Every finding on record at Moweaqua Rehab & HCC

Based on observation, interview, and record review, the facility failed to follow physician orders when administering medications including multiple doses of intravenous antibiotics for two (R7, R8) residents out of three residents reviewed for medication administration in a sample list of eight residents. Findings include: 1. R7's Electronic Medical Record (EMR) documents medical diagnoses as Multiple Sclerosis, Heart Failure, Epilepsy, Acute Osteomyelitis, Sacral Pressure Ulcer, Need for Personal Care, and Bacteremia. R7's Minimum Data Set (MDS), dated [DATE], documents R7 as cognitively intact. R7's Physician Order Sheet (POS), dated February 2025, documents a physician order starting 2/1/25 for Ertapenem Sodium one Gram (GM) every 24 hours intravenously for wound infection until 2/3/25. This same POS documents a physician order starting on 2/3/25 for Ertapenem Sodium one gram (gm) every 24 hours intravenously for wound infection until 2/11/25. Notify Physician if medication is missing. R7's Medication Administration Record (MAR), dated February 2025, documents R7 was not administered Ertapenem Sodium One GM on 2/1/25, 2/2/25, 2/5/25, 2/8/25 and 2/10/25. R7's Nurse Progress Notes do not document R7's Ertapenem Sodium One Gram (GM) not being administered on 2/1/25, 2/2/25, 2/5/25, 2/8/25 and 2/10/25. R7's Nurse Progress Notes do not documents notifications being made to R7's Physician, R7, nor R7's Power of Attorney (POA). R7's Medication Error Report, dated 2/3/25, documents R7's Ertapenem Sodium One GM was not administered on 2/1/25 and 2/2/25 due to staff not being able to locate the medication. The facility was unable to provide medication error reports due to R7's Ertapenem Sodium not being administered on 2/5/25, 2/8/25 and 2/10/25. On 2/11/25 at 1:00 PM, R7 was laying in his bed with a Peripherally Inserted Central Catheter (PICC) line in place in his Left Upper arm. On 2/11/25 at 1:05 PM, R7 stated the nurses are 'hit an miss' administering his Ertapenem Sodium One Gram (GM) via his PICC (peripherally inserted central catheter) line. R7 stated, Sometimes they (staff) are good about it and other times I have to wait for hours. Then I ask about it and they tell me they will get it. No one ever returns to give me the antibiotic. That is the entire reason I have to have this PICC line. If they (staff) aren't going to give it to me, then I should not have to have this PICC line. Now I was told that I have to have it (IV antibiotic) for more days due to the staff didn't give it right. That isn't right. On 2/11/25 at 1:45 PM, V7, Agency Registered Nurse (RN), stated she worked on 2/1/25 and 2/2/25 as R7's nurse. V7 RN stated she looked for R7's Ertapenem Sodium IV antibiotic, but was not able to find it. V7, RN, stated she did not give R7's antibiotic on those two days, and did not notify the Physician. V7, RN, stated she was told later that the facility has a back up medication storage system, which did include the antibiotic, which was onsite that weekend. V7, RN, stated, I guess I should have called somebody, but I can't be expected to give something I can't find. I should not have to call the doctor every time someone doesn't get their medication. 2. R8's Electronic Medical Record (EMR) documents medical diagnoses of Epilepsy and Dementia. R8's Minimum Data Set (MDS), dated [DATE], documents R8 as severely cognitively impaired. R8's Physician Order Sheet (POS), dated December 2024, documents a physician order starting 12/6/24 for Briviact Oral Tablet 50 milligram (MG). Give 50 mg by mouth two times a day for Epilepsy. R8's Medication Administration Record (EMR), dated December 2024, documents R8 received the scheduled doses of Briviact 50 mg in the morning and evening of 12/17/24. R8's Nurse Progress Note, dated 12/17/24 at 8:04 PM, documents R8 was given the wrong dose of Briviact (anti-epileptic) medication. This same note documents, (R8) was mistakenly given two doses from a card of another resident with 100 milligram (mg) Briviact, though (R8) is ordered 50 mg of Briviact. R8's Medication Error Report, dated 12/17/24, documents R8 received the wrong dose of Briviact. This same report documents R8 was ordered 50 mg Briviact twice daily and was mistakenly given Briviact 100 mg on 12/17/24. On 2/11/25 at 3:00 PM, V5, Nurse Practitioner (NP), stated R7's Intravenous (IV) antibiotic Ertapenem Sodium One GM was ordered daily for R7's Sacral Pressure Ulcer, which is infected. V5, NP, stated Ertapenem wound be considered a critical medication necessary for R7's wound healing. V5, NP, stated V5 is not aware R7 had any side effects from the staff not administering this medication, but 'absolutely could have'. V5, NP, stated there is no excuse for V7, Agency Registered Nurse (RN), to not call V5, NP, on 2/1/25 to report R7's medication could not be located. V5, NP, stated the facility did in fact have R7's Ertapenem, which was in the Stat Safe medication storage system. V5, NP, stated she found out R7 did not have his Ertapenem on 2/3/25. V5, NP, stated V5 is onsite five days per week for half days, which is during the time R7 is scheduled to receive his IV antibiotic through his PICC line. V5, NP, stated the staff could have notified her while she was in the building, and she would have addressed the situation immediately. V5, NP, stated R8 has Briviact 50 mg ordered twice daily for his Seizure Disorder. V5, NP, stated all residents medications should be administered as ordered by the prescriber. V5, NP, stated V6, Agency Licensed Practical Nurse (LPN), mistakenly administered Briviact 100 mg to R8. V5, NP, stated R8 did not have any significant medical complications due to this error. V5, NP, stated, (R8) was lucky to not have any significant issues due to this error. It could have been much worse. Overdosing the resident's neurological symptoms could cause ill effect. On 2/13/25 at 10:05 AM, V1, Administrator, stated the facility does not have a policy or guidelines on medication errors. V1 stated it is the expectation for nursing staff to follow the physician orders, and if there a reason a resident does not get their medication or gets the wrong dose, then the staff should reach out to the provider.

