The facility's grievance logs dated 7/31/25 - 2/23/26 document 22 grievances and all 22 grievances were filed in Resident Council meetings. The facility provided one call light audit for documentation to verify actions were taken to address the 22 grievances.

Facility failures resulted in two deficient practices.A. Based on interview and documents review, the facility failed to conduct an annual Legionella Risk Assessment to assess where Legionella and other opportunistic waterborne pathogens can grow and spread. This has the potential to affect all 37 residents residing at the facility. B. Based on observation, interview and record review, the facility failed to utilize Enhanced Barrier Precautions as ordered per policy for two of four residents (R6, R15) reviewed on Enhanced Barrier Precautions, in a sample of 28.Findings include:A. The Facility Resident Census Roster and Facility Matrix/802, dated 3/17/26, were reviewed. The Census Roster documented 37 Residents resided in the Facility.The Legionella Risk Assessment (complete annually or upon disruption of the water source) not dated, was not completed.On 3/19/26 at 1:23 PM, V9 (Maintenance Director) stated the Legionella Risk Assessment has not been completed since he has been here approximately 3 1/2 years ago.B. The Facility Resident Census Roster and Facility Matrix/802, dated 3/17/26, were reviewed. The Census Roster documented 37 Residents resided in the Facility.Enhanced Barrier Precautions policy revised 10/28/24, documents handwashing must be conducted after touching blood, body fluids, secretions, excretions and contaminated items, immediately after gloves are removed and between tasks and procedures on the same resident. Personal Protective Equipment (gloves and gowns) for Enhanced Barrier Precautions is necessary when performing high-contact care activities.1. R6's Physician Order dated 2/10/26, documents Enhanced Barrier Precautions.R6's current care plan documents, R6 has a wound and Enhanced Barrier Precautions were initiated on 01/23/2026. Interventions include Isolation Personal Protective Equipment (PPE) available at the entrance room and staff to wear PPE for high-risk activities per protocol.On 3/17/26 at 1:30 PM, V4 (Licensed Practical Nurse) was observed to don non-sterile gloves, apply lotion to R6's bilateral lower extremities, place the lotion on the resident's bed, rub the lotion in R6's lower extremities, pick up the lotion and put the lotion on the bedside table with gloves still donned, remove gloves, wash hands and pick up the lotion bottle, carry the lotion to the treatment cart and place the lotion in a drawer of the treatment cart without disinfecting the bottle of lotion and did not don a gown during high contact cares.Throughout the survey on 3/17/26 through 3/19/26, R6 did not have an Enhanced Barrier Precaution sign posted nor was Personal Protective Equipment available for use outside the room.2. R15's Physician Order dated 3/10/26, documents Infection precautions - enhanced barrier Staff wear gown/gloves when in direct patient contact.R15's current care plan documents Enhanced Barrier Precautions during personal care were initiated on 03/10/2026.On 3/17/26 at 10:15 AM, V4 (Licensed Practical Nurse) was observed to don non-sterile gloves, remove R15's elastic wraps on bilateral lower extremities, assess/rub/feel the lower extremities of R15's skin, reach for the lotion on bedside table, apply lotion to bilateral lower extremities, place lotion bottle back on bedside table, remove gloves, wash hands, then pick up the contaminated bottle of lotion with bare hands and place the bottle on the treatment cart without disinfecting the bottle of lotion and did not don a gown during high-contact cares.On 3/17/26 at 3:30 PM, V2 (Director of Nursing) confirmed gloves and gowns should be worn during high contact care. Enhanced Barrier Signs should be posted and a PPE cart should be available outside the resident's door when on Enhanced Barrier Precautions.

Based on interview, observation and record review, the facility failed to ensure residents were monitored, assessed, interventions were implemented, changes in conditions were identified in a timely manner, appropriate notifications were made, and outcomes investigated for 5 of 5 residents (R6, R15, R37, R43, R48) with a change in condition in a sample of 28.Findings include: 1.R37's Nurse's Notes dated 3/4/2026 documents R37 returned from a hospital stay. Resident is in Contact and Airborne Precautions in a private room at this time for ten days from the point of contact. Coarse crackles throughout all lobes of her lungs. R37's Nurse's Notes dated 3/5/26 at 1:15 AM document that resident is on isolation related to Influenza A. No respiratory assessment or vital signs noted. R37's Nurse's Notes after her admission assessment dated [DATE] do not contain any physical assessments of R37. No targeted assessments related to current Influenza A for which she was in transmission-based precautions. No generalized skilled nursing assessments of R37 while she was in transmission-based precautions. To include no vital signs documented on 3/6; 3/8; 3/9; 3/10; 3/12; or 3/13. On 3/11/2026 at 10:30 AM V1 (Regional Administrator) confirmed there were no targeted or general physical assessments of R37 after her hospitalization and while she was in transmission-based precautions and being acutely ill due to Influenza A. We should be assessing anyone who is sick every shift until they are stable for 72 hours. The Change in Condition policy revised 9/21/25, documents a full assessment by the nursing staff will include but not limited to full set of vital signs, level of consciousness, respiratory status including lung sounds, abdomen including last bowel movement and urine properties, functional status, pain and glucometer test if diabetic or decreased level of consciousness, notify physician, notify family and initiate vital signs every shift for a minimum of 72 hours or until condition has stabilized. The Charting and Documentation policy revised 11/5/19, documents medical record entries shall be made by the person providing or supervising/observing the service documented. Narrative documentation/Progress Notes will be documented on the premise of charting by exception. Documentation will include information on assessment, notifications, interventions and evaluation including but not limited to incidents/accidents, change in condition, physician notification, responsible party notification, refusal of medications/treatment or recommendations, status updates and transfers or discharges. The Neuro/Head Trauma Assessment form documents to Assess as follows: a) initial, b) every 15 minutes x 4, c) every 1 hour x 4 hours, d) every 4 hours x 8 hours, e) every shift for the remainder of the 24 hours. 2. R6 was admitted on [DATE] with diagnoses of Venous Insufficiency, Alzheimer's Disease, Dementia, Right ankle and foot Gout, Dysphagia and Atrial Fibrillation. On 3/17/26 at1:30 PM, V4 (Licensed Practical Nurse) stated I need to call Hospice to report a change in condition. She didn't eat supper last night or breakfast this morning. I think she is transitioning (final stage of the dying process). The Progress Notes included a Physician Assistant visit note on 3/10/25 which documented no new findings. As of 3/18/26 at 9:25 AM, R6's Progress notes did not include any assessment of R6's condition change, Hospice notification, physician notification or family notification. The Hospice visit note dated 3/19/26 documents R6's lungs sound were congested and diminished, weak moist cough, representative wishes to treat symptoms, an antibiotic and a steroid medication was ordered to treat symptoms, the facility nurse reported during this hospice visit R6 had remained in bed the past 3 days due to increased weakness and fatigue, sleeping the majority of the time and has been refusing food/fluids and medications, although drank 240 milliliters of water during hospice visit. On 3/19/26, R6 was transferred to a private room for the dying process. 3. R15 was admitted on [DATE] with diagnoses of Dementia, Atrial Fibrillation, Cellulitis of lower extremities, Age related Cataracts, Heart Failure and Osteoarthritis. The Physician Orders document R15 was on antibiotics 2/24/26 through 3/5/26 for cellulitis of lower extremities and a Urinary Tract Infection. The Progress Notes between 2/19/26 and 3/5/26 did not include documentation that R15 refused cares or exhibited agitation behaviors. On 3/5/36 at 1:30 AM, R15 refused to get into bed; 3/8/26 at 8:33 PM, refused shower three times; and on 3/10/26 at 8:17 PM, refused to have leg wraps removed and had agitation. The Progress Notes between 3/5/26 and 3/11/26 do not include any other documentation that assessments were conducted or interventions implemented for the new onset of behaviors. The record does not include urinary assessments such as output, color, clarity, smell or pain associated with urination. On 3/11/26 at 6:42 AM, the Progress Note documents the Nurse was at Nurses' station when she heard someone yelling that R15 was on the floor. Upon entering R15's room, she was observed lying on her left side with head pointed toward the door, the overhead light was off and the room was dark. R15 was incontinent of bladder, and her pants were down by her ankles. R15 had a hematoma the size of a tennis ball on her left side forehead and bruising noted on left knee. Notifications were made and R15 was sent to the hospital and returned later the same day. The Progress Notes continue to document R15's refusal of cares. On 3/13/26, a urinalysis was ordered, abnormal results were reported on 3/14/26 and antibiotics were ordered 3/16/26. R15's current care plan documents her call light will be within reach when in her room and will be encouraged to use it for assistance and she will have a safe environment with glare-free light, a working and reachable call light and personal items within reach. Throughout the survey on multiple occasions on 3/17/26, 3/18/26 and 3/19/26, R15 was observed in bed or in her wheelchair next to the bed with no light on and the call light not within reach. On 3/18/26 at 11:54 AM, R15 was in her wheelchair sitting to the right of her bed. The call light was hanging from the wall between each bed (left side of her bed), behind a nightstand and was unreachable. A light hanging on the right side of the wall behind her bed did not have a knob/switch or pull cord to turn light off or on. On 3/18/26 at 11:56 AM, R34 (R15's roommate) stated R15's light has not worked since R15 has been in the room and the ceiling light switch was on the wall next to the door entrance/exit. R34 stated We can't use the light (ceiling light) because it blinds you, it's so bright. (R15) can't reach her lights anyway. She asks me or I just help her. The ceiling light was turned on and it was unable to be looked at due to its brightness. 4. R43 was admitted on [DATE] with diagnoses of Wedge Compression Fracture of Thoracic Spine, urinary Retention, Type 2 Diabetes Mellitus and Reflex Neuropathic Bladder. R43's Progress Note dated 1/19/26 at 3:54 AM, documents R43 was complaining of lower abdomen and penis pain. The indwelling catheter was changed, urine was flowing and pain was gone. There was no further Nursing documentation in the Progress Notes, assessments were conducted or that vital signs were conducted between 1/19/26 at 3:15 PM and 1/21/26 at 4:12 AM. On 1/21/26 at 4:12 AM, R43's Progress Note documents the nurse entered R43's room to administer morning medications and get a blood sugar and found R43 unresponsive to name, breathing rapidly, conducted vital signs: blood pressure 70/40 mmhg (millimeters of mercury), which was a much lower blood pressure than previous blood pressures), respirations 30 breathes per minute (12-20 breathes per minute are within normal range), oxygen saturation at 45% (90% and above is within normal limits), pulse was 46 beats per minute (60-90 beats per minute are within normal range) and no temperature was recorded. R43 was transferred to the hospital via Ambulance. The Emergency Department Provider Notes dated 1/21/26 at 4:31 AM, documents upon arrival, R43 had an elevated heart rate, rapid breathing, low blood pressure, mouth was extremely dry, lungs had congestion, felt warm to touch, aroused to voice only and urine was cloudy. The Clinical Impression was documented as Severe Sepsis (a life-threatening condition where an infection triggers organ dysfunction, requiring urgent medical intervention to prevent death), Altered Mental Status and Urinary Tract Infection with hematuria (blood). The Discharge Summary documented R43 was placed on comfort care and expired on 1/25/26. R43's record did not include documentation there was an inquiry into R43's hospitalization outcome, discharge disposition or that a discharge summary completed. 5. R48 was admitted on [DATE] with diagnoses of Cerebral Infarct, Alzheimer's Disease and Chronic Obstructive Pulmonary Disease. On 1/12/26 at 8:00 AM, The Physician documents in the Progress Notes that R48 had a fall, the hospital was concerned with lower back issues, had x-rays taken and there were no fractures noted. The nursing staff also stated that R48 has been having a little bit of a cough. The Physician is okay to go ahead and swab for a 4 Plex (Influenza A/B, RSV and COVID) test. On 1/12/26 at 12:31 PM, the nurse's progress note documents R48 had a deep cough, lung sounds were abnormal, and the Physician was notified. On 1/13/26, the Physical Therapy note documents R48 had a decrease in strength, balance, transfers, ambulation and ability to perform activities of daily living. On 1/15/26 at 7:05 AM, the Progress Note documents the nurse was alerted by the kitchen staff R48 was on the floor in the dining area. The Progress Note documents R48 was actively bleeding from her nose and had no other visible trauma. R48 was transferred to the hospital for evaluation due to being on a blood thinner and the amount of blood coming from her nose. The Emergency Department note documents R48 had a ground level fall resulting in facial trauma, nasal fracture with hematoma (blood clot), facial bruising and laceration on her arm. R48 was sent back to the nursing home. The record did not include documentation that neurological assessments or assessments of other body systems were conducted from when R48 returned from the Emergency Department on 1/15/26 at 10:55 AM and 1/16/26 at 10:26 AM when evaluated by the Physician and ultimately sent to the Emergency Department due to increased lethargy, decreased orientation, not alert to baseline, blood pressure of 200/163 laying down and 120/70 when sitting up and fluctuating, decrease in oxygen saturations, pupils pinpoint (indicates a neurological issue) and not reactive to light. The Hospital's Discharge summary dated [DATE] documents R48 was admitted with nasal bone fracture, facial ecchymosis and a laceration on her arm following a ground level fall (1/15/26) with concern for possible recurrent stroke and sepsis in the context of urinary tract infection and acute kidney injury or chronic kidney disease. R48 was discharged from hospital with Hospice services. R48's record did not include documentation the Plex 4 test was conducted, ongoing assessments of cough and decline in condition, neurological checks and body system assessments were conducted, that the Interdisciplinary Group evaluated R48's fall and/or discharge, nor was there an inquiry into R48's hospitalization outcome, discharge disposition or a discharge summary completed. On 3/19/26 at 12:31 PM, V2 (Director of Nursing) stated she didn't know what a 4 Plex test was and the tests were not in the facility for use. V2 stated any COVID, Influenza or RSV test would be retrieved from the local hospital and brought back to the facility for use. V2 was unaware that R48 had sustained a fall on 1/15/26. V2 stated R48 fell on 1/5/26 and broke her nose but was fine after and went to the hospital on 1/15/26 because she had a change in condition and never came back. V2 was unable to state the reason R48 did not return from the hospital. On 3/20/26 at 2:00 PM, V1 (Administrator) reviewed R6, R15, R43 and R48's records and agreed changes in conditions, post fall assessments, discharge dispositions, interventions, etc. were not documented, implemented or followed up on. V1 stated it was unable to be determined if the nurses or other staff members were providing appropriate cares and identifying and reporting changes in a resident's condition.

Based on observation, record review, and interview, the facility failed to ensure residents had functioning lights in their rooms for three (R12, R15, R29) of three residents reviewed for comfortable home like environment in a total sample of 28.Findings include:The facility's undated Maintenance Director Job Description documents The primary purpose of this position is to maintain the orderly functioning of all equipment in the facility including the kitchen, laundry, heating, air conditioning, and elevators as well as purchasing necessary supplies for repairs, maintenance, and emergencies.The facility's Resident Council Meeting minutes dated 01/19/26 documents concerns were raised that some light bulbs need replaced.On 3/18/26 during the Resident Council Meeting R12 who is alert and oriented reported he is unable to turn his overbed light on when he is in bed because there is not a chain or string on the light and it has been that way since he moved to that room. R12 reported V9 (Maintenance Director) was aware and came into R12's room some time ago and observed that there was not a chain or string on the overbed light so that R12 could turn the light on from his bed.On 3/18/26 between 11:50 AM and 1:00 PM, the following was observed:1.R29's overbed light did not have a string which could be reached from the bed.2.R15 has a light hanging on the right side of the wall behind her bed. The light did not have a knob/switch or pull cord to turn light off or on. R34 (R15's roommate) who is cognitively intact stated R15's light has not worked since she has been in this room and the light on the ceiling's switch was on the wall next to the door entrance/exit. R34 stated We can't use the light (ceiling light) because it blinds you it's so bright. R15 can't reach the lights. She asks me or I just help her. The ceiling light was turned on and it was so bright it could not be looked at directly.3.R12's overbed light did not have a chain or cord for R12 to be able to turn the light on and off when he is in bed. The wall switch by the entrance/exit door to room switched off and on and it controls the upper half of the overbed lights in the room. R12 present and reports if he wants a light on then all of the lights in the room have to be on and that is not fair to R27 (R12's roommate). R27's overbed light does have a string attached so that R27 can turn his overbed light on and off while he is in bed.

Based on interview and record review the facility failed to transfer a resident to the hospital with written explanation to the receiving hospital about the resident's condition for one resident (R37) of three residents reviewed for transfer to the hospital in a total sample of 28. Findings include:The Facility's undated Transfer Agreement with (Local Hospital System) documents that the facility will Transfer all necessary medical records, or in the case of an emergency, as promptly as possible, transfer and abstract of the pertinent medical and other records necessary in order to continue to the patient's treatment without interruption and to provide identifying and other information, including medical, social, nursing and other care plans. Such information shall also include, without limitation and if available, current medical findings, diagnoses, advanced medical directives, rehabilitation potential brief summary of the course of treatments at the Transferring Facility, nursing, dietary information, ambulation status and pertinent administrative and social information. The Facility's Resident Transfer and Discharge Policy dated 11/2025 documents the purpose of the policy as to ensure that (This Facility) Properly documents resident transfers and discharges; has a standardized discharge planning process that addresses residents' discharge goals and needs, and involves residents and IDT (Interdisciplinary Team). R37's Medical Record documents that she was admitted [DATE] with diagnosis to include but not limited to COPD (Chronic Obstructive Pulmonary Disease), Pneumonia and Sepsis. Throughout the survey R37 was able to answer all questions appropriately other than having a hard time finding the correct word. When words were provided, she would confirm or deny which word she meant. R37's Nurse's Notes dated 3/2/26 at 1:52PM V20 (Registered Nurse) documented that R37 was being sent to the emergency room due to leaning, drooling and slurred speech. R37's chart did not show any documentation of a full physical assessment, vital signs, blood sugar results or pulse oximetry. On 3/19/26 at 12:15 PM V20 (Registered Nurse) stated she did not fill out any discharge paperwork because it was just an ER visit. V20 confirmed that she did not inform the receiving facility (local emergency room) in writing of what R37's assessment results at the facility were, what she had done so far, the family's contact information, list of current medications or advanced directive status. On 3/19/26 at 12:18 PM V7 (Registered Nurse) stated Nope, we just call report, we haven't sent out transfer forms for a while now. On 3/19/26 at 1:00 PM V1 (Regional Administrator) stated All staff should be using our standardized transfer form that communicates all of the required information to the hospitals. Those forms should be used. V1 (Regional Administrator) confirmed there was no transfer form in place for R37 and that there should have been.

Based on observation, interview and record review the facility failed to ensure a resident maintained the ability to walk for one resident (R20) of twelve residents whose ADL (Activity of Daily Living) were reviewed in a total sample of 28.Findings include:The Facility's Activities of Daily Living policy dated 03/17/2025 documents Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The Facility's Activities of Daily Living policy documents Care and services to improve, prevent and/or minimize functional decline will include appropriate restorative plans, appropriate pain management, as well as treatment for depression and symptoms of depression. Appropriate restorative plans may include but not limited to the following areas: 1. Range of Motion (passive or active) 2. Splint/Brace assistance 3. Bed Mobility 4. Transfers 5. Walking 6. Dressing and/or grooming 7. Eating and/or swallowing.R20's Occupation Discharge summary dated 12/2026 documents Transfer program established/Trained: walk to/from meals with use of FWW (Front wheeled walker), gait belt, wc (wheelchair) follow as needed and SBA (Standby Assist.) R20's Walking electronic documentation task documented N/A for all shifts for 02/01/26 through present. Throughout the survey R20 propelled herself to and from meals in her wheelchair. On 3/18/26 R14 CNA (Certified Nurse Aide) stated that R20 isn't on a walking program as far as I know, She usually rolls herself wherever she wants to be.On 3/17/26 R20 stated They (CNA staff) used to come in and walk me to and from meals, but they don't anymore I don't know why.On 3/19/26 1050AM V17 (COTA/Certified Occupational Therapy Assistant) stated that R20 should be walking to and from meals. V17 stated (R20) can do it with distant supervision, but she tends to comply and walk for a month or so then she quits and then loses her endurance and ends back on therapy. V17 stated that the staff should be encouraging and/or walking with R20 to and from meals. V17 stated it would be the expectation if R20 was not walking that the staff document why she didn't. Walk to dine programs have been a problem in this building, they don't get done regularly unless someone complains. On 3/19/26 V2 (Director of Nursing) R20's walking documentation did not document any walking for R20 throughout February or March 2026.