Based on observation, interview, and record review, the facility failed to protect residents' rights to be free from physical and verbal abuse by R1. These failures affected four residents (R1, R2, R3, R4,) of thirteen reviewed for abuse in the sample of thirteen and resulted in R1 punching R2 in the face with R2 receiving defensive hand wounds requiring medical evaluation at the hospital and prescriptions for oral and topical antibiotic treatments, R1 using verbal expletives towards R3, and R1 kicking R4 in the legs. Findings include: The facility Abuse, Prevention, & Prohibition Policy (12/2024) documents: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals and The resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse; corporal punishment and involuntary seclusion. The same policy documents Instances of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. The facility's abuse log (November-December, 2024) documents allegations of R1 physically abusing R2 on 12/7/2024, physically abusing R3 on 12/10/2024, and physically abusing R4 on 12/18/2024. R1's Resident Assessment (12/13/2024) documents R1 has short-term and long-term memory problems, moderately impaired decision making ability, has physical and verbal behavioral symptoms directed towards others placing R1 and others at risk for physical injury, and has wandering behavior significantly intruding on the privacy or activities of others. The same record documents R1 does not have any upper extremity impairment in range of motion and independently uses a wheelchair for mobility. R1's SBAR Communication Form (12/10/2024) documents: Resident's confusion and physical aggression has gotten worse. Resident wanders around facility all day, not easy to re-direct, Has had multiple situations where staff have been unable to re-direct. Resident is a high fall risk and frequent faller- Resident is a safety risk for himself and others as he becomes combative towards staff members when they attempt to re-direct. The same record documents R1 was in an altercation with another resident during the previous weekend. R1's Progress Notes (12/10/2024) document: Resident is experiencing increased confusion and increased behaviors. R1's confusion and physical aggression have worsened. Resident wanders around facility all day, not easy to re-direct, has had multiple situations where staff have been unable to redirect. Resident is a high fall risk and frequent faller and safety risk for self and others as resident becomes combative towards staff members when they attempt to redirect. The same record documents V5 (Registered Nurse) redirected R1 from propelling R1's wheelchair into R6. The facility's Petition For Involuntary Admission (12/18/2024) documents: Resident (R1) is demonstrating unprovoked physical aggression towards other residents. Threw a glass of water at resident, growls, screams at other residents, grabs at other residents, tries to run others over with wheelchair, kicked another resident in shin. (R1's) behavior provokes confrontation with other residents. When redirected, becomes physically aggressive with staff. R1's Psychiatric Progress Note (12/22/2024) documents R1 was hospitalized from 12/18/2024-12/29/2024 for agitation and physical aggression towards others and received a 1:1 sitter for safety while hospitalized . R1's care plan (printed 1/2/2025) documents a 12/16/2024 entry that R1 has a behavioral problem and a goal that R1 will have fewer episodes of behaviors, including wandering into others rooms, and a decrease in behaviors to less than four times a week. The same record does not document any interventions for staff to implement to decrease R1's behaviors. 1. R2's diagnosis list (printed 1/3/2025) documents diagnoses including Dementia without behavioral disturbance. R2's Resident Assessment (10/24/2024) documents R2 has fully intact cognition, does not have any behavioral symptoms directed towards others, requires moderate to maximal staff assistance to perform activities of daily living, and uses a wheelchair for mobility with moderate staff assistance. The facility incident report (12/17/2024) documents on 12/7/2024, R1 approached R2 and attempted to remove R2's hat from R2's head in a physical altercation resulting with R2 suffering a laceration and bruising to R2's hand. The same record documents both R1 and R2 were transferred to the hospital for evaluation and treatment. R1's Progress Notes (12/7/2024) document: Writer made aware of physical altercation between resident (R1) and another resident (R2). Residents separated and investigation began. Resident (R1) states (R2) had my hat and (R1) punched (R2) in the face. R2's Progress Notes (12/7/2024) document R2 stated: (R1) tried to take my hat and punched me in my face, I am [AGE] years old and I am still going to defend myself, so I grabbed (R1's) hand to stop (R1) from further punching me and then I punched (R1) to keep (R1) off of me. R2's hospital report (12/7/2024) documents R1 punched R2 on the face on 12/7/2024 and R2 also sustained skin tears and bruising to R2's hand during the altercation with R1. The same record documents R2 was prescribed oral and topical antibiotic treatment for R2's injuries sustained during the incident with R1. R2's Orders (printed 1/3/2025) document the following orders: Amoxicillin-Potassium Clavulanate Tablet, 875-125 milligrams, take one tablet by mouth two times a day for skin tears for 10 days (starting on 12/8/2024) and Mupirocin External Ointment 2%, apply to right hand topically three times a day for right hand skin tear for seven days (starting on 12/8/2024). R2's Progress Notes document the following: -12/10/2024: Continues on antibiotic therapy related to skin wounds acquired during resident altercation. Right hand remains bruised and swollen. -12/11/2024: Continues on antibiotic therapy related to skin wounds acquired during resident altercation. Right hand remains bruised and swollen. -12/13/2024: Bruising noted to right hand, resident had previous incident involving another resident which has resulted in this bruising. New order received to monitor bruising. On 1/3/2025 at 1:00PM, R2 reported R1 has always wandered in and out of resident rooms continuously, and on 12/7/24, R1 approached R2 and tried to take R2's hat off of R2's head, and then R1 punched R2 in the left front cheek area, followed R2 striking R1 back while defending R2's self from further strikes from R1. R2 reported R1 has wandered into R2's room at all times of the day and night, including the middle of the night. On 1/3/2025 at 2:12PM, V6 (Licensed Practical Nurse) reported separating R1 and R2 during their altercation on 12/7/2024. V6 reported R2's knuckles were bleeding when V6 approached R1 and R2. V6 reported hearing residents frequently say R1 wanders into their rooms and takes things. 2. R3's diagnosis list (printed 1/3/2025) documents diagnoses including: Major Depressive Disorder, Adjustment Disorder With Depressed Mood, and Insomnia. R3's Resident Assessment (12/30/2024) documents R3 has fully intact cognition, does not have any behavioral symptoms directed towards others, requires substantial to maximal staff assistance to perform activities of daily living, and uses a wheelchair for mobility. The facility incident report (12/17/2024) documents on 12/10/2024, R3 was in the hallway near R5's room and R1 was also present and attempting to enter R5's room. The report documents R3 had asked R1 to not enter R5's room, followed by R1 then calling R3 bad names and throwing a cup of water onto R3. The same record documents R5 observed R1 throw water onto R5 in the hallway after R3 had asked R1 to not wander into R5's room. On 1/3/2025 at 10:07AM, R3 reported R1 wanders continuously throughout the facility in R1's wheelchair, and has wandered in R3's room one hundred times, I'm not joking. R3 reported R1 stole food, soda, and candy from R3's room last summer, so R3 now has R3's items locked. R3 reported R1 has beaten nurse aide staff and also spit on them. R3 reported observing R1 hit staff hard. R3 reported being scared of R1 because R1 is so mean. R3 reported being outside of R5's room on 12/10/2024 and observed R1 wander into R5's room. R3 reported telling R1 at the time to get out of R5's room, followed by R1 throwing a cup of water onto R3, hitting R3 in the torso and legs with the water. R3 reported later in the same day, R1 came all the way inside of R3's room in R1's wheelchair and called R3 a fat (expletive) and ugly. R3 reported facility staff then removed R1 from R3's room after R3 began screaming. R3 reported R1 has always called R3 names and staff are aware. 3. R4's diagnosis list (printed 1/3/2025) documents diagnoses including: Cerebral Infarction (stroke), Hemiplegia and Hemiparesis (partial paralysis and weakness on one side of the body), and Generalized Muscle Weakness. R4's Progress Notes (November-December, 2024) document R4 is blind. R4's Resident Assessment (12/22/2024) documents R4 has severe cognitive impairment, requires moderate to maximal staff assistance to perform activities of daily living, has upper and lower extremity range of motion impairment, and uses a wheelchair for mobility. The facility incident report (12/24/2024) documents on 12/18/2024, R1 and R4 were located in the facility living room and V9 (Certified Nurse Aide) overheard R5 and R6 telling R1 to not kick R4. The same report documents written statements made by R5 and R12 of directly observing R1 kicking R4 on 12/18/2024. The report also documents interviews with R8 and R9 who both expressed R1 caused them to feel unsafe living in the facility. On 1/2/2025 at 2:17PM, V8 (Regional Nurse) reported V9 (Certified Nurse Aide) had reported to her on 12/18/2024 that R4 was seated in R4's wheelchair by the nurse's station when R1 approached R4 in R1's wheelchair and began kicking R4 without provocation. V8 reported R1's aggression towards other residents had been increasing. On 1/3/2025 at 2:38PM, R1 was seated in R1's wheelchair, entered R7's room independently, and began touching R7's personal items. R7 was present in R7's room along with R7's family (unidentified). V10 (R7's medical provider) was also present and discussing medical discharge information with R7 and R7's family. R7's family asked R1 to stop touching R7's personal items. No staff were present or nearby R7's room. On 1/3/2025 at 3:17PM, V11 (Regional Director of Operations) reported R1 did currently have 1:1 staff supervision, but the staff member providing the supervision had been pulled to work elsewhere leaving R1 unsupervised, therefore, the observation of R1 in another resident's (R7) room was isolated. On 1/3/2025 at 3:46PM, R1 was seated in R1's wheelchair and propelling down the hallway. No facility staff were present with R1. R1 then entered R10 and R11's room, where both residents were sleeping. R10 was sleeping in R10's wheelchair located near the doorway, with R10's feet flat on the floor, and R11 was sleeping in bed. R1's wheelchair wheels nearly ran over R10's toes repeatedly as R1 moved back and forth in R1's wheelchair. R1 then began touching R10's personal items located in an open drawer for several minutes before proceeding further into R10/R11's room to a table containing drinking glasses. At 3:53PM, R1 then picked up a drinking glass containing a beverage and drank from the glass, at which time R11 woke from sleep, and stated No, (R1), no (R1), stop. Facility staff then walked by R10/R11's room and removed R1 from R10/R11's room. On 1/3/2025 at 3:53PM, R6 reported R1 keeps trying to get into everyone's room. On 1/3/2025 at 2:46PM, V5 (Registered Nurse) reported R1 was attempting to intentionally ram R1's wheelchair into R6 on 12/10/2024. On 1/6/2025 at 11:17AM, R8 reported R1 wanders frequently and R8 has had to throw (R1) out of R8's room twice recently.