Based on observation and record review the facility failed to perform a urinary catheter flush in a way that prevented cross contamination of clean areas for one (R14) of two residents reviewed for catheter care in a total sample of 28.Findings include:The facility's Indwelling Catheter policy dated 12/23/2023 documents Only persons (facility staff personnel, family members, or patients themselves) who know the correct technique of aseptic insertion and maintenance of the catheter should handle the catheters. Irrigation:5. Put on gloves6. Remove catheter from catheter drain bag7. Cleanse catheter tubing with alcohol8. Connect syringe to catheter tubing9. Flush catheter by inserting the water from syringe into the catheter. Remove syringe10. Cleanse end of catheter tubing and catheter drain bag with alcohol and reconnect to catheter drain bag12. Place syringe and other equipment into plastic bag13. Remove gloves and wash hands. On 03/18/2026 at 11:15 AM V4 (LPN) donned PPE gloves and gown outside of the room and entered room and shut door with gloved hands then removed gloves and washed hands and donned new gloves. V4 then opened the package containing the syringe for the flush, opened the Acetic Acid bottle and drew up solution into the syringe. V4 then laid the syringe on the bedside table and then with gloved hands moved R14's walker, pulled up the leg of R14's pants. V4 then opened two alcohol swabs and laid the swabs directly on the outside packaging, then disconnected the foley drainage bag from the inserted tubing and handed the drainage bag from the inserted tubing to R14 who then rolled it back and forth in his fingers while V4 was performing care. V4 picked up one alcohol swab and wiped the insertion end of the catheter tubing and then began flushing the catheter slowly. R14 requested she quit flushing after around 25 milliliters of Acetic Acid had been instilled and V4 complied. V4 then wiped both ends of the catheter tubing with alcohol swabs. V4 manipulated the catheter tubing directly outside R14's urethra until R14 said ok. V4 then pulled R14's pants up, put his walker back where R14 wanted it and moved R14's bedside table back within reach. V4 then removed gloves and gown and washed her hands.

Based on interview and record review the facility failed to reweigh a resident with a significant weight loss for one resident (R1) of three residents reviewed for weight loss in a total sample of 28. Findings include:The Facility's Weight Assessment and Interventions dated December 30, 2024, documents The nursing staff will measure resident weights on admission, and then weekly for four weeks. If no weight concerns are noted at this point, weights will be measured monthly The Facility's Weight Assessment and Interventions dated December 30, 2024, documents any weight change of 5 pounds or more within 30 days will be retaken the next day for confirmation. If the weight is verified, nursing will notify: a. The provider b. Dietary manager/dietician. R1's Medical Record documents he was admitted to the facility on [DATE] with diagnosis to include but not limited to Hemiplegia and Hemiparesis after Cerebral Infarction, Noncompliance with cares and Displaced Trimalleolar Fracture. R1's weight dated 2/2/26 was 142 pounds. R1's weight dated 3/5/26 was 127.5 pounds. On 3/18/26 at 11:00 AM V2 (Director of Nursing) confirmed that R1 did not have his admission weights done on the day of admission and then weekly and that the second time R1 was weighed there was a 14.5 pound difference and R1 should have been reweighed the next day (3/6/26) V2 (DON) confirmed there was no documentation of weekly admission weights or any reweigh of R1 after the 14.5 pound difference.

Based on interview and record review, the facility failed to ensure medical records were accurately documented with resident assessments for one of twelve residents (R48) reviewed for accurate documentation in a sample of 28.Findings include:The Charting and Documentation policy revised 11/5/19, documents medical record entries shall be made by the person providing or supervising/observing the service being documented. Narrative documentation/progress notes will be documented under the premise of charting by exception. It is anticipated that all routine care and services will be delivered within established standards of professional practice and regulatory guidance and may not be reflected in the medical record. Documentation will include information on assessment, notifications, interventions and evaluation including but not limited to incidents/accidents, change in condition, physician notification, responsible party notification, refusal of medication/treatment or recommendations, education provided, status updates/summaries as required. Transfer, discharge or leave of absences.On 3/18/26, R48's record was reviewed. The record noted R48 was on neurological checks following a fall with head trauma per policy. The electronic record did not include post fall neurological checks.On 3/18/26 at 11:45 AM and 2:45 PM and on 3/19/26 at 11:45 AM, R48's neurological assessment monitoring post fall, on 1/15/26 were requested. On 3/19/26 at 2:15 PM, V2 (Director of Nursing) provided R48's Neuro/Head Trauma Assessment form dated 1/15/26. Each assessment entry beginning 1/15/26 at 7:05 AM through 1/17/26 3rd shift is documented in the same handwriting, although the nurse's initials for each entry were unique.On 3/19/26 at 2:30 PM, V1 (Administrator) reviewed the Neuro/Head Trauma Assessment form and agreed each of the neurological assessments were documented in the same handwriting. V1 stated the record appeared to be falsified.

Based on interview and record review, the facility failed to ensure hospice communication was coordinated and the required documents were available and accessible to the facility staff for one resident (R6) reviewed for hospice care management in a sample of 28. Findings include:The Hospice Care policy revised 8/25/25, documents the facility will work in coordination with the contracted hospice agency to provide a safe continuum of care for the resident's end of life. The Hospice agency will participate in the residents' plan of care and provide services/supplies outside the general as needed procedures and be available 24 hours a day.R6 was admitted on [DATE] with diagnoses of Venous Insufficiency, Alzheimer's Disease, Dementia and Dysphagia. R6 elected Hospice Benefits on 9/24/25.R6's current Care Plan lacked specific Hospice responsibilities/interventions or that R6 was utilizing a self-adjusting and alternating pressure mattress.The Hospice binder located at the nurse's station included a Hospice Plan of Care dated 9/24/25 through 12/22/25. The binder did not include an updated Hospice Plan of Care, visit notes, visit update notes, which Hospice providers were involved with R6's care, frequency of visits and/or responsibilities of those providers or correspondence between facility and Hospice staff.On 3/17/26 at 10:28 AM, V4 (Licensed Practical Nurse) performed skin care treatment to R6's bilateral lower extremities and on 3/17/26 at 1:30 PM, V4 stated I need to call Hospice and report a change in condition. (R6) did not eat supper last night or breakfast this morning. V4 stated she didn't know if Hospice staff participated in the facility's Interdisciplinary Team meetings and that the Hospice nurse usually receives a verbal report from the facility nurses prior to their visit.On 3/17/26 at 9:47 AM, 10:48 AM, 12:46 PM, 1:30 PM, 2:30 PM and 3:32 PM, R6 was observed to have a dual functioning system that delivers continuous self-adjusting and alternating pressure mattress in which appeared not powered on.On 3/17/26 at 3:32 PM, V2 (Director of Nursing) was taken to R6's room and showed the alternating pressure mattress was not powered on. V2 confirmed the power light was not on and stated I don't know. The mattress doesn't seem to be flat, so I don't think it's really hurting anything. I'll call hospice and see what they say about it. On 3/17/26 at 3:55 PM, V2 stated the alternating pressure mattress was unplugged and is now working.On 3/18/26 at 9:45 AM, R6's record did not include documentation the Hospice was notified of R6's change in condition.On 3/19/26, the Hospice binder was reviewed and the Hospice nurse dated, timed and initialed to indicate a visit had been conducted the early morning of 3/19/26 although no note or status update was included.On 3/19/26 at 2:30 PM, V1 (Administrator) was notified the Hospice binder had not included an updated Hospice Plan of Care, Visit Notes or correspondence between the Hospice and facility. It was unable to be determined if Hospice was notified of R6's change in condition, if the facility or Hospice provided the air mattress or if there were instructions for the use. The facility's Care Plan did not include specific interventions and responsibilities related to Hospice.On 3/20/26 at 9:06 AM, R6 was transferred to a private room to pass peacefully.

Based on interview and record review, the facility failed to ensure Influenza and Pneumococcal immunizations were offered to three of five residents (R6, R17, R37) reviewed for immunization compliance in a sample of 28.Findings include: The Influenza Vaccine policy revised 10/10/25, documents all residents will be given information on the importance of adult immunizations. Prior to administration each resident or resident's legal representative shall receive education regarding the risks, benefits and potential side effects of the immunization. Evidence of education is to be documented on the individual resident's medical record. Consent form must be signed prior to administration by the resident or responsible party after reviewing the vaccination information statement. The resident or responsible party may revoke consent by providing facility with a request in writing. Verbal consent is acceptable.The Pneumococcal Vaccination policy revised 10/28/24, documents prior to administration each resident or resident's legal representative shall receive education regarding the risks, benefits and potential side effects of the immunization. Evidence of education is to be documented on the individual resident's medical record. Consent form must be signed prior to administration by the resident or the party responsible may revoke consent by providing facility with a request in writing.1.R6's immunization record documents Pneumococcal vaccine was refused, and the Influenza vaccine was administered on 10/17/25.R6's Universal Vaccine Consent Form- Long-Term Care Facility signed by the resident's representative on 10/17/25, does not specify that vaccine information was given to the resident's representative nor the name of which vaccine is being consented for.2. R17's immunization record documents Influenza vaccine was administered on 10/17/25.R17's Universal Vaccine Consent Form- Long-Term Care Facility signed by the resident's representative on 10/17/25, does not indicated which vaccinations were accepted or declined nor that vaccine information was given to the resident's representative.3. R37's immunization record documents Pneumococcal and Influenza vaccinations were refused.R37's Universal Vaccine Consent Form- Long-Term Care Facility signed by R37 on 10/17/25, indicated she declined to receive the Influenza vaccination only and did not indicate that vaccine information was given to the resident.On 3/18/26 at 1:00 PM, V2 (Director of Nursing/Infection Preventionist) reviewed R6, R17 and R37's Universal Vaccine Consent Form-Long-Term Care Facility and agreed the consent forms were incomplete and should have indicated which vaccines were accepted or declined and which vaccine information was given to the resident or resident's representative.

Based on interview and record review, the facility failed to ensure COVID-19 vaccinations were offered to three of five residents (R6, R17, R37) reviewed for immunization compliance in a sample of 28.Findings include:The COVID-19 Vaccination policy dated 7/15/21, documents all residents are to be offered the COVID-19 vaccine unless the immunization is medically contraindicated. Residents and/or Residents Representatives are provided with education regarding the benefits and risks and potential side effects associated with vaccine. The medical record includes documentation that indicates the resident or resident's representative was provided education and accepts or refuses the vaccination.1.R6's immunization record does not document the COVID-19 vaccination was administered or refused.R6's Universal Vaccine Consent Form- Long-Term Care Facility signed by the resident's representative on 10/17/25, does not specify that vaccine information was given to the resident's representative nor the name of which vaccine is being consented for.2. R17's immunization record documents COVID-19 vaccination was refused.R17's Universal Vaccine Consent Form- Long-Term Care Facility signed by the resident's representative on 10/17/25, does not indicate which vaccinations were accepted or declined nor that vaccine information was given to the resident's representative.3. R37's immunization record documents COVID-19 vaccination was refused.R37's Universal Vaccine Consent Form- Long-Term Care Facility signed by R37 on 10/17/25, indicated she declined to receive the Influenza vaccination only and did not indicate that vaccine information was given to the resident.On 3/18/26 at 1:00 PM, V2 (Director of Nursing/Infection Preventionist) reviewed R6, R17 and R37's Universal Vaccine Consent Form-Long-Term Care Facility and agreed the consent forms were incomplete and should have indicated which vaccines were accepted or declined and which vaccine information was given to the resident or resident's representative.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement interventions for a resident with a known history of elopement and exit-seeking behaviors to prevent elopement and failed to provide adequate supervision for one of one residents (R5) reviewed for elopement risk in the sample of six. These failures resulted in R5 exiting the facility on 1/5/26 without staff knowledge and being found at a local coffee shop two blocks away, near a busy highway, during cold weather conditions when a concerned citizen called 911, and emergency medical services responded.These failures resulted in an Immediate Jeopardy that began on 1/5/26. V1 (Administrator) was notified of the immediate jeopardy on 1/27/26 at 12:10 PM. While the Immediate Jeopardy was removed on 1/28/26, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and quality assurance.Findings include:The facility's Wandering & Elopement Assessment and Prevention policy revised 6/4/2024 documents all residents in this facility shall be assessed for elopement/unsafe wandering, to ensure their safety and prevention from elopement. Elopement is defined as a resident unable to protect themself, who departs the healthcare facility or enters a non-resident area unsupervised or undetected. An incident report will be completed by the Nursing Supervisor noting all investigative procedures, witness statements, and any other pertinent information.R5's census line documents R5 was admitted to the facility on [DATE].R5's Elopement Assessments dated 9/7/23 and 4/3/25 document R5 is at risk for elopement and has previously eloped from the facility. The 4/3/25 assessment also documents R5 exhibits exit-seeking behaviors.R5's Wandering/Elopement assessment dated [DATE] documents R5 has a history of leaving the facility.R5's care plan was updated on 1/6/26 to include wander guard placement, and physician orders dated 1/6/26 document a wander guard was placed on R5. R5's care plan further documents R5 has Alzheimer's/Dementia, Poor Safety Awareness, is at Risk for Falls and R5 walks with a walker and staff supervision.R5's Nurse Progress Note dated 1/7/26 at 11:47 AM documents R5 remains on 15-minute checks for safety and observation after a recent exit-seeking episode.R5's electronic record revealed no Nurse Progress Note or assessment regarding R5 eloping from the facility on 1/5/26.The National Weather Service report for Monmouth, Illinois, dated 1/1/26-1/24/26, documents that on 1/5/26 the outside temperature was a high of 49 F and a low of 28 F.On 1/26/26 at 9:45 AM, R5 was observed lying in bed with the call light attached to the blanket, watching television. R5 was only alert to self during conversation. A walker and manual wheelchair were at the foot of R5's bed.On 1/26/26 at 11:15 AM, V3 (R5's Friend) stated that on 1/5/26, V3 received a call from V1 (Administrator) informing her that R5 had exited the facility, possibly by following visitors out the door unnoticed. V3 stated V1 told her she was very upset and felt terrible that R5 had gotten out, but V1 had found R5 at a local coffee shop. V1 told V3 that R5 stated he had left to help someone fix their car. V3 stated she was notified only after R5 was found, not when he was missing. V3 further stated that shortly after R5 was admitted to the facility in February 2023, R5 had eloped another time because R5 wanted to go to a parade, and nobody would take him. V3 stated R5 was found walking on a busy street and brought back to the facility.On 1/26/26 at 12:05 PM, V2 (Director of Nursing) stated staff and V1 made her aware they were looking for R5 and could not find him. V2 stated she immediately started searching the back hallways and other resident rooms. V2 stated she was told the facility received a call that R5 was found. V2 stated she does not know why there is no documentation in R5's chart regarding the elopement and that it should have been documented in R5's electronic medical record. V2 further stated she assumed the documentation was there.On 1/26/26 at 12:20 PM, V1 (Administrator) stated that on 1/5/26 an unknown Certified Nursing Assistant came to the front office asking if they had seen R5. V1 stated they began searching bathrooms and resident rooms, and when they realized R5 was not in the facility, they searched the perimeter. V1 stated she drove two blocks east, saw EMS (emergency medical services) lights at a local coffee shop, and found R5 there. V1 stated a concerned citizen had called 911 after seeing R5 walking with his walker. V1 stated she was not aware the incident was not documented in R5's chart.On 1/26/26 at 1:45 PM, V8 (Certified Nursing Assistant/CNA) stated R5 got out of the facility, and nobody knew he had left. V8 stated R5 has gotten out before, though V8 was not present during prior incidents. V8 stated R5 can ambulate with a walker or wheelchair depending on the day.On 1/26/26 at 1:48 PM, V6 (CNA) stated she saw R5 walking in the hallway with his walker between approximately 3:50 PM and 4:15 PM. V6 stated after assisting another aide, she was informed staff could not find R5. V6 stated she joined the search and drove with the activity director, locating EMS lights at a local coffee shop where R5 was found.On 1/26/26 at 1:53 PM, V7 (CNA) stated she was told R5 got out of the facility while she was working, but she was not involved in the search because she was assisting another resident.On 1/26/26 at 2:15 PM, V1 (Administrator) stated R5 did not have a wander guard prior to 1/5/26 because R5 refused to wear it, and this refusal was not documented. V1 confirmed R5 previously eloped in September 2023 and was found walking on a street.The facility submitted an abatement plan on 1/27/26 and was advised by the regional office to make revisions before it would be accepted. The facility submitted the revised abatement plan on 1/28/26. Again, the facility was advised to make revisions to the plan. The final abatement plan was submitted on 1/29/26.On 1/29/26 this surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1.All staff members present were in-serviced on 1/27/26 and 1/28/26 on the elopement policy and procedure. All remaining staff members will be in-serviced via telephone prior to their next shift by administrator and/or designee.2.On 1/28/26, audit conducted by administrator and director of nurses by auditing medical chart to ensure interventions are in place and documentation of event with all action taken is recorded.3. On 1/28/26 all nurses were in serviced on incident charting and completion by Director of Nursing.4. On 1/27/26 all residents had an updated wandering/elopement assessment completed by Director of Nursing and Assistant Director of Nursing. Care plans were reviewed for accuracy by Director of Nursing on 1/28/26.