Based on interview and record review, the facility failed to revise residents' care plans following resident to resident physical and verbal abuse incidents. This failure affects four residents (R1, R2, R3, R4) of four reviewed for care plans in the sample of thirteen. Findings include: The facility's abuse log (November-December, 2024) documents allegations of R1 physically abusing R2 on 12/7/2024, physically abusing R3 on 12/10/2024, and physically abusing R4 on 12/18/2024. R1's Resident Assessment (12/13/2024) documents R1 has short-term and long-term memory problems, moderately impaired decision making ability, has physical and verbal behavioral symptoms directed towards others placing R1 and others at risk for physical injury, and has wandering behavior significantly intruding on the privacy or activities of others. The same record documents R1 does not have any upper extremity impairment in range of motion and independently uses a wheelchair for mobility. R1's SBAR Communication Form (12/10/2024) documents: Resident's confusion and physical aggression has gotten worse. Resident wanders around facility all day, not easy to re-direct, Has had multiple situations where staff have been unable to re-direct. Resident is a high fall risk and frequent faller- Resident is a safety risk for himself and others as he becomes combative towards staff members when they attempt to re-direct. The same record documents R1 was in an altercation with another resident during the previous weekend. R1's Progress Notes (12/10/2024) document: Resident is experiencing increased confusion and increased behaviors. R1's confusion and physical aggression have worsened. Resident wanders around facility all day, not easy to re-direct, has had multiple situations where staff have been unable to redirect. Resident is a high fall risk and frequent faller and safety risk for self and others as resident becomes combative towards staff members when they attempt to redirect. The same record documents V5 (Registered Nurse) redirected R1 from propelling R1's wheelchair into R6. The facility's Petition For Involuntary Admission (12/18/2024) documents: Resident (R1) is demonstrating unprovoked physical aggression towards other residents. Threw a glass of water at resident, growls, screams at other residents, grabs at other residents, tries to run others over with wheelchair, kicked another resident in shin. (R1's) behavior provokes confrontation with other residents. When redirected, becomes physically aggressive with staff. R1's Psychiatric Progress Note (12/22/2024) documents R1 was hospitalized from 12/18/2024-12/29/2024 for agitation and physical aggression towards others and received a 1:1 sitter for safety while hospitalized . R1's care plan (printed 1/2/2025) documents a 12/16/2024 entry that R1 has a behavioral problem and a goal that R1 will have fewer episodes of behaviors including wandering into others rooms and a decrease in behaviors to less than four times a week. The same record does not document any interventions for staff to implement to decrease R1's behaviors. 1. R2's diagnosis list (printed 1/3/2025) documents diagnoses including Dementia without behavioral disturbance. R2's Resident Assessment (10/24/2024) documents R2 has fully intact cognition, does not have any behavioral symptoms directed towards others, requires moderate to maximal staff assistance to perform activities of daily living, and uses a wheelchair for mobility with moderate staff assistance. The facility incident report (12/17/2024) documents on 12/7/2024, R1 approached R2 and attempted to remove R2's hat from R2's head in a physical altercation resulting with R2 suffering a laceration and bruising to R2's hand. The same record documents both R1 and R2 were transferred to the hospital for evaluation and treatment. R1's Progress Notes (12/7/2024) document: Writer made aware of physical altercation between resident (R1) and another resident (R2). Residents separated and investigation began. Resident (R1) states (R2) had my hat and R1 punched (R2) in the face. R2's Progress Notes (12/7/2024) document R2 stated: (R1) tried to take my hat and punched me in my face, I am [AGE] years old and I am still going to defend myself, so I grabbed (R1's) hand to stop (R1) from further punching me and then I punched (R1) to keep (R1) off of me. R2's hospital report (12/7/2024) documents R1 punched R2 on the face on 12/7/2024, and R2 also sustained skin tears and bruising to R2's hand during the altercation with R1. The same record documents R2 was prescribed oral and topical antibiotic treatment for R2's injuries sustained during the incident with R1. R2's Orders (printed 1/3/2025) document the following orders: Amoxicillin-Potassium Clavulanate Tablet, 875-125 milligrams, take one tablet by mouth two times a day for skin tears for 10 days (starting on 12/8/2024) and Mupirocin External Ointment 2%, apply to right hand topically three times a day for right hand skin tear for seven days (starting on 12/8/2024). R2's Progress Notes document the following: -12/10/2024: Continues on antibiotic therapy related to skin wounds acquired during resident altercation. Right hand remains bruised and swollen. -12/11/2024: Continues on antibiotic therapy related to skin wounds acquired during resident altercation. Right hand remains bruised and swollen. -12/13/2024: Bruising noted to right hand, resident had previous incident involving another resident which has resulted in this bruising. New order received to monitor bruising. On 1/3/2025 at 1:00PM, R2 reported R1 has always wandered in and out of resident rooms continuously and on 12/7/24, R1 approached R2 and tried to take R2's hat off of R2's head and then R1 punched R2 in the left front cheek area followed R2 striking R1 back while defending R2's self from further strikes from R1. R2 reported R1 has wandered into R2's room at all times of the day and night including the middle of the night. On 1/3/2025 at 2:12PM, V6 (Licensed Practical Nurse) reported separating R1 and R2 during their altercation on 12/7/2024. V6 reported R2's knuckles were bleeding when V6 approached R1 and R2. V6 reported hearing residents frequently say R1 wanders into their rooms and takes things. R2's care plan (printed 1/3/2025) does not document R1 abused R2 and does not document any subsequent abuse related care planning for R2. 2. R3's diagnosis list (printed 1/3/2025) documents diagnoses including: Major Depressive Disorder, Adjustment Disorder With Depressed Mood, and Insomnia. R3's Resident Assessment (12/30/2024) documents R3 has fully intact cognition, does not have any behavioral symptoms directed towards others, requires substantial to maximal staff assistance to perform activities of daily living, and uses a wheelchair for mobility. The facility incident report (12/17/2024) documents on 12/10/2024, R3 was in the hallway near R5's room and R1 was also present and attempting to enter R5's room. The report documents R3 had asked R1 to not enter R5's room, followed by R1 then calling R3 bad names and throwing a cup of water onto R3. The same record documents R5 observed R1 throw water onto R5 in the hallway after R3 had asked R1 to not wander into R5's room. On 1/3/2025 at 10:07AM, R3 reported R1 wanders continuously throughout the facility in R1's wheelchair and has wandered in R3's room one hundred times, I'm not joking. R3 reported R1 stole food, soda, and candy from R3's room last summer, so R3 now has R3's items locked. R3 reported R1 has beaten nurse aide staff and also spit on them. R3 reported observing R1 hit staff hard. R3 reported being scared of R1 because R1 is so mean. R3 reported being outside of R5's room on 12/10/2024 and observed R1 wander into R5's room. R3 reported telling R1 at the time to get out of R5's room, followed by R1 throwing a cup of water onto R3, hitting R3 in the torso and legs with the water. R3 reported later in the same day, R1 came all the way inside of R3's room in R1's wheelchair and called R3 a fat (expletive) and ugly. R3 reported facility staff then removed R1 from R3's room after R3 began screaming. R3 reported R1 has always called R3 names and staff are aware. R3's care plan (printed 1/3/2025) does not document R1 abused R3 and does not document any subsequent abuse related care planning for R3. 3. R4's diagnosis list (printed 1/3/2025) documents diagnoses including: Cerebral Infarction (stroke), Hemiplegia and Hemiparesis (partial paralysis and weakness on one side of the body), and Generalized Muscle Weakness. R4's Progress Notes (November-December, 2024) document R4 is blind. R4's Resident Assessment (12/22/2024) documents R4 has severe cognitive impairment, requires moderate to maximal staff assistance to perform activities of daily living, has upper and lower extremity range of motion impairment, and uses a wheelchair for mobility. On 1/2/2025 at 2:17PM, V8 (Regional Nurse) reported V9 (Certified Nurse Aide) had reported to her on 12/18/2024 that R4 was seated in R4's wheelchair by the nurse's station when R1 approached R4 in R1's wheelchair and began kicking R4 without provocation. V8 reported R1's aggression towards other residents had been increasing. The facility incident report (12/24/2024) documents on 12/18/2024, R1 and R4 were located in the facility living room and V9 (Certified Nurse Aide) overheard R5 and R6 telling R1 to not kick R4. The same report documents written statements made by R5 and R12 of directly observing R1 kicking R4 on 12/18/2024. The report also documents interviews with R8 and R9 who both expressed R1 caused them to feel unsafe living in the facility. R4's care plan (printed 1/3/2025) does not document R1 abused R4 and does not document any subsequent abuse related care planning for R4. On 1/3/2025 at 2:38PM, R1 was seated in R1's wheelchair, entered R7's room independently, and began touching R7's personal items. R7 was present in R7's room along with R7's family (unidentified). V10 (R7's medical provider) was also present and discussing medical discharge information with R7 and R7's family. R7's family asked R1 to stop touching R7's personal items. No staff were present or nearby R7's room. On 1/3/2025 at 3:17PM, V11 (Regional Director of Operations) reported R1 did currently have 1:1 staff supervision, but the staff member providing the supervision had been pulled to work elsewhere leaving R1 unsupervised therefore the observation of R1 in another resident's (R7) room was isolated. On 1/3/2025 at 3:46PM, R1 was seated in R1's wheelchair and propelling down the hallway. No facility staff were present with R1. R1 then entered R10 and R11's room where both residents were sleeping. R10 was sleeping in R10's wheelchair located near the doorway, with R10's feet flat on the floor, and R11 was sleeping in bed. R1's wheelchair wheels nearly ran over R10's toes repeatedly as R1 moved back and forth in R1's wheelchair. R1 then began touching R10's personal items located in an open drawer for several minutes before proceeding further into R10/R11's room to a table containing drinking glasses. At 3:53PM, R1 then picked up a drinking glass containing a beverage and drank from the glass, at which time R11 woke from sleep, and stated No, (R1), no (R1), stop. Facility staff then walked by R10/R11's room and removed R1 from R10/R11's room. On 1/3/2025 at 3:53PM, R6 reported R1 keeps trying to get into everyone's room. On 1/3/2025 at 2:46PM, V5 (Registered Nurse) reported R1 was attempting to intentionally ram R1's wheelchair into R6 on 12/10/2024. On 1/6/2025 at 11:17AM, R8 reported R1 wanders frequently and R8 has had to throw (R1) out of R8's room twice recently.