Based on record review and interview, the facility failed to maintain complete and accurate clinical records for two residents (R3, R5) of three reviewed for documentation out of a sample list of six.Findings include:The facility's Charting & Documentation Policy revised 11/5/2019. The purpose of this policy is to maintain a medical record to serve as a legal document that details the services provided to the residents, or any changes in the residents' medical or mental condition, through charting and documentation. Documentation will include information on assessment, notifications, interventions and evaluation including but not limited to: Incidents/ Accidents, Change in Condition, Physician Notification and Responsible party, education provided to resident and or responsible party.1. R5's electronic medical record contained no Nurse Progress Note or assessment regarding R5's elopement from the facility on 1/5/26.R5's care plan was updated on 1/6/26 for wander guard placement, and physician orders dated 1/6/26 documented the wander guard was placed. However, there was no documentation of the elopement event, staff response, or resident condition after returning to the facility.On 1/26/26 at 12:05 PM, V2 (Director of Nursing) stated she assumed documentation was completed but confirmed it was missing from R5's chart.On 1/26/26 at 12:20 PM, V1 (Administrator) stated she was not aware the incident was not documented in R5's chart.2. R3's Medical Diagnosis list documents R3 has Alzheimer's Disease and Dementia.R3's current care plan documents R3 is at risk for Falls and Elopement/Wandering and a wonder guard was placed on R3 on 1/28/26.R3's Nurse Progress Note dated 12/31/25 documents R3 has a bruise under her left eye that is healing. There is no documentation in R3's chart explaining how the bruise occurred, nor any follow-up assessment or investigation.On 1/28/26 at 1:30 PM, V2 (Director of Nursing) stated all incident/accident documentation has been recorded in the facility's internal Risk Management system, which does not carry over into the resident's electronic medical record. V2 stated any assessments related to an incident would not be found in the residents' chart for this reason. V2 further stated she is in-servicing nurses on how to ensure assessments and incident documentation are entered into the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure complete and timely physician notification following a resident accident and subsequent change in condition for one of three residents (R1) reviewed for notification of change out of a sample list of three. This failure resulted in R1 experiencing excruciating pain to her right hand due to a delay in notifying the physician and ultimately leading to a diagnosis of a fracture.Findings include:The facility's Physician Notification Policy revised 11/5/2022 documents a facility will immediately inform the resident; consult with the resident's physician; and notify, of a significant change in condition in a resident's physical, mental, or psychosocial status or a need to alter treatment significantly.The facility's Change in Condition Procedure revised 9/21/2022 documents a change in condition requires notification of Medical Doctor of change and resident assessment information. R1's Nurse Progress Note dated 8/12/25 documents R1, who utilizes a wheelchair was on a supervised outing with facility staff. While navigating a grassy area, R1 slid forward out of her wheelchair, landing on her knees and both hands. Staff immediately assessed the resident on-site. R1 voiced she was fine and attempted to reposition herself independently. Staff assisted her back into the wheelchair without issue and returned R1 to the facility. R1 was assessed upon return to facility and Physician, Director of Nursing (DON), and Administrator were notified, and an intervention was initiated for foot supports to be added to R1's wheelchair to prevent future sliding incidents.R1's Medical Diagnoses revealed R1 has Myasthenia Gravis and Cerebellar Ataxia, both of which affect muscle strength, coordination, and mobility.R1's Minimum Data Set (MDS) dated [DATE] documents that R1 is cognitively intact and requires substantial/maximal assistance with standing and transfers. R1's Nurse Progress Note dated 8/12/25 at 3:50 PM, documents R1 reported minimal pain in the right hand following a fall earlier that day. R1's right hand had mild edema and scant discoloration observed on the 3rd, 4th, and 5th fingers. Ice was applied to the right hand. R1 stated It does not hurt really unless she moves her fingers.R1's Nurse Progress Note dated 8/13/25 at 12:30 AM documents R1 was complaining of discomfort right hand, right hand is very swollen and bruised, unable to grip with hand. R1's right great toe is painful and bruised. Ice offered for hand, resident declined, the pressure causes discomfort. R1 states she injured her hand on outing in wheelchair.R1's Nurse Progress Note dated 8/13/25 at 10:30 AM documents R1 was up in her recliner chair with right lower extremity (RLE) elevated due to swelling on the top of right foot area from the previous incident on 8/12/25. Bruising continues to R1's right great toe between toe and top of right foot. R1's right hand remains swollen with bruising. Will continue to monitor.R1's Nurse Progress Note dated 8/13/25 at 11:30 AM documents Ordered through portable X-Ray two view Xray of right hand due to moderate swelling and moderate bruising with pain, per V9 (Medical Director).R1's Nurse Progress Note dated 8/14/25 at 10:45 AM documents R1's X-ray results of right hand reveal prominent displaced fractures involving the base of the proximal phalanges of the third through fifth digits.On 9/10/2025 at 8:50 AM, R1 was seated in a wheelchair and had a hard cast on her right wrist. R1 was pleasant and alert during the interview. When asked about the injury, R1 stated, (R1) was with (V3/Activity Director) on my way to the store. (V3) was pushing me in my wheelchair, and we hit a curb or something on the ground, and (R1) fell out into the grass and broke her hand. R1 stated they had her foot in a boot as well because of her toe, but it's doing better. R1 stated she normally wears foot pedals outside of facility but forgot them that day. R1 stated if she had foot pedals on the chair she would not have fallen out. R1 further stated that she immediately felt excruciating pain in her right hand shortly after her fall and that she made the staff aware of the pain as soon as staff arrived to help R1 up from the ground. On 9/10/25 at 9:54 AM, V3 (Activity Director) stated that the facility regularly takes residents on outings to a local store, located one block from the facility. V3 reported, We take side streets when we walk because it's less busy. There's a three-four-foot patch of grass off the sidewalk. V3 explained that during the outing on 8/12/2025, she remained with R1 while other residents and staff returned to the facility. V3 stated, I told her hold on, I'll put my bags down and help you. V3 reported that R1 self-propels using her arms and feet, and that as V3 attempted to assist R1 through the grassy area, which was uneven, then it happened so fast that R1's wheelchair's front wheels were in the grass and the rear wheels remained on concrete. V3 stated, (R1) slipped out of wheelchair going forward and I think R1 put her feet down to break the fall and was on her knees, put her hands down on the ground to break her fall. (R1) then rolled over in the grass. V3 noted that R1 was not wearing foot pedals at the time, adding, She never does wear them. V3 acknowledged, It was swollen very quickly. I should've done things differently-I probably should have had foot pedals on, or pulled her backwards, or taken her another way. V3 contacted the facility immediately, and two Certified Nursing Assistants (CNAs) were sent to assist, as V3 is not a CNA or nurse.On 9/10/25 at 10:30 AM, V4 (Licensed Practical Nurse/LPN) stated that she was made aware of the fall by V2 (Director of Nursing) and was unsure who assisted R1 at the scene. V4 reported, I don't remember any CNAs leaving the floor to go help. V4 stated that R1 did complain of pain during her assessment upon returning to the facility. However, V2 directed staff to wait a day or two before determining whether R1 needed an X-ray or further evaluation. V4 also stated she was told that V3 was pushing R1 in her wheelchair when they hit something, causing R1 to fall forward. V4 added, I was told that (R1) stopped her fall using her hands on the ground.On 9/10/25 at 12:00 PM, V2 (DON) stated that on 8/12/2025, she received a call from V3 (Activity Director) reporting that R1 had slid out of her wheelchair while outside the facility at a local store and was on the ground. V2 stated she sent two CNAs to assist because V3 was not certified to lift or transfer residents. Upon R1's return to the facility, V2 assisted V4 (LPN) with the assessment. V2 reported that R1 did not complain of pain, swelling, or bruising at that time, so they decided to monitor her condition. V2 stated that on 8/13/2025 at 12:30 AM, V5 documented increased pain, swelling, and discoloration to R1's hand. V2 acknowledged that V5 should have reported this change in condition to the physician. V2 also stated that V6 (RN) documented continued pain and swelling on 8/13/25 without notifying the physician.On 9/10/25 at 1:05 PM, V8 (CNA) stated on 8/12/2025, she and V7 (CNA) were passing lunch trays when V2 (DON) informed them that R1 had fallen outside of a local store and needed assistance. V8 reported that when they arrived, R1 was sitting on the ground. V7 and V8 used a gait belt to assist R1 back into her wheelchair. V8 stated, (R1's) right hand was very swollen, and (R1) was complaining that it hurt. V8 observed that R1's hand became more swollen and bruised over the next few hours. V8 stated she provided care for R1 again on 08/13/2025, and R1 continued to complain of pain in her right hand and foot. V8 reported that she notified V4 (LPN), and that V2 responded, (R1) hand will be fine-it's probably just a sprain. V8 stated that V4 appeared upset and felt R1 needed an X-ray. V8 further stated we are often told by management to not report things.On 9/10/25 at 1:30 PM, V7 (CNA) stated that when she and V8 arrived at the scene on 8/12/2025, R1 was sitting on the ground with her legs extended and hands on the ground. V7 reported that R1 stated her hand was very sore and asked staff to be careful with it. V7 observed that R1's hand was swollen, bruised, and stated, Her hand was hurting her very bad. V7 stated that she and V8 notified a nurse but could not recall which nurse was informed. V7 also stated she was not aware of R1 refusing to wear foot pedals, noting, Sometimes she wears them and sometimes she doesn't.On 9/10/25 at 8:30 AM, V9 (Medical Director) stated he remembers receiving the call on 8/12/25 regarding R1's fall. V9 stated he does not remember exactly what was said to him at that time, but if it was conveyed to him that R1 was in a lot of pain or had swelling V9 would have sent R1 to the emergency room to be evaluated. V9 stated when he saw R1 the next day he ordered an Xray. V9 stated he expects to be notified any time a resident has a condition change or increased pain. V9 stated he does not recall the facility calling him with updates on R1's change of condition.

Based on observation, interview, and record review, the facility failed to implement appropriate safety interventions for cognitively impaired residents and failed to complete therapy evaluations after multiple falls for two (R1 and R2) of three residents reviewed for falls. These failures resulted in R1 sustaining a left foot fracture and experiencing three falls over a 24-day period, and R2 sustaining a displaced rib fracture and right radial neck fracture following an unwitnessed fall. R2 was later placed on hospice services due to declining condition. Findings include: The facility's Fall Reduction policy revised 11/5/19 documents a therapy screen will be recommended for residents who are at risk of falling. The care plan should be reviewed after every fall and updated with a new intervention. Residents with falls should be reviewed weekly to identify root cause, effectiveness for interventions, and make care plan revisions. 1.) R1's Minimum Data Set MDS dated [DATE] documents R1 is cognitively impaired. R1's fall risk assessment dated [DATE] documents R1 is high risk for falls. R1's current care plan documents R1 has a diagnosis of Dementia and R1 is at risk for falls due to poor safety awareness. R1 has fallen on 5/6/25, 5/20/25, and 5/30/25. R1's current care plan further documents R1 is independent with transfers, toileting, and mobility in R1's room. R1's Unwitnessed Fall report dated 5/6/25 at 5:30 AM, documents R1 was found in R1's room sitting on the floor beside R1's bed. R1 was barefoot at the time of the fall. R1 stated R1 slipped trying to get up to go to the bathroom. R1's Nurse Progress Note dated 5/6/25 documents R1 had an x-ray of left foot which revealed a fracture to the head of the fifth metatarsal on left foot. R1 is non-weight bearing to the left foot. R1's Nurse Progress Note dated 5/20/25 documents R1's roommate yelled for help because R1 had fallen out of R1's bed and was on the floor. R1 was sitting on R1's bedroom floor in front of her bed with her legs straight out in front of her. R1's bed was not in lowest position and R1 did not have gripper socks on. R1's room was dark, and her call light was within reach. R1 stated I just fell out of bed and I was trying to go to the bathroom. Fall Intervention is to apply anti slip strips on floor beside R1's bed. R1's Nurse Progress Note dated 5/30/25 documents R1 was seen sitting on the floor by the side of the bed. R1 stated R1 slid off the bed. R1 was sitting with her back supported by the side of the bed and R1's bilateral lower extremities were extended in front of R1. R1 was assisted back to bed by two staff members, R1 was instructed to turn on call light on when wanting to go to bathroom. R1's electronic medical chart does not contain documentation of a therapy evaluation after R1's falls on 5/6/25, 5/20/25, and 5/30/25. On 6/17/25 at 9:30 AM, R1 was lying in R1's bed with R1's eyes closed. Metal half rails were up on the side of the bed. On 6/17/25 at 9:15 AM, V1 (Administrator) stated that R1 is confused and rolled out of bed onto the floor. R1 was inching to the side of the bed and rolled out. R1 had not been evaluated by therapy since admission to the facility. On 6/17/25 at 10:00 AM, V2 (Director of Nursing) stated R1's falls are usually at night when R1 gets up to go to the bathroom. V2 is unsure when R1 was last screened for a therapy evaluation. V2 further stated that some of R1's safety interventions are not appropriate because R1 takes off R1's gripper socks and will not leave them on. V2 also stated R1 would not remember to use a call light for assistance. V2 confirms R1 does not have very good memory recall especially at night R1 becomes more confused. V2 confirmed R1 should have been evaluated by therapy to ensure it was safe for R1 to be toileting and ambulating in R1's room independently. On 6/17/25 at 9:35 AM, V3 Certified Nursing Assistant (CNA) stated V3 was unaware of R1's fall with a fracture to left foot. R1 gets up on her own and does her own thing in her room. We push R1 in a wheelchair to the dining room because R1 cannot walk very far and R1 is confused and disoriented. On 6/17/25 at 1:31 PM, V6 (R1's Family Member) stated R1 has dementia and was placed in the facility after a fall at home. R1 is unable to care for herself and is very forgetful and does not recognize her family anymore. V6 stated R1 would need help with toileting and ambulating as R1 has had past falls and is very forgetful and unsteady. 2.) On 6/17/25 at 12:50 PM, R2 was lying in bed with eyes closed. R2 was not responsive to voice. R2's family was at the bedside. R2 had half rails on each side of the bed. R2's Fall assessment dated [DATE] documents R2 is at moderate risk for falls. On 6/17/25 at 1:00 PM, V6 (R2's Family Member) stated when R2 admitted to the facility approximately four weeks ago R2 was alert and oriented and had been doing things on her own at home. R2 sustained a fall at home and was admitted to the facility for rehab. V6 further stated R2 had a diagnosis of Cancer but had been doing well health wise. V6 stated R2 has fallen approximately four times since being admitted to the facility and has continued to decline each time. V6 stated R2 had an unwitnessed fall on 5/29/25 and sustained a fractured elbow, rib and shoulder. R2 was admitted to hospice after the fall per recommendation of the facility. There is not enough staff here to provide care, R2's call light doesn't show when it is on at the nurse's station because the panel is broken. V6 further stated V6 regrets bringing R2 to this facility and feels if he had not, R2 would not currently be in the condition she is in. R2's admission Nurse Progress Note dated 5/7/25 documents R2 was admitted to the facility for therapy. R2 was cognitively intact and required assistance of one staff member and a walker for ambulation and transfers. R2's Social Services Note documents R2 is alert and oriented and was admitted to the facility on [DATE] for short term therapy with plans to discharge home after therapy in completed. R2's Nurse Progress Note dated 5/13/25 documents R2 was found on the floor of R2s room crawling on her hands and knees stating R2 thought there was water on the floor coming from the hallway. R2 stated she did hit her head and touched her right-side temple. With the help of staff R2 was helped up and into her wheelchair. R2 was reeducated to use the call light system, location and how and when to use it. R2 was encouraged to call for help when needed. R2 states I thought there was water all over the floor. R2's Nurse Progress Note dated 5/20/25 documents R2 was observed on her bottom in front of R2's recliner with her knees bent. R2 had a small skin tear on her left elbow. Educated R2 on the importance of calling for assistance when she needs to use the bathroom to ensure her safety so R2 does not fall and harm herself. R2 was helped into her recliner. R2's Nurse Progress Note dated 5/21/25 documents R2 was observed on her hands and knees on the floor looking under her bed. When asked if she needed help R2 stated she was looking for something she had dropped. No signs of injury, R2 is alert and oriented, no abnormalities to head or back or discoloration. R2 was assisted back to bed. R2's Nurse Progress Note dated 5/29/25 documents R2 had an unwitnessed fall and was observed sitting in R2's wheelchair inside her room. R2 apparently was outside of her room trying to go home. A head-to-toe assessment completed. R2 was able to move all extremities and was unable to raise her right arm all the way but was able to elevate her left all the way up. R2 has large abrasion on her right side back. R2 is complaining of inability to catch her breath although she says it is due to her lung cancer. R2's Nurse Progress Note dated 5/29/25 documents R2 is complaining of pain on right side and right arm from the fall. R2's physician was notified and ordered a mobile x-ray to be performed at the facility. R2's X-Ray results dated 5/30/25 documents R2 has a displaced rib fracture to the eighth rib and a right radial neck fracture. R2's Census documents R2 was admitted to Hospice on 6/1/25. On 6/17/25 at 10:00 AM, V6 (Certified Nursing Assistant) stated when R2 admitted to the facility R2 was alert/oriented and walked with a walker and was an assist of one. R2 was often unsteady and slowly became worse to where two staff had to help R2. R2 was not confused until around the end of May. After R2 fell on 5/29/25 R2 did not get out of bed.

Based on record review and interview the facility failed to follow facility policy and obtain a physician order for care after a resident's Gastronomy tube (G-tube) became clogged. This failure resulted in R1's G-tube being replaced with an indwelling urinary catheter. This indwelling urinary catheter was used to administer enteral tube feedings for two days resulting in R1 experiencing emesis, loose stools, and being hospitalized . This failure affected 1 of 1 residents reviewed for Gastrostomy Tubes (R1) in a sample of 3. These failures resulted in an Immediate Jeopardy. The facility presented an abatement plan to remove the immediacy on 10/1/24. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned 10/2/24 to the facility for revisions. The facility presented a revised abatement plan on 10/4/24, and the survey team accepted the abatement plan on 10/4/2024. While the Immediate Jeopardy was removed on 10/4/24, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of their removal plan and Quality Assurance monitoring. Findings include: Policy titled Care and Treatment of Feeding Tubes revised 04/07/22 documents, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines: 2. Only tubes designed or intended for enteral feeding will be utilized, except under extenuating circumstances and for the shortest time possible. This policy continues, 12. The facility will notify and involve the medical provider or designated practitioner of any complications, and in evaluating and managing care to address the complication and risk factors. An undated policy titled Significant Condition Change and Notification documents 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. Emesis and diarrhea or other abnormal assessment findings are included. Within the procedure of this policy documents, when any of the above situations exists, the licensed nurse will contact the resident's representative and their medical practitioner. The medical practitioner will be contacted immediately for any emergencies regardless of the time of day. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the medical practitioner. After two attempts, there is no response to the calls, the medical director will be contacted. A section titled Documentation reads, All significant changes will be recorded on the Communication Board and in (an electronic charting system) and in the resident record. Policy reviewed 01/2017 and titled Changing a Gastrostomy Feeding Tube documents, 1. Verify that there is a physician's order for this procedure. Under a section titled General Guidelines documents, 2. Feeding tube replacement must be performed by a licensed nurse who has received training and demonstrated competency in this procedure as allowed by state practice act. Policy Charting and Documentation reviewed 01/2017 documents, Policy 1. Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc. (etcetera), as well as routine observations. 2. Be concise, accurate, and complete and use objective terms. This policy documents, 3. Chart as often as necessary and as need arises. A section titled Procedures documents, 17. Tube Feedings: a. Documentation that proper tube placement is verified prior to each feeding. b. Intake data, c. Resident's tolerance to tube feeding. d. Any removal and/or reinsertion of the tube. e. Any complications as a result of the tube feeding. Physician Order Sheet (POS) dated 10/01/24 document R1 has diagnoses of dysphagia following cerebral infarction, gastrostomy status, hemiplegia and hemiparesis affecting left non-dominant side, aphasia and aphonia. R1's 09/18/24 POS documents orders to clean G-tube site daily and to provide G-tube feedings four times daily as supplement feeding. R1's Progress notes have no documentation between 09/14/24 when R1 returned from the local hospital after having a G-tube replaced and 09/17/24 at 5:07 AM when R1 had a large emesis and diarrhea. V3/ADON/Assistant Director of Nursing documented in R1's Progress note dated 09/17/24 at 5:07 AM R1 had a large emesis and diarrhea. At 5:37 AM V3 documented R1 feels better but has some audible congestion. V6/LPN/Licensed Practical Nurse/MDS/Minimum Date Set documented in R1's Progress note dated 09/17/24 at 11:26 AM X-Ray d/t (due to) possible aspiration and monitor for placement of G-Tube was ordered. (R1) had episodes of vomiting. V23/Advanced Practice RN-Registered Nurse documented a Rehabilitation evaluation status post functional decline on 09/17/24 at 1:38 PM stating that (R1) was seen and had emesis all over the front of her gown, and staff reported (R1) was seen in (ED-Emergency Department) on 9/14/24 due to G-tube being pulled out. V23 documented. Staff reports (R1) has had large, soft (bowel movements) in the last 24 hours. (R1) does have rhonchi and an order for chest and abdomen X-rays have been ordered. V23 further documents, Nursing staff notified that if these complications remain, (R1) needs to be seen in the emergency department to rule out aspiration pneumonia, displacement of the catheter tubing or an intestinal blockage. V23's documentation concluded with, Physiatry (sic) on consultation for additional recommendations. Medical management per attending physician and team. V21/Agency LPN/Licensed Practical Nurse documented in R1's Progress note dated 09/17/24 at 2:32 PM that R1 had two episodes of emesis and loose stool. X-Ray was ordered due to R1 abdomen being distended, crackles in lungs, abdomen firm to the touch. V9/LPN documented in R1's Progress note dated 09/17/24 at 3:45 PM that Contracted Radiology Company arrived and obtained a one view X-Ray of R1's abdomen and two view X-Ray of R1's chest due to vomiting and possible aspiration and to check placement of R1's G-tube. R1's Patient Report form with a fax time stamp of 9/17/24 at 8:44 PM documents that Contracted Radiology Company performed a one view X-Ray of R1's abdomen for cough, severe emesis, diarrhea, possible aspiration, pneumonia, verify G-tube placement. R1's radiology results dated 09/17/24 document, Percutaneous gastrostomy tube overlies the left upper abdominal quadrant. For intraluminal confirmation, follow-up imaging is recommended following the administration of either air or oral contrast. R1's X-Ray was electronically signed by V22/Physician Contracted Radiology Company on 09/17/24 at 8:27 PM. R1's Medication Administration Record documents V8/Licensed Practical Nurse administered 240 cc's/cubic centimeters of feeding per tube on 09/18/24 at 10:00 AM. V7/Registered Nurse documented in R1's Progress note dated 09/18/24 at 3:06 PM (R1) continues to have emesis episodes. (R1) not tolerating any bolus feeding through G-tube. (R1) had imaging completed through (Contracted Radiology Company) that recommended follow up imaging. R1 was transported via ambulance to the local emergency department. ED/Emergency Department Triage notes dated 09/18/24 at 3:26 PM and signed by V10, ED RN/Registered Nurse, document, (R1) presents to emergency department with complaints of 'concerning outpatient imaging regarding her G-tube'. V10 further documents, Per nurse report, (R1) has been vomiting after every tube feeding. (R1) was seen here on Saturday (09/14/24) and had G-tube replaced after nursing home could not get it back in. (Indwelling urinary catheter) in place on arrival. At 3:36 PM V10 documented, Per (V2/RN and DON/Director of Nurses) (R1) pulled her G-tube out on Monday (09/16/24) and they replaced it with the (indwelling urinary catheter) on Monday (09/16/24) and have been doing the tube feedings through that since then. (ED) provider note written by V5/ED Physician, dated 09/18/24 at 3:32 PM document, This is a [AGE] year-old female who presents to the ED for G-tube dislodgement apparently today (we are) not quite sure, nursing home did not report when the tube came out. (R1) was here (ED) on (09/14/24) with G-tube displacement (R1) had a (larger size G-Tube) and that was dislodged, and they replaced it with a (smaller size G-tube). (R1) arrives with (an indwelling urinary catheter) in place today. Patient has a G-tube secondary to stroke and difficulty swallowing. This provider note further documents, (Facility) also reports (R1) has vomiting every time she receives a feed. At 3:35 PM, V5 documented, (R1's long term care facility) states they have been giving feeds through the (indwelling urinary catheter) since Monday (09/16/24). V5's Provider Note (continued) documents, Medical Decision Making: Differential includes displacement of G-tube (indwelling urinary catheter), dehydration, electrolyte disturbance, SBO (small bowel obstruction) among other diagnoses. 09/18/24 at 6:17 PM, V5 documented, Radiology just called and states that they see (R1's) feeding tube is actually in the transverse colon and not the stomach. 10/02/24 at 2:07 PM, V3, ADON/Assistant Director of Nursing stated that the facility is notified of radiology results via fax. V3 stated, They come to our fax, they are usually pretty quick. On 09/26/24 at 3:36 PM V3 stated that R1's G-tube which was placed on 09/14/24 would not flush on Sunday (09/15/24) or Monday (09/16/24) per V8/Licensed Practical Nurse. V3 stated, (V8) couldn't get (R1's) tube feeding through. I told her (V8) to take it out and put an (indwelling urinary catheter) in. (R1) started vomiting early Tuesday (09/17/24) around 5:00 AM on my shift. V3 stated she did not contact V4/R1's physician to obtain an order to insert an indwelling urinary catheter. V3 stated she did not advise V8 to check placement or order an X-Ray to check R1's tube placement. V3 stated she did not advise V8 to send R1 to the ED to replace R1's G-tube or to check placement before administering tube feeding through the newly inserted tube. V3 stated I didn't suggest it, maybe I should have. I was charge nurse on duty that day. V3 stated she was unsure what the policy regarding trouble shooting G-tubes stated. Employee corrective action form dated 09/27/24 documents V3 was given a three-day suspension for Manager's failure to follow/enforce departmental policies and procedures. Practiced outside of scope - failed to provide nurse manager oversight. On 09/26/24 at 3:46 PM V8 stated that R1's feeding tube clogged on 09/16/24. V8 stated twice that she called V4/R1's physician to obtain the order, then stated, I got direct orders from my (V3) Assistant Director of Nursing to insert R1's indwelling urinary catheter. V8 stated that she removed R1's G-tube on 09/16/24 and replaced it with an indwelling urinary catheter. V8 confirmed she has not received training or competency on replacing G-tubes and was not sure what the facility policy states regarding troubleshooting G-tubes. On 09/27/24 at 11:30 AM V2/RN/ DON/Director of Nurses stated the facility has not offered G-tube training to nurses. Employee corrective action form dated 09/27/24 documents V8 was suspended for three days due to failure to follow department policies and procedures. The corrective action further documents V8 failed to notify a physician or document on difficulty with and changing a G-tube on 09/16/24. V8 was unable to provide paper or electronic documentation of changing R1's G-tube to an indwelling urinary catheter. V8 stated to ensure R1's newly placed indwelling urinary catheter was correctly positioned, I would check for residual, or push it in until it stops (feels resistance), or get an X-Ray, that would be the best option. V8 stated she did not obtain an X-Ray to check for correct placement of R1's feeding tube prior to administering R1's bolus feeding and stated, I was not directed to by my (V3) Assistant Director of Nursing. R1's Medication Administration Record documents V8 administered R1's bolus feedings at 10:00 AM on 09/16/24 and 09/18/24 at 10:00 AM. On 09/27/24 at 9:24 AM, V2/RN/ DON/Director of Nurses stated she learned on 09/17/24 that V8 had inserted an indwelling urinary catheter after removing R1's G-Tube per the direction of V3/Assistant Director of Nursing. V2 stated that R1 had begun vomiting early in the morning of 09/17/24. V2 stated that V3 had acknowledged R1's physician should have been notified. V2 stated the indwelling urinary catheter should have been checked for placement by X-ray and that R1 was not sent to the ED until two days after R1's indwelling urinary catheter was inserted. V2 confirmed R1's indwelling urinary catheter should not have been used bolus feedings and placement should have been verified. On 09/27/24 at 1:16 PM V2 stated she there is no electronic or paper charting from 09/16/24 when V8 stated she removed R1's G-tube and placed an indwelling urinary catheter. V2 confirmed V4/R1's physician should have been notified and she would have sent R1 to the ED but wasn't. On 09/26/24 at 4:09 PM V4 stated, No, I was never told staff inserted and fed through an (indwelling urinary catheter). I would never say to insert an (indwelling urinary catheter) to use as a feeding tube. I would have ordered the resident to go to the ED for evaluation and tube replacement if they chose to do so. V4 stated he has never talked with staff at the facility about R1's tube being clogged or removed. On 10/01/24 at 8:04 AM V10, Emergency Department Registered Nurse stated that it is not safe nursing practice to administer tube feeding through an indwelling urinary catheter. V10 stated it was apparent R1's indwelling had been used to administer feeding because it had feeding residue left in it. V10 stated she called the facility, who advised the G-tube had been changed to the indwelling urinary catheter which they had been using to bolus feed R1 since Monday (09/16/24). V10 stated R1 was vomiting because the tube was in her transverse colon. On 09/26/24 at 2:30 PM V5/ED Physician stated R1 had been to the ED on 09/14/24 and left after having a G-tube replaced. When R1 arrived at the ED on 09/18/24, she had an indwelling urinary catheter in place of her G-tube. V5 stated while it may be common to insert an indwelling urinary catheter in the G-tube site, it should only be done temporarily to keep the site open, and the resident should be immediately sent to the ED. V5 stated he wouldn't recommend feeding through an indwelling urinary catheter. V5 stated, My concern is (the facility) didn't check placement with an X-Ray and fed through it for two days. V5 stated hospital X-Ray confirmed R1's indwelling urinary catheter was located in her transverse colon which caused her to have emesis and diarrhea for two days. An Immediate Jeopardy situation was identified to have occurred on 09/16/24 at approximately 10:00am when V8/LPN removed R1's G-tube and replaced it with an indwelling urinary catheter without obtaining a physician order or verifying placement. V8 and other licensed nurses proceeded to administer bolus tube feedings via R1's indwelling urinary catheter intermittently through 09/18/24 causing R1 to have vomiting, diarrhea and hospitalization . On 10/01/24 at 10:14 AM, V1/Administrator was notified of the Immediate Jeopardy. On 10/04/24, the surveyor confirmed through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy. 1. On 10/1/24, V15/Regional Director of Operations educated V1 and V2/RN and DON/Director of Nurses on their responsibilities to provide nursing staff with education and resources to provide appropriate oversight. Educational Tools included in the teaching also consisted of Audit tools, Weekly Committee Meeting policy, Rounding forms, Nurse's Skills Checklist Schedule, Monthly Education Calendar 2024, and CNA's (Certified Nurses Aide) Competency schedule. On 10/2/24, V15 ensured V2/RN/ DON/Director of Nurses was competent to perform the education and in-servicing with the staff. 2. On 10/2/24 and 10/3/24, facility nurses were in-serviced, and competencies were completed on Enteral Feeding via Gravity Bag, via Continuous pump via Syringe, Enteral Feedings-Safety Precautions, Confirming Placement of Feeding Tubes, Changing a Gastrostomy Feeding Tube, Significant Condition Change & Notification and Charting and Documentation. Two nurses (one prn staff and one on medical leave) are scheduled to receive training/competency. 3 & 4. The Employee Orientation Nursing Policies/Agency Orientation included a review of the following policies: Enteral Feeding via Gravity Bag, via Continuous pump via Syringe, Enteral Feedings-Safety Precautions, Confirming Placement of Feeding Tubes, Changing a Gastrostomy Feeding Tube, Significant Condition Change & Notification and Charting and Documentation. Two nurses (1 prn/as needed staff and 1 on medical leave) are scheduled to receive training/competency. The Administrator or Director of Clinical Operations ensures when an Agency staff member books an open position, the DON or Nurse Manager receives the required documentation. 5. V8's (Licensed Practical Nurse) Employee Corrective Action Plan Form dated 9/27/24 documented a 3-day suspension for failure to follow department policies and procedures: no MD notification, no documentation of G-tube difficulty or the G-tube was changed on 9/16/24. V3's (Assistant Director of Nursing/Registered Nurse) Employee Corrective Action Form dated 9/27/24 documented a 3-day suspension for failure to follow/enforce department policies and procedures, practiced outside of scope, failed to provide nurse manager oversight. The Time Detail Reports documented V3 nor V8 worked 9/28/24, 9/29/24 or 9/30/24. 6. On 10/3/24, the Change of Condition Audit was revised and accurately completed. 7. Dietary Order Audit completed by V2/RN and DON/Director of Nurses on dated 9/28/24 and on 10/3/24. 8. The Order Recap Report dated 9/26/24 through 10/3/24 was reviewed for new orders and proper notifications. 9. On 10/2/24 and 10/3/24, the In-service Education Record documented education to all nurses regarding the Change in Condition Bulletin Board Documentation (Electronic Health Record). 10. The New Order Audit tool was reviewed and appropriate for use. 11. The In-service Education Report- Admission Policy dated 10/1/24 was attended by V2 (Director of Nursing) and V6 (MDS Coordinator/Care Planning/LPN). Quality Assurance audit tool was reviewed and appropriate for use. Admission policy revised on 10/1/24. 12. Medical Doctor notified, and policies reviewed on 10/3/24.

Based on record review and interview the facility failed to notify a physician of abnormal radiology results and a change in condition for 1 resident (R1) of 3 residents reviewed for change of condition. This failure resulted in R1 experiencing emesis and diarrhea for two days followed by hospitalization . Findings include: An undated policy titled Significant Condition Change and Notification documents 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. Emesis and diarrhea or other abnormal assessment findings are included. Within the procedure of this policy documents, when any of the above situations exists, the licensed nurse will contact the resident's representative and their medical practitioner. The medical practitioner will be contacted immediately for any emergencies regardless of the time of day. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the medical practitioner. After two attempts, there is no response to the calls, the medical director will be contacted. A section titled Documentation reads, All significant changes will be recorded on the Communication Board and in (an electronic charting system) and in the resident record. R1's Physician Order Sheet (POS) dated 10/01/24 documents R1 has diagnoses of dysphagia following cerebral infarction, gastrostomy status, hemiplegia and hemiparesis affecting left non-dominant side, aphasia and aphonia. R1's 09/18/24 POS documents orders to clean G-tube (gastrostomy tube) site daily and to provide G-tube feedings four times daily as supplement feeding. V21/Agency LPN/Licensed Practical Nurse documented in R1's Progress note 09/17/24 at 2:32 PM R1 had two episodes of emesis and loose stool. V3/ADON/Assistant Director of Nursing documented in R1's Progress note dated 09/17/24 at 5:07 AM R1 had a large emesis and diarrhea. At 5:37 AM V3 documented R1 feels better but has some audible congestion. R1's radiology results dated 09/17/24 document, Percutaneous gastrostomy tube overlies the left upper abdominal quadrant. For intraluminal confirmation, follow-up imaging is recommended following the administration of either air or oral contrast. V7/Registered Nurse documented in R1's Progress note dated 09/18/24 at 3:06 PM (R1) continues to have emesis episodes. (R1) not tolerating any bolus feeding through G-tube. (R1) had imaging completed through (Contracted Radiology Company) that recommended follow up imaging. R1 was transported via ambulance to the local emergency department. There is no documentation that V4/R1's physician was notified. ED/Emergency Department Triage notes dated 09/18/24 at 3:26 PM and signed by V10, ED RN/Registered Nurse, document, (R1) presents to emergency department with complaints of 'concerning outpatient imaging regarding her G-tube'. V10 further documents, Per nurse report, (R1) has been vomiting after every tube feeding. (R1) was seen here on Saturday (09/14/24) and had G-tube replaced after nursing home could not get it back in. (Indwelling urinary catheter) in place on arrival. At 3:36 PM V10 documented, Per (V2/RN and DON/Director of Nurses) (R1) pulled her G-tube out on Monday (09/16/24) and they replaced it with the (indwelling urinary catheter) on Monday (09/16/24) and have been doing the tube feedings through that since then. R1's Emergency Department (ED) provider note written by V5/ED Physician, dated 09/18/24 at 3:32 PM documents, This is a [AGE] year-old female who presents to the ED for G-tube dislodgement apparently today (we are) not quite sure, nursing home did not report when the tube came out. (R1) was here (ED) on (09/14/24) with G-tube displacement (R1) had a (larger size G-Tube) and that was dislodged, and they replaced it with a (smaller size G-tube). (R1) arrives with (an indwelling urinary catheter) in place today. Patient has a G-tube secondary to stroke and difficulty swallowing. This provider note further documents, (Facility) also reports (R1) has vomiting every time she receives a feed. As of 10/01/24 R1's electronic medical record did not have documentation of the facility notifying V4/R1's physician that (R1) experienced emesis and diarrhea after bolus feedings on 09/17/24 and 09/18/24 or R1's abnormal X-Ray results on 9/17/24 recommending follow-up imaging. On 09/26/24 at 3:36 PM V3/Assistant Director of Nursing stated that R1's G-tube would not flush. V3 stated, (V8/Licensed Practical Nurse) couldn't get (R1's) tube feeding through. I told her to take it out and put an (indwelling urinary catheter) in. (R1) started vomiting early Tuesday (09/17/24) around 5:00 AM on my shift. V3/Assistant Director of Nursing stated that she did not contact V4/R1's physician to report R1's vomiting and diarrhea on 09/17/24. On 09/26/24 at 3:46 PM V8/Licensed Practical Nurse stated that R1's feeding tube clogged on 09/16/24. V8 stated twice that she called V4/R1's physician to obtain the order, then stated, I got direct orders from my Assistant Director of Nursing to insert (R1's) indwelling urinary catheter. V8 stated she removed R1's G-tube on 09/16/24 and replaced it with an indwelling urinary catheter. V8 stated she did not contact V4/R1's physician before inserting an indwelling urinary catheter and didn't know if (V3/Assistant Director of Nursing) called (V4/R1's physician) prior to giving the order. V8 stated that she did not contact V4 when R1 vomited after the 10:00 AM feeding on 09/18/24. On 09/27/24 at 9:24 AM, V2/RN/DON/Director of Nurses stated she learned V8/Licensed Practical Nurse had inserted an indwelling urinary catheter after removing R1's G-Tube on 09/16/24 per the direction of V3/Assistant Director of Nursing. V2 stated R1 had begun vomiting early in the morning of 09/17/24. V2 stated V3 had acknowledged V4/R1's physician should have been notified but wasn't. On 09/27/24 at 1:16 PM V2 confirmed V4/R1's physician should have been notified of R1's G-tube being clogged and R1's change of condition when she was vomiting and having loose stools between 5:07 AM on 09/17/24 and 3:00 PM on 09/18/24 but wasn't. On 09/26/24 at 4:09 PM V4, stated, No, I was never told staff inserted and fed through an (indwelling urinary catheter). I would never say to insert an (indwelling urinary catheter) to use as a feeding tube. I would have ordered the resident to go to the ED for evaluation and tube replacement if they chose to do so. V4 stated he has never talked with staff at the facility about R1's tube being clogged or removed.

Based on record review and interview the facility failed to ensure licensed nurses were trained and competent in skills necessary to care for residents with a G-tube (gastrostomy tube) affecting 1 resident reviewed for Gastrostomy Tubes (R1) in a sample of 3. This failure led to R1 having emesis and diarrhea for two days and being hospitalized . Findings include: Policy titled Care and Treatment of Feeding Tubes revised 04/07/22 documents, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines: 2. Only tubes designed or intended for enteral feeding will be utilized, except under extenuating circumstances and for the shortest time possible. This policy continues, 12. The facility will notify and involve the medical provider or designated practitioner of any complications, and in evaluating and managing care to address the complication and risk factors. Policy reviewed 01/2017 and titled Changing a Gastrostomy Feeding Tube documents, 1. Verify that there is a physician's order for this procedure. Under a section titled General Guidelines documents, 2. Feeding tube replacement must be performed by a licensed nurse who has received training and demonstrated competency in this procedure as allowed by state practice act. R1's' Physician Order Sheet (POS) dated 10/01/24 document R1 has diagnoses of dysphagia following cerebral infarction, gastrostomy status, hemiplegia and hemiparesis affecting left non-dominant side, aphasia and aphonia. R1's 09/18/24 POS documents orders to clean G-tube site daily and to provide G-tube feedings four times daily as supplement feeding. R1's Emergency Department (ED) medical records document R1 was seen in the ED on 09/18/24 for a G-tube dislodgement. R1 arrived in the ED with an indwelling urinary catheter in place which the facility had placed on 09/16/24 and were administering bolus tube feedings through. On 09/18/24 at 6:17 PM, V5/ED Physician documented he was notified by radiology R1's indwelling urinary catheter was located in her transverse colon, not in her stomach. R1's Progress note document R1 experienced emesis and diarrhea between 09/17/24 at 5:07 AM and 09/18/24 at 3:06 PM when she was transferred to the ED. V9/LPN/Licensed Practical Nurse documented in R1's Progress note dated 09/17/24 at 3:45 PM contracted radiology company arrived and obtained a one view X-Ray of R1's abdomen and two view X-Ray of R1's chest due to vomiting and possible aspiration and to check placement of R1's G-tube. R1's radiology results dated 09/17/24 document, Percutaneous gastrostomy tube overlies the left upper abdominal quadrant. For intraluminal confirmation, follow-up imaging is recommended following the administration of either air or oral contrast. R1's X-Ray was electronically signed by V22/Physician Contracted Radiology Company on 09/17/24 at 8:27 PM. R1's Medication Administration Record documents V8/LPN administered 240 cc's/cubic centimeters of feeding per tube on 09/18/24 at 10:00 AM. V7/Registered Nurse documented in R1's Progress note dated 09/18/24 at 3:06 PM (R1) continues to have emesis episodes. (R1) not tolerating any bolus feeding through G-tube. (R1) had imaging completed through (Contracted Radiology Company) that recommended follow up imaging. R1 was transported via ambulance to the local emergency department. On 09/26/24 at 2:30 PM V5/ED Physician stated R1 had been to the ED on 09/14/24 and left after having a G-tube replaced. When R1 arrived at the ED on 09/18/24, she had an indwelling urinary catheter in place of her G-tube. V5 stated while it may be common to insert an indwelling urinary catheter in the G-tube site, it should only be done temporarily to keep the site open, and the resident should be immediately sent to the ED. V5 stated he wouldn't recommend feeding through an indwelling urinary catheter. V5 stated, My concern is (the facility) didn't check placement with an X-Ray and fed through it for two days. V5 stated hospital X-Ray confirmed R1's indwelling urinary catheter was located in her transverse colon which caused her to have emesis and diarrhea for two days. On 09/26/24 at 3:36 PM V3/Assistant Director of Nursing stated V8/Licensed Practical Nurse reported R1's G-tube was not patent. V3 stated she directed V8 to remove the G-Tube and insert an indwelling urinary catheter. V3 stated R1 began vomiting around 5:00 AM on 09/17/24 after her morning tube feeding. On 09/26/24 at 3:36 PM V3 stated that R1's G-tube which was placed on 09/14/24 would not flush on Sunday (09/15/24) or Monday (09/16/24) per V8/Licensed Practical Nurse. V3 stated, (V8) couldn't get (R1's) tube feeding through. I told her (V8) to take it out and put an (indwelling urinary catheter) in. (R1) started vomiting early Tuesday (09/17/24) around 5:00 AM on my shift. V3 stated she did not contact V4/R1's physician to obtain an order to insert an indwelling urinary catheter. V3 stated she did not advise V8 to check placement or order an X-Ray to check R1's tube placement. V3 stated she did not advise V8 to send R1 to the ED to replace R1's G-tube or to check placement before administering tube feeding through the newly inserted tube. V3 stated I didn't suggest it, maybe I should have. I was charge nurse on duty that day. V3 stated she was unsure what the policy regarding trouble shooting G-tubes stated. On 09/26/24 at 3:46 PM V8 stated that R1's feeding tube clogged on 09/16/24. V8 stated twice that she called V4/R1's physician to obtain the order, then stated, I got direct orders from my (V3) Assistant Director of Nursing to insert R1's indwelling urinary catheter. V8 stated that she removed R1's G-tube on 09/16/24 and replaced it with an indwelling urinary catheter. V8 confirmed she has not received training or competency on replacing G-tubes and was not sure what the facility policy states regarding troubleshooting G-tubes. V8 further stated to ensure R1's newly placed indwelling urinary catheter was correctly positioned, I would check for residual, or push it in until it stops (feels resistance), or get an X-Ray, that would be the best option. V8 stated she did not obtain an X-Ray to check for correct placement of R1's feeding tube prior to administering R1's bolus feeding and stated I was not directed to by my (V3) Assistant Director of Nursing. R1's Medication Administration Record documents V8 administered R1's bolus feedings at 10:00 AM on 09/16/24 and 09/18/24 at 10:00 AM, after the 09/17/24 X-Ray recommended follow up imaging with air or contrast. On 09/27/24 at 9:24 AM, V2/Director of Nursing stated she learned on 9/17/24 that V8 had inserted an indwelling urinary catheter after removing R1's G-Tube on 09/16/24. V2 stated the indwelling urinary catheter should have been checked for placement by X-ray and that R1 was not sent to the ED until two days after R1's indwelling urinary catheter was inserted. V2 confirmed R1's indwelling urinary catheter should not have been used bolus feedings and placement should have been verified but wasn't. On 09/27/24 at 11:30 AM, V1/Administrator stated the facility has not offered specialized G-tube training to nursing staff.