Based on interview and record review, the facility failed to monitor and document a residents' tube feeding administration amounts, gastric tube placement, residuals, feeding complications, and consultation to ensure adequate nutritional intake was being administered via the tube feeding. These failures affect one (R3) of one resident reviewed for tube feedings from a total sample list of eight residents reviewed. These failures resulted in R3 having nausea and vomiting with tube feeding administration, the tube feeding being shut off without a physician order/consultation, and R3 experiencing continued significant weight loss. Findings include: The undated facility tube feeding skills checklist documents to monitor resident for feeding intolerance, document the verification of tube placement, amount and time of enteral feeding and amount of flush and report complications to the supervisor and medical practitioner. R3's progress notes, dated 8/16/24, document R3 was admitted to the facility with a history of intellectual disability, hematuria, hydronephrosis, genitourinary surgery, depression, chronic leukemia, spondylosis, osteoarthritis, persistent atrial fibrillation, and a need for assistance with personal care. R3's admission nutritional assessment, dated 8/29/24, documents an order for R3 to have regular, soft, bite sized foods. R3's weight summary, dated 8/16/24, documents R3's admission weight at 149 pounds. R3's weight summary, dated 10/2/24, documents R3's weight at 131.6 pounds, a 12% weight loss in 17 days. R3's medical record does not document the implementation of any Dietician recommendations or physician notifications of Dietician recommendations from admission throughout R3's entire facility stay. On 10/31/24, R3 was sent to the hospital for blood in the urine and a penile abscess. R3's hospital notes, dated 11/3/24, document a potassium level of 3.3milligrams (mg), compared to R3's potassium level, dated 7/18/24 of 3.8mg, and R3's magnesium level, dated 11/3/24 of 1.8mg, indicative of malnourishment, dehydration, and weakness to the degree that a feeding tube was placed for supplemental nutrition and fluids. R3's body mass index was documented on this date at 17.3, severely malnourished. R3's hospital discharge notes document on 11/27/24, R3 returned to the facility with a peg tube and an order for Osmolite 1.5 at 90cubic centimeter (cc) per hour for 14 hours with a 50cc tapwater flush every four hours, in addition to an oral diet of soft, bite sized food, dysphagia level three. R3's physician orders, dated 11/27/24, document the facility was administering R3's Osmolite 1.5 at 90cc for 12 hours, instead of the 14 hours as ordered upon discharge. R3's weight summary, dated 11/27/24, documents R3's weight as 130 pounds. R3's weight summary, dated 12/2/24, documents R3's weight as 128.9 pounds. R3's physician progress notes, dated 12/3/24, documents V5, Physician, was asked to review R3's situation regarding poor oral intake, deconditioning, and weight loss. R3's notes document that the peg tube feeding is running from 6:00PM to 6:00AM, 12 hours at a time, and another two pound weight loss has occurred. R3's physician orders, dated 12/3/24, document a change in tube feeding formula from Osmolite 1.5 at 90cc per hour to Jevity 1.5 at 50cc per hour to increase in 10 cc increments until reaching 70cc per hours for twelve hours, from 6:00PM to 6:00AM. R3's progress notes document R3 vomiting once on 12/4/24 and three times on 12/7/24 with feedings stopped on 12/4/24 and 12/7/24. R3's physician orders do not document an order to stop feedings, nor any consultation with the Dietician. R3's medical record does not contain documentation of verification of tube placement, amount of enteral feeding administered, or that all episodes of vomiting were reported to the physician and supervisor. On 12/9/24 at 10:20AM, V22, Registered Nurse/RN stated on 12/6/24 at 2:00AM, R3 vomited after dinner, and after his tube feeding was started, he vomited twice more. V22 stated she turned off R3's tube feeding and did not notify anyone. On December 7, 2024, I saw that he ate about 25% of his meal and then threw it up. The on call physician was then notified by the other nurse. At one point, we discussed talking with the Dietician, but it just didn't go anywhere. On 12/9/24 at 10:06AM, V4, Registered Dietician (RD), stated she was unaware the MD did not accept her recommendations for the tube feeding formula amounts and she was not made aware of R3 vomiting, so that another type of formula could be tried. Stopping the feedings was not the right choice in someone with malnourishment, we could have tried different formulas. On 12/9/24 at 12:00PM, V3, Nurse Practitioner stated she was never provided V4's, RD, recommendations. If I had gotten them, I would have communicated them to the doctor and definitely considered them, but neither I nor the physician were made aware of them. On 12/9/24 at 12:15PM, V2, Corporate Director of Nursing, stated when caring for residents with tube feedings, staff should be documenting intake and output incuding flushes and tube feedings, verification of placement and any complications. If they don't (document), you don't know if they are receiving all of the nutrition that they need. I would expect the Dietician would be involved at admission, weekly, and when there is a change of condition. Certainly the physician and Director of Nursing should be notified with any complications related to the feeding.