Based on observation, interview and record review, the facility systemically failed to implement facility wide protocols to address respiratory symptoms as evidenced by: failed to recognize respiratory symptoms of facility staff and residents as a possible contagious illness (RSV, COVID 19 Influenza); failed to perform the required COVID-19 testing on staff and residents actively demonstrating signs and symptoms of a possible infectious respiratory illness, or after close contact with a resident or staff member that had tested positive for COVID-19; failed to test for other infectious respiratory illnesses when a COVID 19 test was negative and the resident was symptomatic; failed to immediately implement the required transmission based precautions for residents with suspected respiratory illness; and, failed to wear proper PPE (Personal Protective Equipment) when caring for a COVID-19 positive resident. These failures have the potential to affect all 39 residents currently residing in the facility. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 9/21/23 when R34 became symptomatic with congestion, chest discomfort, and a cough. The facility failed to identify that R34's symptoms were potential signs/symptoms of COVID-19 and did not test nor isolate R34 while he was symptomatic. While the immediacy was removed on 11/29/23, the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of the removal plan including their Inservice training and Quality Assessment oversite. 33960 Findings include: On 11/20/2023 at 9:05 AM, Upon entrance to facility, multiple staff were wearing surgical face masks. V2 (DON/Director of Nursing/Infection Preventionist) stated that some staff were not feeling well. V2 also stated there were no positive COVID-19 residents in the facility, and no residents were currently in transmission based precautions. The CDC (Centers for Disease Control and Prevention) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 5/8/23, documents, NIOSH Approved particulate respirators with N95 filters or higher used for: NIOSH Approved particulate respirators with N95 filters or higher can also be used by HCP (Healthcare Professionals) working in other situations where additional risk factors for transmission are present, such as when the patient is unable to use source control and the area is poorly ventilated. They may also be considered if healthcare-associated SARS-CoV-2 transmission is identified and universal respirator use by HCP (Health Care Personnel) working in affected areas is not already in place. Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Healthcare facilities should have a plan for how SARS-CoV-2 exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed. The decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current SARS-CoV-2 infection for a patient with symptoms of COVID-19 can be made based upon having negative results from at least one viral test. If using NAAT (molecular), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining Transmission-Based Precautions and confirming with a second negative NAAT. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test. HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Responding to a newly identified SARS-CoV-2-infected HCP or resident: When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered. R34's Nurses' notes, dated 9/21/23 at 12:36 a.m., document, Resident states that he thinks he has Pneumonia. R34's Nurses' notes, dated 9/21/23 at 12:46 a.m., document, Lungs clear states he feels congested and has some discomfort in chest. R34's current electronic record has no documentation of R34 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. R28's Nurses' notes, dated 9/22/23 at 9:22 a.m., document, Resident complains of cough and chest congestion. Doctor notified and orders received to offer Geri-tussin as directed PRN (as needed). R28's current electronic record has no documentation of R28 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R28's Nurses' notes, dated 9/26/23 at 8:11 a.m., document, Resident had a large emesis this a.m. R28's Nurses' notes, dated 9/26/23 at 12:30 p.m., document, Resident had no further emesis this shift. COVID test done, and it was negative. R28's current electronic record has no documentation of R28 being tested for potentially contagious illnesses (RSV, Influenza) other than COVID-19 or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing until 10/24/23. R28's Nurses' notes, dated 10/4/23 at 10:26 a.m., document, Resident voicing concerns related to continuous cough. Resident states that Mucinex and Geri-tussin are not providing enough relief. Doctor was notified and assessed resident and gave orders for Keflex (antibiotic) 500 mg (milligrams) twice a day for seven days. As R28's respiratory symptoms continued, R28's current electronic record has no documentation of R28 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. R38's Nurses' notes, dated 10/5/23 at 2:18 p.m., document, This nurse has noted increased cough. Cough producing yellow sputum. Resident also has congestion in the nasal area. R38's current electronic record has no documentation of R38 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R34's Nurses' notes, dated 10/10/23 at 3:49 p.m., document, Resident noted to have a cough this a.m. Cough is occasional and non-productive. As R34's respiratory symptoms continue, R34's current electronic record has no documentation of R34 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. R38's Nurses' notes, dated 10/11/23 at 1:55 p.m., document, Started antibiotic for URI. Resident has a productive cough with yellow phlegm. Lung sounds are congested. As R38's respiratory symptoms continue, R38's current electronic record has no documentation of R34 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R7's Nurses' notes, dated 10/16/23 at 1:20 p.m., document, Resident noted to have increased productive cough with purulent sputum. Lung sounds crackles in bilateral lower lobes. Doctor notified. New orders for Levaquin (antibiotic) 500 mg (milligrams) by mouth daily for 10 days and guaifenesin 400 mg by mouth twice a day for 10 days. R7's current electronic record has no documentation of R7 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. R26's Nurses' notes, dated 10/19/23 at 8:24 a.m., document, New order for Mucinex 400 mg one tablet by mouth twice a day for seven days for cough/congestion per doctor. R26's current electronic record has no documentation of R26 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. R34's Nurses' notes, dated 10/19/23 at 10:33 a.m., document, Fax sent to doctor in regards to resident having an occasional cough and some congestion, waiting for reply. As R34's respiratory symptoms continued, R34's current electronic record has no documentation of R34 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. R21's Medication Administration note, dated 10/22/23 at 8:30 a.m. and 1:13 p.m., document that R21 received PRN doses of guaifenesin 400 mg for sinus drainage. R21's current electronic record has no documentation of R21 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R16's Nurses' notes, dated 10/22/23 at 10:51 a.m., document, Resident noted to have a non-productive cough and nasal congestion. Doctor notified and gave orders for Tylenol 650 mg by mouth every six hours PRN, guaifenesin 400 mg every twelve hours PRN, and Geri-tussin every eight hours PRN. R16's current electronic record has no documentation of R16 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. On 11/21/2023 at 1:35 P.M., a review of the required facility COVID-19 positive report documents on 10/22/23 at 12:09 P.M., V14 (Housekeeping Supervisor) tested positive for COVID-19 and at 12:10 P.M., R3 tested positive for COVID-19. This same report documents that V15 (Dietary Aide) tested positive for COVID-19 on 11/1/23. At that time, V2 (Director of Nurses/Infection Preventionist) confirmed that no contact tracing was done to determine which facility residents or staff that would have been directly exposed to V14, V15, or R3 in the previous 48 hours in order to begin the day 1, day 3 and day 5 COVID-19 testing. On 11/21/2023 at 1:50 P.M., V2 stated, I have just been testing (COVID-19 testing) when someone has symptoms, that's it. I don't keep a record of any of the tests, only the positive ones. I thought that was the new guidance. V2 verified that she didn't have any policies specific to COVID-19, influenza, or RSV. The facility's Daily Assignment Sheets, dated 10/20-10/22/23, document that the following staff would have had direct exposure to R3: V11 (Registered Nurse-RN), V16 (Certified Nursing Assistant-CNA), V6 (CNA), V10 (CNA), V17 (Hydration Aide), V18 (RN), V19 (CNA), V8 (LPN-Licensed Practical Nurse), V13 (CNA), V20 (CNA), V21 (CNA), V22 (RN), V23 (CNA), V24 (CNA), V25 (LPN), V26 (CNA), and V27 (CNA). R26's Nurses' notes, dated 10/23/23 at 8:40 a.m., document, Doctor assessed resident this a.m. and new order received for Keflex 500 mg by mouth three times a day for 10 days. R26's current electronic record has no documentation of R26 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) until 10/24/23 or being placed in transmission based precautions. R14's Nurses' notes, dated 10/24/23 at 9:15 a.m., document, Resident presents with signs and symptoms of common cold COVID test negative. As R14's respiratory symptoms continue, R14's current electronic record has no documentation of R14 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R10's Nurses' notes, dated 10/24/23 at 9:16 a.m., document, Resident presents with signs and symptoms of common cold COVID test negative. As R10's respiratory symptoms continue, R10's current electronic record has no documentation of R10 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R26's Nurses' notes, dated 10/24/23 at 9:54 a.m., document, Resident presents with signs/symptoms of common cold and is COVID negatives. As R10's respiratory symptoms continue, R10's current electronic record has no documentation of R10 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R34's Nurses' notes, dated 10/24/23 at 9:56 a.m., document, Resident presents with signs/symptoms of common cold and is COVID negative. As R34's respiratory symptoms continue, R34's current electronic record has no documentation of R34 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R7's Nurses' notes, dated 10/24/23 at 9:57 a.m., document, Resident presents with signs/symptoms of common cold and is COVID negative. As R7's respiratory symptoms continue, R7's current electronic record has no documentation of R7 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R28's Nurses' notes, dated 10/24/23 at 9:57 a.m., document, Resident presents with signs/symptoms of common cold and is COVID negative. As R28's respiratory symptoms continue, R28's current electronic record has no documentation of R28 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R16's Nurses' notes, dated 10/24/23 at 9:58 p.m., document, Resident presents with signs and symptoms of common cold and is COVID-negative. As R16's respiratory symptoms continue, R16's current electronic record has no documentation of R16 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R14's Nurses' notes, dated 10/25/23 at 1:54 p.m., document, Resident's lung sounds assessed due to signs and symptoms of a cold. As R14's respiratory symptoms continue, R14's current electronic record has no documentation of R14 having follow-up testing for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R34's Nurses' notes, dated 10/25/23 at 2:07 p.m., documents, Resident's lung sounds assessed related to signs and symptoms of a cold. As R34's respiratory symptoms continue, R34's current electronic record has no documentation of R34 having follow-up testing for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R14's Nurses' notes, dated 11/1/23 at 2:21 p.m., document, Resident refused shower times two. Resident stated he was too tired and cold and just did not want to. As R14's respiratory symptoms continue, R14's current electronic record has no documentation of R14 being tested for potentially contagious illnesses (COVID-19, RSV, Influenza) or being placed in transmission based precautions. R5's Nurses' notes, dated 11/15/23 at 7:50 p.m., documents, Resident lying in bed with 2-3 blankets on her up to her chin also wearing flannel pajamas. Warm to touch. Temperature 101.5 face flushed. Blankets removed and given Tylenol. R5's current electronic record has no documentation of R5 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R5's Nurses' notes, dated 11/16/23 at 10:52 a.m., document, Temperature 101. Appears Lethargic. As R5's respiratory symptoms continue, R5's current electronic record has no documentation of R5 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R26's Medication Administration Note, dated 11/16/23 at 1:06 p.m. and 11/17/23 at 7:21 a.m., document that R26 was administered Tylenol 650 mg by mouth as needed for complaints of a headache. As R26's respiratory symptoms continued, R26's current electronic record has no documentation of R26 being tested for potentially contagious illnesses (COVID-19, RSV, Influenza) or being placed in transmission based precautions. R8's Nurses' notes, dated 11/16/23 at 6:39 p.m., document, Resident nauseated and has a headache. Given Tylenol other medications held. R8's current electronic record has no documentation of R8 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R8's Nurses' notes, dated 11/17/23 at 7:00 a.m., document, Resident complains of not feeling well. Stomach upset. Temperature 100.9 degrees. R8's Nurses' notes, dated 11/17/23 at 8:15 a.m., document, Doctor seen resident. States it's viral. No new orders. As R8's respiratory symptoms continue, R8's current electronic record has no documentation of R8 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R18's Nurses' notes, dated 11/17/23 at 1:51 p.m., document, Refused shower times three attempts. Stated he didn't feel well. Came out for both meals. R18's current electronic record has no documentation of R18 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R1's Nurses' notes, dated 11/18/23 at 10:24 a.m., document, Resident has mucous in the base of her throat. Resident encouraged to try and cough it up. R1's current electronic record has no documentation of R1 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R18's Nurses' notes dated 11/18/23 at 12:45 p.m., document, Resident refused to come out for lunch stated he doesn't feel well. As R18 continues to feel ill, R18's current electronic record has no documentation of R18 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R1's Nurses' notes, dated 11/19/23 at 11:30 a.m., document, Resident sleeping most of this morning. Lung sounds congested. As R1's respiratory symptoms continued, R1's current electronic record has no documentation of R1 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R36's Nurses' notes, dated 11/19/23 at 2:09 p.m., document, Resident has no voice. Resident states other than being generally blah. R36's current electronic record has no documentation of R36 being tested for potentially contagious illnesses (RSV, COVID-19, Influenza) or being placed in transmission based precautions. R26's Nurses' note, dated 11/20/23 at 7:46 a.m. document, Doctor here to see resident. New order for Cephalexin (antibiotic) 500 mg by mouth three times a day for URI (upper respiratory infection.) As R26's respiratory symptoms continue, R26's current electronic record has no documentation of R26 being tested for potentially contagious illnesses (COVID-19, RSV, Influenza) or being placed in transmission based precautions. R1's Nurses' notes, dated 11/20/23 at 8:05 a.m., document, COVID tested as resident not feeling well with negative results. Doctor saw this am with new orders to start antibiotic for Bronchitis. As R1's respiratory symptoms continued, R1's current electronic record has no documentation of R1 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R5's Nurses' notes, dated 11/20/23 at 8:09 a.m., document, Resident COVID tested due to reports of resident not feeling well and results are Negative. As R5's respiratory symptoms continued, R5's current electronic record has no documentation of R5 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R25's Nurses' notes, dated 11/20/23 at 8:15 a.m., document, Resident not feeling well COVID test negative. R25's current electronic record has no documentation of R25 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R28's Nurses' notes, dated 11/20/23 at 8:24 a.m., document, Doctor seen resident who is complaining of a cough. New order for Robitussin 10 ml (milliliters) by mouth twice a day for five days. R28's current electronic record has no documentation of R28 being tested for potentially contagious illnesses (COVID-19, RSV, Influenza) until 11/22/23 or being placed in transmission based precautions. R36's Nurses' notes, dated 11/20/23 at 11:43 a.m., document, Resident complains of sore throat and afebrile raspy voice COVID tested for symptoms and due to roommate not feeling well with negative results. As R36's continued to feel ill, R36's current electronic record has no documentation of R36 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions; nor was there any follow-up COVID-19 testing. R1's Nurses' notes, dated 11/21/23 at 10:33 a.m., document, Continues on antibiotic for URI (Upper Respiratory Infection). Has productive cough. Has difficulty coughing it up and out. As R1's respiratory symptoms continued, R1's current electronic record has no documentation of R1 being placed in transmission based precautions. On 11/21/2023 at 11:30 AM, frequent coughing was heard across the hall from facility Family Room coming from R9's room. V2 (DON/Infection Preventionist) verified that it was R9 coughing. V2 stated that R9 was not feeling well and had spiked a temperature during the night with a persistent cough. V2 confirmed that transmission based precautions were not implemented nor was R9 tested for COVID-19 with R9 exhibiting symptoms of an upper respiratory illness. On 11/21/23 at 12:50 p.m., R9 had droplet isolation precaution signage on his door. V6 (CNA) applied a surgical mask, face shield, gown, and gloves. V6 entered R9 room with R9's meal tray. At 12:58 p.m., V6 exited R9's room. V6 stated, (R9's) hospice nurse just told us that we need to wear isolation stuff for (R9). I think he has COVID, but I'm not totally for sure. When I went into the room, I was wearing a surgical mask, a face shield, a gown, and gloves. I haven't had COVID for over two years now. I can't tell you the last time I was tested here. It's been a while. On 11/21/2023 at 1:15 P.M., a review of the facility Staff Call-In log from March 2023 through November 2023 documents most recent COVID-19 positive staff member as V13 (Certified Nursing Assistant) on 11/18/2023. At that time, V2 stated, (V13) came into work on 11/18/23 at 6:00 A.M. stating she didn't feel well. She was assigned the residents in rooms 24-36 (R3, R7, R10, R14, R20-R22, R27, R29). About halfway through her shift she began complaining of cough, fatigue, shortness of breath and a fever. (V5 Registered Nurse/ Assistant Director of Nursing) called me and told me what was going on. I told her to test her (COVID-19). Her test came back positive, and we sent her home. I only test people (residents or staff) if they are not feeling well. At that time, V2 confirmed that V13 was not tested prior to working with the residents, despite V13 stating she didn't feel well. V2 also stated that no contact tracing was done to determine which facility residents or staff that would have been directly exposed to V13 in the previous 48 hours in order to begin the day 1, day 3 and day 5 testing for COVID-19. During the survey on 11/20/23 and 11/21/23, V7 (Care Plan Coordinator/Infection Preventionist) was observed wearing a surgical mask while in the facility. On 11/21/23 at 2:30 p.m., V7 (Care Plan Coordinator) had a raspy voice. V7 stated, These symptoms started a week ago with a sore throat and a headache. I tested and it was negative. I'm still having symptoms, but it's laryngitis. I haven't tested for COVID again since the first one was negative. V7 confirmed that she has not been required to stay home while exhibiting these symptoms. The facility's COVID-19 testing (Residents) log, dated 11/22/23, documents that R9 tested positive on 11/22/23 with symptoms starting on 11/21/23. On 11/22/23 at 08:27 AM, a tour of the facility determined only one resident (R9) was currently in transmission based precautions. On 11/22/23 at 09:29 AM, V14 stated, I can't remember if I tested on (October) 20th or 22nd. But it was that weekend (October 21-22, 2023). I had been to the doctor on Friday because I wasn't feeling well. I came into work late on Friday. I tested myself at home and I was off work the following week (October 23-27, 2023). I am a working supervisor. I am all over the building, helping my staff. On 11/22/23 at 09:11 AM, V7 stated, I submit the (COVID-19) Testing Log. The dates recorded are the dates I was informed that the COVID Test was done on that date and was positive. I don't keep any testing logs of tests done, that are not positive. Since the pandemic ended, we quit keeping any logs except for positive staff or residents. On 11/22/2023 at 9:15 AM, the facility was unable to provide documentation of COVID-19 testing of staff or residents. V2 stated, I don't keep a (COVID-19) testing log of negative tests. I tell (V7) when someone tests positive. I tell her the date and time the test was done, and she submits the information. I didn't know I was supposed to keep logs. On 11/22/23 at 09:32 AM, V5 (RN/Assistant Director of Nursing) stated, Right now I have (R1 & R26) who are symptomatic of an upper respiratory infection. COVID-19 symptoms are cough, congestion, headache, fever, nausea and vomiting. If a resident has symptoms, I notify the doctor and then COVID-19 test them. If they are negative, I just treat them as having an upper respiratory infection. The residents are not put in isolation unless they are actually COVID-19 positive. We don't retest them if they continue to be sick. If a staff member is symptomatic, we immediately test them. If they are negative, they can continue to work. They are not retested . I have only tested on ce, but it was because I tested myself. The facility has not tested me in the last two months. On 11/22/23 at 09:46 AM, V14 stated, That Friday (10/20/23) at work, I started having symptoms of a head cold. I had a headache and congestion. I didn't think it was COVID. I worked that day, but I didn't test. Over the weekend, my daughter told me that I should really consider testing. I didn't test until after the weekend. R26's Nurses' notes, dated 11/22/23 at 10:43 a.m., documents, Continues on antibiotic for URI coughing noted. As R26's respiratory symptoms continue, R26's current electronic record has no documentation of R26 being tested for potentially contagious illnesses (COVID-19, RSV, Influenza) or being placed in transmission based precautions. R28's Nurses' notes, dated 11/22/23 at 11:38 a.m., document, Resident tested for COVID at 11:20 am due to fever of 100.0 resident states that he just feels like he has cold. Results Negative. R28's current electronic record has no documentation of R28 being tested for other potentially contagious illnesses (RSV, Influenza) or being placed in transmission based precautions. On 11/28/23 at 12:47 p.m., V9 (Licensed Practical Nurse/LPN) stated, If a staff member is sick no fever and negative, they can work as long as they are wearing a mask. My symptoms started on 11/19/23, I was hot then cold with the chills and aching all over. I tested after my shift was over on 11/19/23 and I was (COVID-19) positive. The facility's Staff Call Ins Report, dated 11/18-11/29/23, documents that V9 (LPN) tested positive for COVID-19 on 11/20/23 and that she was symptomatic starting 11/19/23. On 11/22/23 at 3:05 P.M., V1 (Administrator in Training) was notified of the Immediate Jeopardy. On 11/27/23, V1 submitted the facility's abatement plan for review. 1. V2 (Director of Nursing/Infection Preventionist) and V7 (Care Plan Coordinator/Infection Preventionist) were educated by V28 (Regional Nurse) on the signs and symptoms of COVID-19 infection and other respiratory illness, when COVID-19 testing is required, facility contact tracing and the implementation of transmission-based precautions for any resident experiencing respiratory symptoms, prior to testing on 11/22/23. 2. V2 and V5 (RN/Assistant Director of Nursing) tested all residents and staff for COVID-19 on 11/22/23, 11/24/23, 11/26/23, and they will continue to test every 3-7 days until no more COVID-19 positives for 14 days. 3. V1 and V2 were educated by V28 on initial outbreak and broad-based/contact tracing testing on 11/22/23. 4. V1 and V2 educated all facility staff on the required PPE when they are caring for a COVID-19 positive resident on 11/23/23. 5. V1 and V2 educated all nursing staff on identification of signs and symptoms of COVID-19 and other contagious respiratory illness, in order to implement physician notification, testing, and transmission-based precautions on 11/22/23. 6. V1 began Quality Assurance monitoring daily of all residents and staff with respiratory symptoms and a implemented a system to determine facility testing and isolation on 11/22/23. 7. On 12/4/23, V1 will be meeting with V31 (IDPH Infection Preventionist) for infection control guidance. Through observation, interview, and record review, it was found that deficient practices continued, and the Immediate Jeopardy could not be removed. The facility's COVID-19 Testing log (employees), dated 11/22/23, documents that V32 (Maintenance Director) tested positive for COVID-19 on 11/22/23. The facility's COVID-19 (resident) Testing log, dated 11/24/23, documents that on 11/24/23, 13 residents (R1, R4, R11, R13, R19, R24, R29, R31, R33, R36, and R38-R40) tested positive for COVID-19 on 11/24/23. The facility's COVID-19 Test

Based on interview and record review, the facility failed to investigate a resident fall, failed to initiate new fall prevention interventions in response to resident's falls, and failed to ensure previously existing interventions to prevent falls were in place for one of three residents (R1) reviewed for falls in the sample of four. This failure resulted in R1 sustaining repeated falls with multiple injuries including the following on 1/7/2023: Left Femoral Neck Fracture requiring surgical repair and Subdural Hematoma which required surgical drain placement. Findings include: The facility's Fall Risk Assessment Policy, revised March 2018, documents the facility will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. This policy states Interpretation and Implementation 1. Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. 7. The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence and cognition. 9. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. The facility's Falls and Fall Risk, Managing Policy, revised March 2018, states, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Fall Risk Factors: f. Footwear that is unsafe or absent. Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with input from the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g. hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. The facility's Accidents and Incidents-Investigating and Reporting Policy, revised August 2018, states, All accidents or incidents involving residents, employees, visitors, vendors, etc, occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. 8. Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities and to ascertain a possible root cause for the fall. 9. The IDT (Interdisciplinary Team) will review the fall and investigative material and make recommendations to possible prevent further occurrences. 10. The Care Plan will be updated to reflect the event and the recommendations of the IDT. R1's Hospital History and Physical, dated 10/17/22, prior to R1's facility admission, documents R1 has had multiple hospitalization s for falls, has had struggles with multiple falls at home, and had presented for a fall resulting in a thoracic compression fracture for which R1 was admitted for pain control. R1's Facesheet documents R1 admitted to the facility on [DATE] with diagnoses to include but not limited to: Parkinson's Disease, Cerebral Infarction, Unspecified Falls, Weakness, Dizziness, Giddiness, Anxiety Disorders, Dementia, Epilepsy, Unspecified Injury of Head, Wedge Compression Fracture of Unspecified Thoracic Vertebra, and Subsequent Fracture with Routine Healing. This Facesheet documents R1's most recent hospital stay was 1/7/23-1/17/23. R1's Census Report, dated 1/27/23, documents R1 originally admitted to the facility on [DATE] and was discharged from the facility on 1/7/23 and returned on 1/17/23. The facility's Historical Incident Log, undated, documents R1 had unwitnessed falls on 11/17/22, 12/16/22, 12/19/22, 12/20/22, 1/3/23 and 1/7/23. R1's Minimum Data Set (MDS) Assessment documents R1 with a Brief Interview for Mental Status score of 10/15, indicating moderate cognitive impairment. This same MDS Assessment documents R1 requires extensive assistance of two plus person physical assist for bed mobility, transfers, walking in room, and toilet use and requires extensive assist of one person physical assist for dressing. R1's Admission Fall Risk Data Collection, dated 10/25/22, documents R1 is at a high risk for falls. R1's Fall Risk Data Collection, dated 10/26/22, documents the assessment was completed due to R1 having an unwitnessed fall in the facility on 10/26/22 and documents R1 is at a High Risk for falls. This same assessment documents Fall Needs Interventions as: Call don't Fall sign; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; Ensure personal items are within reach; Ensure that the resident is wearing appropriate footwear; Gripper Socks; and PT/OT (Physical Therapy/Occupational Therapy) evaluate and treat as ordered and PRN (as needed). R1's Current Care Plan states, (R1) is at risk for falls, (R1) has a history of falls and has had several falls in the facility. (R1) is confused and is unaware of safety issues. (R1) is impulsive and will not ask for assistance nor will (R1) wait for assistance. The following interventions are documented with an initiation date of 10/26/22: Call don't Fall sign, Be sure (R1's) call light is within reach and encourage (R1) to use it for assistance as needed; Ensure personal items are within reach; Gripper Socks; and PT/OT (Physical Therapy/Occupational Therapy) evaluate and treat as ordered and PRN (as needed). R1's Health Status Note on 10/26/2022 at 8:58 AM documents R1 is alert but confused and that R1 has been verbally and physically abusive to staff. R1's Health Status Note on 10/26/2022 at 12:25 PM documents R1 had gotten out of R1's bed and walked into the bathroom without assistance. R1's Incident Report on 10/26/22 at 3:45 PM documents R1 had an unwitnessed fall in R1's room after ambulating without assistance. This same form documents R1 was transferred to the local area hospital for evaluation and documents R1 was educated to use the call light to call for assistance. R1's Incident Report on 11/17/22 documents R1 was attempting to transfer self to wheelchair and fell on to the floor on R1's buttocks. R1's Health Status Note on 11/17/22 at 1:35 PM, documents R1 was attempting to self-transfer into R1's wheelchair when R1 lost balance and fell to the floor. This same note states, Will place a Call Don't Fall Sign in room to prevent a similar incident. R1's current Care Plan states, Call Don't Fall sign in room within sight with an initiation date of 11/17/22. R1's Care Plan did not document a new intervention in response to R1's 11/17/22 fall to prevent further falls, nor to ensure R1's safety in the event of further falls. R1's Incident Report on 12/16/22 at 4:45 PM documents that R1 was ambulating without assistance. R1 was found on the floor in front of R1's recliner chair. This same report documents R1 stated R1 hit her head during the fall and there was a small dime size area on the back of (R1's) head. Resident Description states, (R1) stated that (R1) was trying to get up to get her bells that were on (R1's) wheelchair because she could not reach her call light. (R1) stated she had hit the back of her head on the floor when she fell . Immediate Action Taken is documented as R1 was given a double call light in case one of them should be out of reach for R1. This same report states, (R1) reaching over for bells that were on her wheelchair and slipped out of her chair due to her call light being thrown over on her bed. On 2/1/23 at 11:15 AM, V2 (Director of Nursing) stated that the facility thought that there was an issue with the resident call light system, so the residents were given bells to use while the call light system was being investigated by maintenance. V2 stated that two call lights were then added to R1's room. One for R1's recliner chair and one for R1's bed. R1's Health Status Note on 12/16/2022 at 9:53 PM, states, (R1) tried to transfer herself again, lost her balance and landed on her bottom. No injuries, bruising, etc. ROM WNL (Range of Motion within normal limits). (R1) is already on neuros (neurological checks) d/t (due to) prior incident. (R1) was transferred back into her wheelchair and brought up to the nurses station. Will monitor. As of 1/27/23 at 11:50 AM, R1's medical record did not contain documentation that an Incident Report, investigation to determine a root cause, or a newly implemented fall prevention intervention was created for R1's second fall on 12/16/22. On 1/27/23 at 11:58 AM, V2 (Director of Nursing) stated, The resident's nurse would initiate the Incident Report and then it would be reviewed by IDT (Interdisciplinary Team). There is no QA (Quality Assurance) doc (document) for that fall. On 1/27/23 at 4:26 PM, V3 (Registered Nurse) stated that on 12/16/22, V3 worked from 2 PM-10 PM. V3 stated that V3 received R1 from V4 (Licensed Practical Nurse) halfway through V3's shift. V3 stated that V4 had reported to V3 that R1 had fallen earlier on V4's shift. V3 stated that right at (third) shift change, it was reported to V3 that R1 had fallen again. V3 stated that V3 assessed R1 while R1 was still on the floor and there were no obvious signs of injury. V3 stated that V3 wrote in R1's Progress Notes about R1's fall but did not create an Incident Report. V3 stated that an Incident Report should have been created regarding R1's fall but that V3 had passed it onto the next shift nurse to create but it was not done. V3 stated that R1 would be noncompliant at times and would tell staff, I'm not waiting for you. I can do it myself. in regards to getting help with mobility. On 1/31/23 at 9:24 AM, V2 stated that R1's nurse (V3) should have stayed over her shift to create the Incident Report for R1's second fall on 12/16/22 since V3 was R1's nurse at the time of R1's fall. V2 stated if the facility had known about R1's second fall on 12/16/22, a new fall prevention intervention would have been added. R1's Incident Report on 12/19/22 at 6:30 AM states, Heard a crash and then yelling. Upon entering the room, (R1) noted to be on the floor at end of the bed between bed and closet lying on her back. (R1) had no shoes on. (R1) hit her head on the floor causing a large hematoma. Large puddle of urine on floor under bed and bed was soaked. This same report documents a root cause of attempting to transfer self with improper footwear. Predisposing Situation Factors are documented as Ambulating without Assist and Improper Footwear. Injuries at the time of incident is documented as Hematoma Top of Scalp. R1's current Care Plan did not document a new intervention in response to R1's 12/19/22 fall to prevent further falls, nor to ensure R1's safety in the event of further falls. R1's Health Status Notes on 12/19/2022 at 11:54 AM states, (R1) has increased confusion this shift. (R1) has been having delusions. (R1) was talking to a wall.(R1) is making statements that make no sense. (R1) has been caught three times this morning transferring self. and also documents that a Urinalysis is pending. On 1/31/23 at 9:30 AM, V2 verified that gripper socks and ensure that (R1) is wearing appropriate footwear were interventions previously initiated onto R1's Care Plan on 10/26/22 when R1 was determined to be a high risk for falls. On 2/1/23 at 11:47 AM, V7 (Registered Nurse) stated that on 12/19/22 around 6:30 AM, V7 was alerted that R1 was on the floor. V7 stated that R1 was lying on the floor at the foot of R1's bed and that R1 had been incontinent of urine. V7 stated that R1 was saying that R1 was trying to get clothes out of R1's closet. V7 stated that R1 was not wearing shoes or socks at the time of R1's fall. V7 stated that V7 recalled palpating a large hematoma on R1's head after the fall. V7 stated that R1 would often try to transfer herself without staff assistance. R1's Incident Report on 12/20/22 at 6:30 AM documents R1 slid out of R1's recliner onto R1's buttocks on the floor. Immediate Action Taken states (R1) requires frequent reminders to use call light and not transfer self. Call Don't Fall sign placed in room as a visual reminder to call for help. R1's Current Care Plan documents Call Don't Fall Sign intervention was revised on 12/20/22 but did not document a new intervention in response to R1's 12/20/22 fall to prevent further falls, nor to ensure R1's safety in the event of further falls. R1's Incident Report on 1/3/23 at 4:05 PM documents R1 was attempting to transfer self from bed to chair to go to the bathroom. R1 was found lying on R1's back in front of R1's bed. R1's Incident Report on 1/7/23 at 8:00 AM states, Incident Description: V5 (LPN) was one room away when I heard a loud crash and screaming. I went to (R1's) room and found her on the bathroom floor on her back. (R1) was screaming in pain and for help. (V5) called for help from other staff. (R1) stated that (R1) walked to the bathroom and peed all the way there and fell . Immediate Action Taken: Staff cleaned the urine off the floor. (R1) was assessed for injuries. (R1) had a hematoma on back of head measuring 1.5 x 2 cm/centimeters. (R1) was placed in bed by three staff members. Upon further assessment, left leg was shorter than right leg and a raised area appeared on left hip. (R1) continued to holler in pain. Vitals were taken. Power of Attorney notified, (V2) was notified, 911 was called and V6 (R1's Physician) was notified. Ambulance arrived around 8:20 AM to take (R1) to ER (emergency room ) to be assessed. Intervention will be toileting every two hours when awake. Predisposing Situation Factors are documented as Ambulating without Assist and Improper Footwear. On 2/1/23 at 10:16 AM, V5 (LPN) stated that on 1/7/23, V5 was going down R1's hallway, passing medications. V5 stated that R1 was still in bed, so V5 stopped at R1's room, told R1 to open R1's eyes because breakfast was going to be coming soon. V5 stated V5 was one door down when V5 heard terrible yelling and screaming coming from R1's room. V5 stated that R1 was on the floor in R1's bathroom and R1 had been incontinent of urine. V5 denied that R1's call light was on and V5 stated R1 was barefoot with no shoes or socks on. V5 stated that due to R1's history of a stroke, R1 is flaccid on R1's left side. V5 stated 911 was called and R1 was then sent to the hospital for evaluation. R1's Health Status Note on 1/7/2023 at 9:55 AM documents that V5 was notified by the Emergency Department that R1 was being transferred to a different area hospital due to R1 having a fractured left hip and subdural bleeding. R1's Radiology Report on 1/7/23 documents XR (X-Ray) Hip Two Views Unilateral Left Impression: Acute distracted avulsion fracture of greater trochanter. Acute impacted femoral neck fracture also suspected. R1's Radiology Report on 1/7/23 documents CT (Computed Tomography) Chest Abdomen and Pelvis W (with) Contrast Impression: 1. Comminuted and mildly impacted fracture of the left femoral neck with extension into the greater trochanter with mild displacement of the greater trochanter fracture fragment. 3. Left hip soft tissue contusion. R1's Radiology Report on 1/7/23 documents CT Head or Brain WO (without) Contrast Impression: 1. Large matched attenuation subdural hematoma overlying the right frontal, parietal and temporal convexities. High attenuation component is most consistent with more recent blood products. A repeated CT Head or Brain WO Contrast on 1/8/23 documents R1 with an acute on chronic right subdural hematoma. R1's Neurointerventional Surgery History and Physical, dated 1/10/23, states, (R1) presented 1/7/23 from (R1's Skilled Nursing Facility) for evaluation following a fall. (R1) sustained a large subdural hematoma, left femoral neck fracture, and an avulsion fracture of the left greater trochanter. (R1) had reversal of Coumadin at the time of admission and subsequently a subdural drain placed on 1/8/23. Interventional Neurology was consulted for MMA (Middle Meningeal Artery) Embolization. (R1) is also POD (post-operative day) one for ORIF (Open Reduction Internal Fixation) medullary implant (proximal femur).

Based on observation, interview and record review the facility failed to assess, monitor and treat a reddened Coccyx area for a Resident at risk for skin breakdown, that worsened and became an Unstageable House Acquired Pressure Ulcer for one of two residents (R37) reviewed for Pressure Ulcers in a sample of 19. This failure resulted in the worsening of a house acquired Pressure Ulcer that required surgical debridement for R37. Findings include: Facility Pressure Ulcer/Pressure Injury Prevention Policy, revised 3/2021, documents: identify whether the resident is at risk for developing or has a Pressure Ulcer/PU or Pressure Injury/PI upon admission; evaluate resident specific risk factors and changes in the resident's condition that may impact the development and/or healing of a Pressure Ulcer; implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors; a Standardized Pressure Ulcer Risk Assessment (Braden Scale) will be used to identify residents who are at risk for the development of pressure ulcers and will be completed upon admission, weekly, for four weeks, and quarterly; an individual plan of prevention will be developed to meet the needs of the resident, including the consideration of mechanical support surfaces, nutrition, hydration, positioning, mobility, continence, skin conditions and overall clinical condition, as well as risk factors; the goal is for the resident to be free of preventable pressure ulcers; interventions for prevention of pressure ulcers will individualized to meet the specific needs of the resident; Braden Scale Mild Risk score (15-18) and Braden Scale Moderate Risk Score (13-14) requires frequent turning, manage moisture with prompt incontinence care and preventative skin care products, manage nutrition with Registered Dietician to access for additional interventions and weight monitoring, utilize positioning, using positioning devices such as wedges and pressure redistribution support surface in bed and chair; and utilize moisturizers to prevent extremely dry skin, consult with a Registered Dietician and consider supplementation as indicated by the assessment of the Registered Dietician. R37's Census Report, dated 10/6/22, documents that R37's original admitted to the Facility was 5/22/22, and that R37 returned back to the Facility, from the local hospital on 6/1/22. R37's Nursing Progress Notes, dated 6/1/22 at 3:45 pm, documents that R37 returned from the local hospital, post surgical for an Open Reduction Internal Fixation (ORIF) to the right ankle, with an electronic wound healing machine (Wound Vac) for the surgical incision. R37 was non-weight bearing. R37's Braden Scale (Pressure Ulcer Risk), dated 5/22/22, documents R37 at Moderate Risk (Score 13) of pressure ulcers and documents that R37's skin is very moist. R37's current Care Plan (date initiated 07/27/2022 and revised on 10/04/2022), documents Pressure Ulcer interventions as administer medications as ordered, monitor/document for side effects No other Pressure Ulcer interventions were documented on R37's Care Plan. R37's Braden Scales (Skin Risk assessment) was not completed upon readmission then weekly for four weeks after readmission to the facility. From 6/1/22 and 10/6/22, R37 had one Braden Scale (Pressure Ulcer Risk) documented. R37's Braden Scale, dated 6/5/22, documents that R37 was a Mild Risk (Score 15) for Pressure Ulcers. The Braden Scale documents that R37's skin is occasionally exposed to moisture. R37's Braden Scale was not completed until 6/5/22, four days after R37's admission back to the facility. R37's Weekly Skin Check, dated 6/5/22, documents R37's right ankle surgical site and no other skin issues. This Weekly Skin check failed to document the existing pressure ulcer. R37's Wound Weekly Evaluation, dated 7/27/22, documents a newly identified house acquired Moisture Associated Skin Damage/MASD to R37's Right Buttock, measuring 1.1 centimeters/cm by 1.6 cm, with no depth (not open), and R37 had no pain. The Wound Evaluation documents a collagen and foam dressing were initiated and that R37's Care Plan update was Not Applicable (N/A) update not needed. R37's Wound Weekly Evaluation, dated 8/2/22, documents shearing to the Right Buttock that was house acquired on 7/25/22, measuring 6.0 cm by 7.0 cm, with no depth. The Wound Evaluation documents that the wound was debrided and a new Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Evaluation documents that no changes were made to R37's Care Plan. R37's Wound Weekly Evaluation, dated 8/22/22, documents that R37's Coccyx (also referred to as Right Buttock) was declining to an Unstageable Pressure Ulcer, measuring 9.0 cm by 10.0 cm by 5.0 cm., with tunneling/undermining from 12:00 to 2:00 o'clock that measures 4.0 cm. The Wound Evaluation documents: slough tissue (yellow, tan, white or stringy) and brown and purulent drainage and a putrid odor. R37's Wound Weekly Evaluation, dated 9/13/22, documents that R37's wound on Buttocks (also referred to as coccyx wound) was an Unstageable Pressure Ulcer, measuring 8.0 cm by 5.0 cm by 5.0 cm., with tunneling/undermining from 1:00 o'clock that measures 7.6 cm. R37's Pressure Ulcer Weekly Wound Evaluation, 9/30/22, documents an Unstageable Pressure Ulcer to the Coccyx, with Slough and Eschar tissue, and a putrid odor. The Coccyx wound measures 7.5 cm by 4.5 cm by 5.0 cm in depth and 6.0 cm tunneling at 11:00 o'clock and 7.0 cm at 1:00 o'clock. The Wound Evaluation documents that the wound is worsening and that R37 has mild pain. The Wound Evaluation also documents that no changes were made to R37's Care Plan. On 10/5/22 at 9:03 am, V3 (Registered Nurse/Assistant Director of Nursing) was performing pressure ulcer care to R37's Coccyx/Right Buttock. The contaminated dressing (dated 10/4/22) was moderately soiled with a brownish color. R37's Pressure Ulcer dressing change observation shows tunneling at approximately 11:00 to 1:00 o'clock and a moderate amount of drainage and pressure ulcer opening the approximate size of a golf ball. No issues were noted with R37's peri-wound. On 10/6/22 at 1:30 pm, V2 (Director of Nursing) verified that R37's Pressure Ulcer was house acquired and that appropriate interventions and monitoring of R37's Pressure Ulcer were not completed per the Facility Policy and R37 does not currently have a Wound Doctor here at the facility. On 10/7/22 at 10:50 am, V8 (Wound and Product Specialist) stated, I am a Wound Consultant Nurse that makes recommendations for Physician Orders. I just reviewed (R37's) electronic pressure ulcer notes on my computer. I have not seen R37's pressure ulcer or laid eyes on it, I am going solely on documentation. I usually only go the the facility about once a month. (R37's) pressure ulcer probably needs a referral to a Wound Clinic and also another debridement. It also had a foul odor, so it probably also needs a culture with the laboratory. I do not think that the Facility has a Wound Doctor that comes to the Facility.