Based on observation, interview, and record review, the facility failed to provide a residents' dietary recommendations to the physician, notify the Registered Dietician and physician of continued weight loss, obtain weights as ordered, follow dietary orders, and failed to report a residents' peg tube (gastric tube) placement to the Registered Dietician upon readmission to the facility. These failures affect one (R3) of three residents reviewed for nutrition on a total sample list of eight residents. These failures resulted in R3 losing 13.5% of his body weight in three and a half months, resulting in malnutrition, dehydration, and peg tube placement due to nutritional insufficiency. Findings include: The facility weight assessment and intervention policy, dated 12/2024, documents the nursing staff will measure residents weight on admission, weekly for four weeks thereafter, and then monthly, if no weight concerns are noted. R3's progress notes, dated 8/16/24, document R3 was admitted to the facility with a history of intellectual disability, hematuria, hydronephrosis, genitourinary surgery, depression, chronic leukemia, spondylosis, osteoarthritis, persistent atrial fibrillation and a need for assistance with personal care. R3's weight summary, dated 8/16/24, documents: R3 weighed 149 pounds on 8/16/24, 131.6 pounds on 10/2/24, 130 pounds on 11/27/24 and 128.9 pounds on 12/2/24. No weight was documented in September 2024. R3's progress notes, dated 10/2/24, document R3 weighed 131 pounds, having lost l2% of his body weight. At this time, recommendations for weight gain were made by V4, Registered Dietician, to provide twice daily supplements and an appetite stimulant, neither of which were implemented. On 10/31/24, R3 was sent to the hospital for blood in the urine and a penile abcess. R3's hospital notes, dated 11/3/24, document a potassium level of 3.3milligrams (mg) compared to R3's potassium level, dated 7/18/24, of 3.8mg and R3's magnesium level dated 11/3/24 of 1.8mg, indicative of malnourishment, dehydration, and weakness to the degree that a feeding tube was placed for supplemental nutrition and fluids. R3's body mass index was documented on this date at 17.3, severely malnourished. On 11/3/24, hospital physician progress notes document a gastric tube placement will be discussed with the guardian given severe malnutrition which appears to have been going on for some time. R3's hospital discharge records, dated 11/27/24, document R3 returned to the facility with orders for oral intake of soft and bite sized food on a dysphagia three diet, with supplemental peg tube feedings. The formula included Osmolite 1.5 at 90 milliliters ml per hour, starting at 6:00PM and stopping at 8:00AM, and 50ml flushes with tap water every four hours. R3's intake records document the facility failed to provide R3 with the Osmolite 1.5 at 90 ml per hour for 14 hours, and instead provided it for 12 hours. Additionally, they did not provide R3 with oral nutrition from 11/27/24 until 11/30/24, when they obtained a nothing by mouth order until a speech consultation is obtained, due to weakness and inability for R3 to eat. R3's intake summary, dated 11/28/24 to 12/7/24, documents the first time oral nutrition is provided to R3 was on 12/5/24. R3's weight summary, dated 12/2/24, documents R3's weight measured 128 pounds, a loss of 13.5 percent of R3's total body weight in 3.5 months. On 12/3/24 at 9:15AM, R3 was laying in bed, with blood and feces covering his sheets. R3's left arm was covered with a bandage, and his fingernails were caked with dark, thick, dough-like matter. R3's teeth were black and brown, with some teeth missing. R3 appeared severely underweight, with bones protruding from his translucent skin, and both legs contracted. On 12/3/24 at 9:17AM, V7 and V11, Certified Nursing Assistants, were cleaning R3's fingernails and body. V7, CNA, stated they were cleaning feces from underneath R3's nails. Both stated when R3 came to the facility in August of 2024, R3 was able to feed himself, they only supervised, and was able to wheel himself throughout the facility in a wheelchair, but now he is too weak to do anything for himself. R3's medical record does not document an attempt to obtain dental services for R3. On 12/4/24 at 10:45AM, V2, Corporate Nurse, stated R3 should have been offered dental services in light of his rotting teeth and weight loss. On 12/3/24 at 11:15AM, V3, Nurse Practitioner (NP), stated R3's tube feeding order from the hospital was intended to be a supplement to oral feedings, and did not contain enough calories to help with weight gain, which is why an additional oral feeding was ordered. V3, NP, stated R3 is malnourished and needs more calories, and the failure on the part of the facility to feed R3 and to notify V4, Registered Dietician, of R3's new tube placement and feeding order, as well as the failure to notify V5, MD, of the recommendations for weight gain by V4, RD, all contributed to R3's increased weight loss. On 12/3/24 at 2:51PM, V5, Medical Doctor (MD), stated he was not made aware of R3's significant weight loss or of V4, RD's, recommendations. V5, MD, stated he was called on 11/30/24 and told R3 was so weak that he couldn't eat. He said he told them not to feed R3 until a speech consult was obtained to make sure he was safe to eat. V5, MD, said he would have utilized the recommendations of (V4, RD), had he known about them, and he was accustomed to collaborating in other facilities with Dieticians. On 12/3/24 at 12:06PM, V4, Registered Dietician (RD), stated she was not aware the facility didn't implement the supplements and other recommendations she made on 10/10/24, and she wasn't notified R3 returned to the facility on a tube feeding until today. V4, RD, stated, I should have been notified of a new resident with a tube feed. (R3's) weight loss was preventable had they implemented supplements, provided me with regular weights, let me know what his oral intake looked like, and communicated with me so that I might have been able to help. He should have had an assessment when he returned. He just continues to lose weight and hyponatremia and hypomagnesemia are indicative of malnutrition and dehydration. On 12/4/24 at 10:15AM, V4, Registered Dietician (RD), stated she calculated R3's current tube feeding order, and it is insufficient to meet R3's caloric needs. (R3) is currently only receiving 990 calories and 42 grams of protein. This is why we have to be involved in all tube feedings from the start so that they get the nutritional support that they need and don't continue to lose weight.