Based on observation, interview, and record review, the facility failed to ensure a door monitoring system for cognitively impaired residents that are assessed as high risk for leaving the facility unattended, was in proper working order; failed to perform recommended weekly door alarm function tests; failed to ensure staff did not engage in the unauthorized practice of propping open exit doors bypassing the door monitoring system; failed to respond timely to door monitoring system alarms; failed to ensure a cognitively impaired, wandering resident's electronic monitoring bracelet was in working order to prevent an elopement; failed to monitor the proper function and placement of resident's electronic monitoring bracelet, every shift; and failed to recognize an incident of elopement as an elopement for three of three residents (R4, R5 and R6) reviewed for elopement, in a sample of three. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 8-23-2022, the facility remains out of compliance at Severity level II, as the facility continues to educate staff on elopement precautions and the facility's policy and procedure for monitoring residents at risk for elopement, Code Orange (Elopement-missing person) drills continue to be performed weekly for one month and monthly thereafter for six months, Exit doors secured with an alarm are tested daily for 30 days then weekly, and continues to implement their Quality Improvement auditing tool regarding compliance with the elopement incident and their plan of action. Findings include: The facility policy, Elopements, (revised) December 2007 directs staff, It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. For the purpose of this policy, missing resident shall be defined to mean a resident who has left the facility grounds without signing him/herself out of the facility. The resident shall not be designated as missing or eloped if he/she is seen leaving the buildings or is seen walking away as a result of responding to a door alarm. Residents who are at risk for elopement shall be provided at least one of the following safety precautions by the facility: Door alarms on facility exits; A personal safety device that will alert facility staff when the resident has left the building without supervision (Code Alert or [electronic monitoring] bracelet/ankle system) and/or Staff supervision. As part of the facility's Preventative Maintenance Program, all door alarms will be checked for proper function on a weekly basis. At no time shall a personal safety alarm (electronic monitoring bracelet) or door alarm be turned off without the continual supervision of the exit. The person responsible for turning off the personal safety alarm or door alarm shall be responsible for resetting the alarm and ensuring that it is in working condition. Failure to reset and test exit alarms will result in serious employee disciplinary action, which can include immediate termination. When a door alarm sounds, staff shall immediately respond to and determine if a resident has exited the building. If, upon investigation, no reason can be found for the sounding of that alarm, the Charge Nurse shall initiate an accounting of all residents at risk for elopement. If, after all at-risk residents are accounted for, the cause of the alarm is still undetermined, a complete head count of all residents will be conducted. All staff shall be trained on the proper procedures to follow in the event a resident is missing from the facility. At a minimum, training and in-service education shall be conducted for each staff member upon orientation and annually, thereafter. The facility (Personal Elopement Safety Bracelet System/electronic monitoring bracelet) User and Instillation Manual Series directs the user, Read and follow these instructions carefully before using your system. Failure to do so could cause an unauthorized departure resulting in injury or death. Warning: Personal Elopement Safety Bracelet System equipment must be operated by trained personnel only who are thoroughly familiar with the procedures outlined in this User Manual. Test the System regularly. Test each monitoring system weekly with all surrounding power devices turned on. Record the results. Test bracelets daily as detailed in the bracelet instructions and the Tester Manual. Record the results in each resident's records. A staff member must be within hearing distance of the alarm or a remote nurse station annunciator at all times. Inspect the System door antennas and magnetic switches at least weekly to be certain that all wire connections are secure. Make daily inspections to confirm the wristband is in place (on the dominate wrist) on each resident and is not damaged in any way. The (Personal Elopement Safety Bracelet System/electronic monitoring bracelet) is an electronic monitoring system designed to assist staff in facilities that care for people who may present wandering risks. If a resident wearing an (electronic monitoring bracelet) attempts to pass through a monitored area, an alarm sounds to alert staff to a possible departure. The alarm continues to sound until staff silences the alarm. Remote Annunciator: the remote annunciator gives a warning before a wandering resident goes out the door. Used at (the) nurse's station, the light panel on the remote annunciator displays a condition yellow and emits a discreet beep when a monitored resident is within range of a System door monitor. This helps promote a quicker response from staff if an unauthorized exit does occur, and in many cases the resident can be simply escorted away from the door, avoiding a departure altogether. 1.) R4's facility Admission Record form documents that R4 was admitted to the facility on [DATE] with the following diagnoses: Dementia, [CONDITION(S)], Repeated Falls. R4's current (8/18/22) facility Elopement Risk Assessment documents, (R4) is cognitively impaired and independently mobile, has a history of elopement, a desire to leave the facility and exit seeks with a purpose. This same assessment documents, (R4) appears to be a visitor and has a diagnosis of dementia. The following interventions are in place: application of an electronic monitoring bracelet/device, (R4's) picture in the (facility) elopement book and (requires) frequent visual monitoring. R4's current Minimum Data Set Assessment, dated 5/11/22 documents, Section C: Cognitive Patterns 8:15 (moderately confused) and Section G: Functional Status: Requires the use of a walker. R4's current Care Plan, dated 8/28/20 includes the following Focus area: (R4) is an elopement risk/wanderer as evidenced by (R4) is often confused and thinks she needs to go home, (R4) has opened (exit) doors recently. Also included are the following Interventions: Make sure (R4) has her wheeled walker when ambulating; Monitor closely when in hallways; Monitor for placement of (electronic monitoring bracelet) and ensure it is working properly every shift. Respond promptly to alarms. R4's Nursing Progress Notes, dated 12/18/21 at 3:30 PM and signed by V6/Registered Nurse (RN) document, (R4) exited through the side (Exit) door. Stopped by this nurse. Said she was going to the bank. Redirected her as to where she was and the colder temperatures out (side) at current time. (R4) came back into the building without any complications. Will continue to monitor. R4's Nursing Progress Notes, dated 2/24/22 at 11:35 AM, and signed by V5/Licensed Practical Nurse (LPN) document, (R4) opened the side (Exit) door leading to laundry. (R4) stepped outside and was redirected back into the building by a housekeeper. (R4) had her coat on and stated she was going home. (R4) then stated she wanted to talk to Social Services. R4's Nursing Progress Notes, dated 2/24/22 at 2:08 PM document, Personal (electronic monitoring bracelet) put on (R4's) right ankle. R4's Nursing Progress Notes, dated 8/17/22 at 4:45 PM and signed by V2/Director of Nurses document, At approximately 4:45 PM on 8/17/2022 assigned nurse (V2) for (R4) noticed (R4) was not in her room. At approximately 5:15 PM, facility was notified by (R4's son) that (R4) was at her sister's house, approximately three blocks from facility. Son accompanied (R4) back to the facility at approximately 6:00 PM The facility Investigation Report, dated 8/17/22 and signed by V1/Interim Administrator documents, At approximately 4:45 PM, assigned nurse for (R4) noticed she was not in her room. At approximately 5:15 PM the facility was notified by (R4's) son that (R4) was at her sister's house, approximately three blocks from the facility. Son accompanied (R4) back to the facility at approximately 6:00 PM Summary of Critical Information Obtained During Investigation: During search of interior of facility it was determined that an exterior door in the kitchen was open and a (Unalarmed) screen door closed, to (give) access to the exterior of the property. Dietary staff members (R15/Dietary Aide and R26/Dietary Aide) state they opened the door due to excess heat in the kitchen. Immediate Action Taken During Investigation: (V1/Interim Administrator) checked all doors for (Alarm Elopement System) function. (An) issue was identified with the (Alarm Elopement System) panel at nurse's station, for door 7. (V1) to call the Company on 8/18/22. On 8/19/22 at 2:00 PM, R4 was observed ambulating with a front wheeled walker in the hallway, near the SE (Southeast) door (Door 7). No facility staff were present. An electronic monitoring bracelet was present to R4's left ankle. On 8/19/22 at 2:10 PM, V1/Administrator stated, I don't have any investigations of (R4's) prior elopement attempts. I wasn't the (facility) administrator at the time. (V2/DON) is unable to recall if they were ever investigated or what new interventions were put in place to prevent further attempts. 2.) R5's facility Admission Record documents that R5 was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease and Hallucinations. R5's current facility Elopement Assessment, dated 8/17/22 documents, (R5) is cognitively impaired and independently mobile with a history of elopement and a diagnosis of Alzheimer's Disease. (R5) is an elopement risk/wanderer and has a wander alert bracelet/(electronic monitoring bracelet) in place. R5's current Minimum Data Set Assessment, dated 5/11/22 documents, Section C: Cognitive Patterns 4:15 (cognitively impaired) and Section G: Functional Status: Requires the use of a walker. R5's current Care Plan, dated 10/21/2020 includes the following Focus areas: (R5) is an elopement risk/wanderer. 8/16/22 (R5) had Exit attempt on 8/3/22, stated he was going home. IDT (Inter Disciplinary Team) placed wander alert bracelet/ (electronic monitoring bracelet) on (R5) due to previous exit attempts. R5's current Treatment Administration Record, dated August 2022 includes the following physician order: Check (electronic monitoring bracelet) on left wrist every shift. Staff initials documenting completion of this order are only present at 6:00 AM, 2:00 PM and at 10:00 PM on 8/8/22. R5's Nursing Progress Notes, dated 8/3/22 and signed by V2/Director of Nurses (DON) document, (R5) exited the front door, stating he was trying to go home. R5's Nursing Progress Notes, dated 8/7/22 at 11:57 PM document, (electronic monitoring bracelet) applied to left wrist. On 8/19/22 at 1:55 PM, R5 was seated in a chair across form the nurse's station. An electronic monitoring bracelet was present to R5's left wrist. On 8/19/22 at 2:15 PM, V2/Director of Nurses stated, We didn't do an investigation when (R5) left the building (August 3, 2022). We didn't have a(n) (electronic monitoring bracelet) to put on him (August 3, 2022). We only have three of them. We haven't been able to order anymore because our bill hasn't been paid. When another resident left on the eighth (August 8, 2022) we put a(n) (electronic monitoring bracelet) on (R5). Nurses are supposed to visualize the bracelet and check the function of the bracelet, each shift and document the results. I don't know why they weren't doing that (for R5). 3.) R6's admitting diagnoses: Intracranial injury with loss of consciousness of the sequela, and Dementia with behavioral disturbance. R6's Admission Elopement Assessment, updated (8/18/2022), and signed by V25/Social Worker documents Elopement Risk: (R6) is cognitively impaired and independently mobile, Elopement Risk Factors: (R6) has a diagnosis of Alzheimer's Dementia, and is at risk for elopement. History of Elopement: (R6) has a history of elopement and wondering activity. Interventions that are put in place to prevent (R6) from eloping: 1.) Application of monitoring bracelet, 2.) Picture in elopement book, 3.) Frequent visual monitoring. Elopement needs: (R6) is an elopement risk/ wonderer, has a history of trying to exit the building. (R6) wanders the hallways and goes in and out of other resident's room. (R6) does not always know where (R6) room is. (R6) now has a roam alert bracelet/(electronic monitoring bracelet) related to exit seeking. Exit attempt on 8/13/2022. (R6's) Admission Care Plan, dated 2/3/2021, includes a care plan for (R6) elopement. (R6) is an elopement risk/wanderer, has a history of trying to exit the building. (R6) wanders in the hallway and into other residents rooms, and lays in the beds. (R6) intervention: (R6) roam alert bracelet/(electronic monitoring bracelet) is on, and must be monitored every shift for proper placement and functioning. (R6's) Minimum Data Set Assessment, dated 8/5/2022, documents under Section AC: Cognitive Patterns-BIMS (Brief interview for Mental Status) is a (99) (R) is unable to complete interview.) The same form documents under Section G: Cognitive Skills for Decision Making is a (3) Severely Impaired-never/rarely made decisions. The same form Section G under Functional Status: Balance During Transition and Walking documents (R6) is not steady, but able to stabilize without staff assistance. (R6's) Progress Notes, dated 7/31/2021 at 1:46 PM documents, (R6) got out of laundry door and started down the ramp. Staff approached (R6) and assisted (R6) back into building with some resistance. (R6) returned to (R6) room. (R6) Progress Notes, dated 8/7/2022 at 1:31 AM documents, (R6) roam alert bracelet/(electronic monitoring bracelet) does not register. (R6) Progress Notes, dated 8/13/2022 at 1:57 PM documents, V16/CNA (Certified Nursing Assistant) approached nurse while on lunch break and stated, that (R6) had gotten out of the back door of the building and was in the facility parking lot. V23/Housekeeper had been in the laundry room and saw (R6) attempting to walk into the street when V23 alerted V16. With help of V16 and V23 they were able to get (R6) back into the building and get (R6) laid down in bed. (R6) roam alert bracelet/(electronic monitoring bracelet) was tested and found to be disabled and that was how (R6) was able to get out without alerting staff. A new roam alert bracelet/(electronic monitoring bracelet) was tested and placed on (R6) and is in full working capacity. (R6) Progress notes, dated 8/19/2022 at 3:49 PM documents, Noted this morning that (R6's) roam alert bracelet/(electronic monitoring bracelet) was not functioning and therefore (R6) will be put on a one on one and a 15 minute check. On 8/22/2022 at 10:24 AM V24/LPN (Licensed Practical Nurse) stated, Last Saturday I was on lunch break and V16/CNA (Certified Nursing Assistance) came outside to inform me that (R6) was found outside near the dumpster. (R6) became combative, so V23/Housekeeper left (R6) outside to come and get help. V16/CNA and V23 were able to get (R6) back into the building and V24/LPN checked (R6) alarm and found it to be nonfunctional, another band was found for roam alert bracelet/(electronic monitoring bracelet) and replaced it for the nonfunctional band. On 8/22/2022 at 9:43 AM V23/Housekeeper stated, V23 was outside in the shed doing laundry and I could see (R6) outside the door roaming around, (R6) was near the ramp by sidewalk. V23 tried to get (R6) inside, but (R6) became combative. So, I left (R6) outside and ran inside screaming for someone to help me. V16/CNA (Certified Nursing Assistant) helped to bring (R6) back into the building. On 8/22/2022 at 11:46 AM V16/CNA stated, V23/Housekeeper was running through the hallways screaming for help. V23 said (R6) was outside and (R6) became combative and V23 wasn't able to get (R6) back into the building. V16 went outside to get (R6) and (R6) was standing by the wheelchair ramp, V16 was able to get (R6) inside the building with no problem. (R6's) roam alarm bracelet/(electronic monitoring bracelet) was not working properly, and did not go off as it should when going in and out of the doors. On 8/18/ at 11 AM (R6) was up walking up and down the hallways appeared to be confused. (R6's) electronic monitoring bracelet was on (R6's) left ankle. On 8/19/2022 at 3 PM (R6) was sitting at the nurses' station playing a board game with a staff member sitting next to (R6), the electronic monitoring bracelet location had been changed and was now in place on (R6's) right wrist area. On 8/19/22 at 8:45 AM an In-Service Education/Meeting Form was hanging at the Nurse's station desk. This form documented, RE: Doors. No doors should be propped open at any time due to safety and elopement risk. All staff must sign below. This form documented V2/Director of Nurses as the Instructor. At that time, V6/Registered Nurse stated, Some of the night shift staff have been placing a piece of paper in the doorframe to by-pass the alarm, when they go outside and smoke. Everybody knows about it. Evidently they finally got caught. The facility form, (Alarm Alert System) Door Module Testing Calendar 2022, provided by V10/Maintenance Director on 8/22/22, documents, Door Module Testing. Door modules must be tested at least weekly on each shift, with all other surrounding power devices turned on. Record the testing results by initialing the appropriate date. Failure to do so could result in injury or death to a person in your care. No documentation of the dates and shifts for the required weekly testing on the Personal Alarm Safety System were noted. On 8/19/22 at 8:49 AM, V2/Director of Nurses (DON) confirmed the In-Service/Education Meeting form, dated 8/8/22 was to educate staff concerning the propping of doors when exiting the building to smoke and due to kitchen staff propping the Exit door in the kitchen, open. V2/DON also stated, I was the nurse working on August seventeenth, second shift, when (R4) eloped from the building. I don't recall when I saw her earlier in the shift, but around 4:45 (PM) I went to give her medications and (R4) wasn't in her room. Her sister was in the room and said she didn't know where she was. I checked the dining room and up by the nurses' station. I called (V3/Assistant Director of Nurses) and (V5/Licensed Practical Nurse) to see if (R4's) family had signed her out earlier in the day and they both told me no. I finally called her son and he said he didn't know where she was, and he would start looking for her. Around 5:15 (PM), (R4's) son called back and said his Aunt had called him and said (R4) had walked to her house. (R4's) son brought (R4) back to the facility around 6:00 (PM), (V17) and V18/Certified Nursing Assistants) CNAs came on duty at 2:00 PM that afternoon. When I asked them if they heard an alarm, they said no. The last person we can figure out that saw (R4) was (V22/Activity Assistant). She remembers handing (R4) a root beer float sometime around 3:30 PM She wasn't really sure of the time. I didn't hear any alarms go off. I don't know which door she went out of or if someone reset the alarm. We have been having problems with Door 7 (Southeast) door. Something is broken and it doesn't always alarm at the nurses' station. On 8/19/22 at 9:18 AM, V1/Administrator stated, I was alerted by (V2/Director of Nurses) on Wednesday night, around 4:45 (PM), that they couldn't find (R4). I did a head count (of residents), searched the building, and searched the perimeter of the building. We alerted (R4's) son and he called back around 5:15 (PM) to say his aunt had called him and said (R4) had somehow walked to her house. R4 is a fall risk but walked all the way without a walker. (R4's) sister had just moved into this house and (R4) had never been there before. The son brought (R4) back around 6:00 PM. When I checked all the (Exit) doors in the building, I found the kitchen staff had propped open the kitchen screen door and found that door 7 (Southeast) door alarmed at the door, but it didn't sound at the nurses' station panel. It's broken. I have alerted the (Elopement Alarm) company and they are supposed to be coming out on Monday (8/22/22). (V10)/Maintenance man is supposed to be checking the doors weekly, but I don't think he has been doing it. When I called the (Elopement Alarm) company to see when they had come to look at the alarm system, they told me it was a couple of years ago. Evidently our company has an unpaid bill and the (Elopement Alarm) company won't come out and fix door 7 until they get paid. I have notified the company and they are working on getting a check cut. All staff are responsible for answering alarms at the doors, but I have to tell you, the (elopement alarms) are very faint. You can't hardly hear them. I know that the staff is very slow to respond to alarms and until I came about a month ago, they didn't even have a protocol to follow when an alarm went off. On 8/19/22 at 10:14 AM, V12 (R4's sister) stated, (R4) just showed up at my door (Wednesday, August 17, 2022) around 3:00 (PM) or so. (R4) was sweating real bad and was breathing hard. We sat in the air conditioner and drank a (soda) and (R4) rested. (R4) didn't have her walker with her. (R4) said at the time that it felt like it was one hundred degrees outside. I called (V13) (R4's son) and told him that somehow (R4) had shown up at my door. (R4) had never been to my house before, I just moved here. (My house) is about six or seven blocks from the home (facility). Good thing (R4) didn't turn the other way, she would have ended up on the highway. On 8/19/22 at 10:26 AM, V13 (R4's son) stated, I was having a late lunch with my nephew (Wednesday, August 17, 2022) around 4:30 (PM) when the home (facility) called and asked if I knew where mom (R4) was. I was upset. They (facility) should know where my mom (R4) is at all times. I told them that she (R4) wasn't with me, but I would start searching for her (R4). Around 5:15 (PM) or so, my aunt (V12) called and said my mom (R4) had showed up on her front porch, without her walker and out of breath. My aunt (V12) sat mom (R4) down in the air conditioning and gave her something to drink. I drove over to my aunt's house, and she (R4) was still hot and sweaty. We sat there for a while, while she (R4) caught her breath and then I drove her (R4) back to the home (facility) around 6:00 (PM). It's ten or eleven blocks from the home (facility) to my aunt's house, with no sidewalks. That means she (R4) had to walk in the roads. She (R4) is lucky she (R4) didn't get hit by a car. Or fall, she (R4) didn't even have her walker with her, and she (R4) has fallen at the nursing home (facility) a number of times already. I know she (R4) has an alarm bracelet on. I'm aggravated, they (facility) didn't even call the police. I'm the one that had to go looking for her (R4). On 8/19/22 at 10:57 AM, V6/Registered Nurse stated, (R5, R6 and R4) all have alarm bracelets on but, (R6's) bracelet doesn't work. It's inactive. The nurse is supposed to use the tester and check each alarm bracelet, every shift and document it on the TAR (Treatment Administration Record). We didn't really have a protocol (when someone went out the door) until recently. It's also really hard to hear the alarms and door 7 doesn't work, so when you are at the nurses' station, you can't hear the alarm. On 8/19/22 at 12:24 PM, V14/Certified Nursing Assistant (CNA) stated, Third shift has a bad habit of putting a piece of paper in the doors. It allows them to go outside and smoke and the alarm on the door is bypassed. On 8/19/22 at 12:26 PM, V8/Certified Nursing Assistant stated, Door 7 (Southeast) door hasn't worked for a long time. I know some of the girls go out that door to get to their cars and smoke. I don't know when the last training on the door alarms was. Up until recently, we didn't really have a protocol to follow when a resident with an alarm bracelet went out the doors. On 8/19/22 at 12:34 PM, a tour of the facility kitchen showed an Exit door to the North side of the building. At that time, the interior door was open, and a screen door was open, to the outside. V15/Cook verified the open door and stated, We open this door, because it gets so hot back here. V15/Cook also verified she was working the afternoon that (R4) left the facility unnoticed and unattended and the screen door was also open at that time. On 8/19/22 at 2:49 PM, V11/Elopement Alert Company Representative stated, The last service date on the alarm system was 2020. We recommend servicing of the system yearly. The last time the facility ordered elopement alert bracelets/(electronic monitoring bracelets) was 2015. On 8/22/22 at 10:51 AM, V17/Certified Nursing Assistant stated, I was working the afternoon that (R4) left the building. I was answering call lights and taking people (residents) to the bathroom. (V2/DON) came around and asked if I had seen (R4). I told (V2) I hadn't seen (R4). I started searching the building, then got in my car and started driving around. Someone eventually texted me and said that they had found (R4). (R4's) wander alert/(electronic monitoring bracelet) did not go off. I didn't hear any alarms. (R4's) walker was in her room. I don't remember the last time I had training on the alarms. On 8/22/22 at 11:00 AM, V10/Maintenance Director stated, I have been the Maintenance Director for just a few weeks. I had about a week that I worked with the previous Maintenance Director. He retired. I didn't get much trailing on the (door) alarms. I know that Door 7 has been broken for a while. On 8/22/22 at 11:30 AM, V20/Certified Nursing Assistant stated, I work third shift. I know some of the girls have been propping the doors open (by-passing alarms) when they go outside to smoke. I don't remember the last training we have had on the alarms. On 8/22/22 at 12:40 PM, V21/Elopement Alarm Company Representative stated, Door 7 is broken. I don't have the part with me to fix it. We hope to get it installed tomorrow morning. On 8/22/22 at 12:50 PM, V22/Activity Assistant stated, We don't have an Activity Director. I'm the only part time Activity Assistant. I have been here one month. I was a truck driver previously. I don't know much about the door alarms or the elopement alarm bracelets/(electronic monitoring bracelets). I was working the afternoon when (R4) left the building. I started passing root beer floats around 2:30 (PM). (R4) would have been about my sixth resident. (R4) was in her room. (R4) didn't appear agitated or anything. (R4) was looking forward to the root beer float. When I left, (R4) was sitting in her chair, eating her float. I didn't hear any door alarms after that. On 8/23/22 at 2:30 PM, V27/Certified Nursing Assistant (CNA) stated, I was the second CNA working when (R4) eloped. We only have 2 (CNAs) on second shift. I was answering call lights. I hadn't seen (R4) yet that afternoon. I don't recall hearing any alarms, to let us know (R4) had left the building. Once we found out that (R4) left the building, I stayed in the building and (V17/CNA) left in her car to look for (R4). An Immediate Jeopardy was identified on 8-23-22 at 12:30 PM The Immediate Jeopardy began on 8-17-22 when R4 exited the building unattended, through an unalarmed door and without facility knowledge. On 8-23-22 at 12:30 PM V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. 100% Staff education began on 08/23/2022. Staff that were not reachable will be educated prior to working their next shift. Contracted staff will also be included in all required education. 2. All staff have been educated on the elopement policy and procedure, reporting criteria, immediate reporting to the administrator or DON, recognizing elopement, steps to take immediately after an elopement or the alarm system is triggered, and elopement prevention. Trainings specifically include the review of the policy and procedure related to: 1. immediate intervention during an elopement, 2. Immediate reporting to the Administrator or designee and the charge nurse designee for immediate intervention 3. Administrator or designee will fully investigate all reported elopements to report timely; 4. All employees will immediately report any elopement. Education provided by Regional Nurse DON, SSD, Administrator, or designee. 3. The Administrator and Director of Nursing have been in-serviced on Elopement Policy and Procedure including immediate intervention during an elopement, proper and thoroughly investigating elopements, timely reporting, proper protocol during an elopement, completing the process identified in the elopement policy, through investigation process, and providing elopement prevention training to all staff including the elopement policy, recognizing elopement, Education was provided by the administrator or designee. 4. All current residents reassessed for elopement risk. All high risk for elopement residents care plans reviewed and appropriate interventions implemented and in place to address their high risk for wandering and their Care Plans updated to reflect elopement status on 8/23/2022 5. All facility staff re-educated to recognize residents at risk for elopement, where to locate any updated/and or current interventions for high-risk residents, how to respond to all door alarms immediately and the facility policy and protocol for Elopement and Annual retraining will be completed as scheduled annually. 6. All facility staff educated on the process to ensure that high risk elopement residents are communicated to all staff in the facility on 8/23/2022 or prior to their next scheduled shift. 7. All facility door alarms inspected on 08/23/2022 by (Service) technician and Maintenance Director and administrator or designee ensured that door alarms are continuously inspected/audited to ensure proper working order and no doors are propped open. Doors will be audited for alarm functioning daily for 14 days then three times per week for the next four weeks then weekly after. Maintenance Director or Designee will audit doors to ensure they are not propped open and for alarm function daily for 14 days then three times per week for the next four weeks then weekly ongoing. Any issues or concerns regarding door function will be reported to the administrator immediately. 8. (electronic monitoring bracelet) placement will be checked every shift by assigned nurse and (electronic monitoring bracelet) function will be checked daily by nurse ongoing. Director of Nursing or Designee will have additional 1-2 (electronic monitoring bracelets) available should (electronic monitoring bracelet) malfunction. If additional (electronic monitoring bracelet) is unavailable resident will be placed on 1:1 supervision immediately until a functioning (electronic monitoring bracelet) is in place. 9. Facility Management staff reeducated by regional nurse consultant and Vice President of Operations via telephone on 8/23/22 at 2:15 PM on reporting elopement incidents to the State Agency. 10. Elopement processes and procedures are added to the facility[TRUNCATED]

Based on interview and record review, the facility failed to accurately assess a high risk resident's fall risk on admission and failed to implement interventions to prevent further falls for one of one resident (R1), reviewed for falls, in a sample of three. These failures resulted in R1 sustaining multiple falls with injuries, including a subarachnoid hemorrhage and fractures of the right lateral orbital wall/maxillary sinuses. FINDINGS INCLUDE: The (undated) facility policy, Fall Risk Assessment Guidelines and Fall Prevention, directs staff, The Fall Risk Assessment is utilized to determine if a resident is at risk for a fall. The assessment tool (Morse Scale) will identify those residents at risk and will trigger nursing interventions to be implemented in the plan of care. The Morse Scale will be completed by the nurse on admission. The Morse Scale findings will be incorporated into the nursing plan of care upon formulation. Nursing interventions should be instituted based on findings and level of risk. Those residents scoring high on the Morse Scale will have hourly rounding during the day and every two hours at night. The resident is identified as risk for falls when the assessment yields a score of 25 or above. R1's Hospital History and Physical, dated 4/26/22 documents, (R1) was admitted to (Hospital Swing Bed) for physical deconditioning. She was originally admitted to acute care on 4/17/22 due to a urinary tract infection with diffuse weakness and deconditioning. She has a history of falls and cognitive impairment that affects her safety awareness. At this time (R1) is seated in a chair with an alarm and the call button within reach. Safety Interventions include: Assistive Device, Non-skid slippers/shoes when out of bed. Chair Alarm active and audible. R1's current facility Face Sheet documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Urinary Tract Infection, Weakness, Fracture of the Lower End of the Right Radius, Acute Kidney Failure, Chronic Kidney Disease, Type 2 Diabetes Mellitus, [CONDITION(S)], Chronic Congestive Heart Failure, Pulmonary Fibrosis and Anxiety. R1's facility Admission Fall Risk Assessment, dated 5/4/22 and completed by V6/Licensed Practical Nurse documents, (R1) has no history of falls. Score = 8, Low Risk. R1's Admission Care Plan, dated 5/5/22 includes the following Focus areas: (R1) is at risk for falls D/T (Due To) being unsteady 2nd (Secondary) to dizziness. Also included are the following Interventions: Be sure (R1's) call light is within reach and encourage her to use it for assistance as needed. R1's facility Fall Investigation, dated 5/8/22 at 8:00 A.M. documents, (R1) attempted to put socks and shoes on herself. After (R1) had put both shoes on, (R1) attempted to stand up unassisted and slid out of bed . (R1) had no injuries noted and was able to do all ROM (Range of Motion). (R1) stated she was attempting to get into chair for breakfast when her foot slid out from underneath her. Immediate Action Taken: (R1) was educated on the importance of waiting for staff to assist before getting up. Placed (R1's) call light within reach and reeducated this resident (R1) on the purpose of the call light system. R1's facility Fall Investigation, dated 5/10/22 at 11:00 A.M. documents, Called to (R1's) room by another nurse. (R1) was lying on the floor with head towards the window and one foot on the bed. (R1) was sitting in her recliner, which sits directly by her bed at the time of the fall. (R1) did not have on proper footwear and call light was on her bed, out of reach. (R1) was assessed for injuries and no injury or redness noted. (R1) was put on neuros (Neurological Checks). (R1) was assisted off the floor by staff and vitals (Vital Signs) were taken. (R1) was educated on proper foot wear and staff was educated on making sure call light is within reach at all times. R1's Medical Record, dated 5/11/2022 at 1:31 P.M. documents, Health Status Note Text: This nurse was sitting at nurse's desk and heard a dish fall to the floor. At that very moment, a resident sitting in front of nurse desk hollered, 'Hey someone is on the floor, someone fell '. This nurse got up to see what was going on and saw (R1) lying face down on the floor in the hallway. (R1) was facing away from the wall with the right side of (R1's) face on the floor and on top of her right hand and arm. This nurse hollered for DON (V2/Director of Nursing) to get assistance. Once I got to resident, (R1) had blood coming from head area and was unresponsive for a couple of minutes. Once (R1) came to, she was attempting to move. (R1) was not answering questions appropriately at first but when she started to get her mind together, she was alert and oriented. Multiple staff came to assist (R1) and assess for injuries. DON was on floor attempting to talk to (R1) and to see where the blood was coming from. Vitals were taken, 911 was called. POA (Power of Attorney) was notified of incident. Once ambulance arrived, (R1) made motion as though she was going to vomit. (R1) did throw up a bit of blood. Noted a hematoma on the right temporal region and blood noted coming from the nose. Once returning to facility, resident's room will be moved closer to nurse's desk. Neuros (Neurological Assessment) initiated and pupils sluggish but equal and reactive. Moving all ext (extremities) and denies pain at time of transfer. R1's emergency room History and Physical, dated 5/11/22 at 12:05 P.M. documents, (R1) presents to the emergency department for a ground level fall. (R1) was recently discharged to (the facility) after a hospital stay for [CONDITION(S)] (Urinary Tract Infection). (R1) fell in the hallway causing head injury and positive loss of consciousness. (R1) is on blood thinners. (R1) admits to headache, but denies other pain. CT (Computerized Tomography) of Brain-Impression: Right frontal/parietal and temporal convexity subdural hematoma. Right lateral orbital wall/maxillary antral fractures. ED Course: (R1) has acute subdural hematoma. (R1) also has some orbital fractures. Discharge to (Regional Trauma Center). R1's Hospital Trauma Surgery Discharge, dated 5/15/22 documents, (R1) was admitted for further evaluation and treatment of injures. Plastic surgery was consulted for evaluation of facial fractures with recommendations for conservative management and avoiding nose blowing. Neurosurgery was consulted for evaluation with imaging showing subdural hematoma and subarachnoid hemorrhage.(R1) was given [MEDICATION(S)] (Prothrombin Complex Concentrate) and monitored in the Intensive Care Unit. Neurosurgery recommends holding all anticoagulants and aniplatelets until seen in follow up in the office. (R1) was discharged to (the facility) in stable condition. Fall risk precautions. R1's Medical Record documents, 5/15/2022 at 10:30 P.M. (R1) returned to facility via ambulance stretcher from (Regional Trauma Center) at this time. (R1) oriented to new room and call system and will be monitor closely. (R1) alert with intermittent short-term memory deficit observed. (R1) placed in bed for comfort. Bruising noted to left arm and facial bruising and right outer thigh bruising. R1's facility Fall Investigation, dated 5/16/22 at 5:40 A.M. documents, (R1) found on floor immediately after hearing a noise. (R1) was at the foot of the bed, on the floor. No complaints of pain. (R1) assessed for injuries, small skin tear to left arm, small knot on back of right head. Neuro assessment done and normal. Assisted off floor by two staff, instructed (R1) to use call light for assistance. Phone call placed to (V2/Director of Nurses) with instructions to monitor neuros closely and to make frequent rounds on resident to prevent another incident. R1's Medical Record documents, 5/16/2022 at 6:15 A.M., (R1) has c/o (Complaints Of) of severe headache and was dry heaving. Nurse assessed (R1) and (R1) unable to take Tylenol due to nausea. (R1's Physician) and HCPOA notified, and orders received to transfer resident to (Local) E.R. for eval (Evaluation) and treat of headache and nausea. Other Neuros remain intact. R1's emergency room Triage Note, dated 5/16/22 at 8:24 A.M. documents, (R1) is resident at (Facility) and returned there yesterday at 10:40 P.M. after discharge from (Regional Trauma Center) post-fall last week with sub arachnoid hemorrhage. (R1) tried to get up today without assist and had an unwitnessed fall at approximately 5:30 - 5:45 A.M. (R1) has bruising to right hip, right periorbital area and right forearm with a small skin tear on forearm. All appear to be older except for the skin tear. Upon arrival (R1) is denying any pain. (R1) does have some vomit on front of gown. CT of Brain: Interval increase in thickness and acute hyperdense component of right cerebral convexity, careful seen, and right greater than left tentorial subdural hematoma. Secondary to mass effect, there is a 6 MM (Milliliter) left midline shift. Right parietal scalp contusion and subgaleal hematoma has increased in size. Transfer to (Regional Trauma Center). On 5/23/22 at 10:20 A.M., V2/Director of Nurses (DON) stated, (R1) had a history of falls. (R1) was admitted to us from a local hospital on 5/4/22 for continued therapy, due to multiple falls. (R1) was to be a short term rehab stay. When a resident is admitted , we do a Fall Risk Assessment. Depending on the score, we have different interventions to put in place. We have low beds and fall mats and bed (pad) alarms in the facility and we also have floor beds. Sometimes we put a resident in a recliner and place them at the Nurse's Station, so we can keep a closer eye on them. (R1) fell on [DATE] when she slid out of bed. Staff was educated to keep her call light close to her at all times and we educated (R1) to use her call light when she needed assistance. (R1) fell again on 5/10/22 when she was found laying on the floor, next to her bed. (R1) had been sitting in her recliner. (R1) did not have on proper foot wear and her call light was on her bed, out of her reach. Staff was reeducated to place her call light within reach and to make sure (R1) was wearing non slip footwear. We did not place an alarm on (R1). On 5/11/22 (R1) fell while ambulating to the kitchen and sustained a head injury. (R1) was admitted to the hospital. The new intervention was to move (R1) closer to the nurse's station when (R1) returned from the hospital. (R1) came back on 5/15/22. We did not put (R1) in a low bed or use a bed (pad) alarm for (R1), or fall mats. On 5/23/22 at 10:39 A.M., V4/Registered Nurse (RN) stated, We got (R1) back from the hospital around 10:30 at night on 5/15/22. (R1) was extremely confused and combative. By 10:45 PM, (R1) had already gotten herself out of bed and was found standing in her room. We tied (R1's) call light around her wrist and put (R1) back to bed. (R1) did not have an alarm on. (R1) was not in a low bed. We did not put (R1) in a recliner and put (R1) within sight at the nurse's station. That's what we were going to do the next time (R1) fell . Around 5:45 the next morning we heard a noise and we found (R1) at the foot of the bed, on the floor. (R1) had a small skin tear on her left arm and a small knot on the back of her head, on the right side. It was right at shift change. I called (V2/DON) who told me to monitor (R1's) neuro (neurological) signs and to make frequent rounds on (R1). I told the day shift, I would put (R1) in a recliner and set her at the Nurse's Station, if it were me. I filled out the reports and left after that. When I left, (R1) was still here. On 5/23/22 at 11:05 A.M., V3/Assistant Director of Nurses (ADON) stated, If someone is at high risk for falls, we can place that resident in a low bed with fall mats or use a bed (pad) alarm to alert staff. (R1) did not have a low bed, or fall mats or a bed alarm. On 5/23/22 at 12:41 P.M., V5/Licensed Practical Nurse (LPN) stated, When (R1) came to us, (R1) had a history of falls. (R1) was definitely at high risk for falls. (R1) did not have a low bed or fall mats or a bed alarm. On 5/11/22, around 11:00 AM, I was charting at the nurse's desk and another resident sitting by the desk, looked down the south hallway and said, 'Hey, somebody fell .' At that same time, I heard a dish break on the floor. Evidently (R1) was walking down the hall, by herself, to return a dish to the kitchen and (R1) fell flat on her face. When I got to (R1), the right side of (R1's) face was laying on the floor. (R1) was bleeding from her nose. We immediately called 911 and sent (R1) to the E.R. (emergency room ). I also worked the morning (R1) fell on [DATE]. (R1) wasn't my patient. All I was involved in was copying papers and calling 911 to send (R1) to the hospital. It was around 7:10 when we sent (R1) in. On 5/23/22 at 12:51 P.M., V6/Licensed Practical Nurse (LPN) stated, I was the nurse who completed (R1's) Fall Risk Assessment. I didn't know (R1) had fallen prior to (R1's) admission. We didn't always have the paperwork, when we admit someone. If I had know that, it would have changed (R1's) fall risk and interventions. On 5/24/22 at 10:57 A.M., V7/Registered Nurse (RN) stated, When I came into work on 5/16/22, (R1) had fallen again. I went to (R1's) room after I had gotten report and (R1) was in bed and yelling that her head hurt and she wanted some Tylenol. When I returned with the Tylenol, (R1) began retching and eventually vomited some bile. At that point I didn't feel comfortable giving (R1) anything, so I called the doctor and requested to send (R1) to the hospital. The other nurse called 911 and I sent (R1) to the (local) E.R.