Based on interview and record review, the facility failed to ensure the dignity of two (R4 and R5) of three residents reviewed for dignity from a total sample list of eight residents reviewed. Findings include: 1.) R4's undated care plan documents R4 has diagnoses that include: amyotrophic lateral sclerosis, low back pain, depression, weakness, dysphagia, speech disturbance, and need for personal care. R4's progress notes dated 10/19/24 document admission to the facility. R4's Minimum Data Set, dated dated [DATE], documents R4 is cognitively intact. On 12/4/24 at 11:23AM, R4 stated a week or so ago, she told the staff at the facility she didn't want V15, Certified Nursing Assistant (CNA), caring for her anymore. R4 stated V15 CNA is very impatient with her and intolerant of her needs, and V15, CNA, makes her feel very disrespected when she needs assistance. On 12/4/24 at 1:35PM, V11, CNA, stated to her knowledge, R4 has never complained about any staff member before, R4 is completely clear headed, and on the day R4 told V11 about the issue, She was so upset, it just broke my heart. On 12/4/24 at 1:42PM, V18, CNA, stated R4 is very easy to care for and very clear. She never complains. On 12/9/24 at 1:30PM, V1, Administrator, stated she is still investigating R4's allegation toward V15, CNA, and V15, CNA, remains suspended. 2.) R5's undated care plan documents R5 has diagnoses that include: hypothyroidism, anxiety, depression, history of a cerebrovascular accident and transient ischemic attack, history of right knee replacement, weakness, cellulitis, and need for assistance with personal care. R5's progress notes document on 11/19/24 R5 was admitted to the facility. R5's Minimum Data Set, dated dated [DATE], documents R5 is cognitively intact. On 12/4/24 at 2:00PM, R5 stated she hesitates to get anyone in trouble and she had not reported this to staff, but V15, CNA, is disrespectful to R5. She rushes me and is intolerant of waiting. She is so impatient that I have had to call her back into my room at times and she is irritated. I don' t have problems with any of the other girls. I don't need this. On 12/9/24 at 3:10PM, V2, Corporate Director of Nursing, stated the expectation of the facility is that dignity should be provided to all residents with all care.

Based on observation, interview, and record review, the facility failed to provide bathing, oral care, and nail care to three (R1, R3, R4) of three dependent care residents reviewed for activities of daily living from a total sample list of eight residents reviewed. Findings includes: 1.) R1's undated care plan documents admission to the facility on [DATE], with diagnoses including: sepsis with septic shock, encephalopathy, dysphagia, depression, morbid obesity, rheumatoid arthritis, weakness, and a need for assistance with personal care. R1's Minimum Data Set, dated dated [DATE], documents R1 as cognitively intact. R1's care plan, dated 5/28/24, documents R1 is dependent on bathing twice weekly, and on bathing days, staff are to check, clean, and trim nails as needed. On 12/9/24 at 3:03PM, R1's nails appeared long, more than 1/2 inch past the toe, with white and yellow matter on and between the toes. On 12/9/24 at 3:00PM, R1 stated her toenails are too long. I have asked the nurse's to cut my toenails and they just don't do it. I'm not a diabetic or anything, but I have stuff between my toes and my toenails and I just don't feel clean but I can't do it, I can't reach them. 2.) R3's undated care plan documents diagnoses that include: history of intellectual disability, hematuria, hydronephrosis, genitourinary surgery, depression, chronic leukemia, spondylosis, osteoarthritis, persistent atrial fibrillation, and need for assistance with personal care. R3's undated census sheet documents R3 was readmitted to the facility from the hospital on 11/27/24. On 12/3/24 at 9:15AM, R3 was laying on a dried, bloody, bedsheet. R3's beard and hair were greasy. R3's had an odor of feces and body fluids. R3's teeth were black and brown, some teeth rotten with mucous covering them. R3's fingernails had a thick brown substance under them. R3's toenails were 1/2 inch beyond the end of the toe, with a yellow substance covering and between the toes. On 12/3/24 at 9:16AM, V7 and V11, Certified Nursing Assistants (CNA), were cleaning under R3's fingernails. V7, CNA, confirmed they were cleaning feces from underneath R3's fingernails and could not say how long it had been there. R3's Minimum Data Set, dated dated [DATE], documents R3 is severely cognitively impaired. R3's care plan, dated 8/20/24, documents R3 requires assistance for oral care and bathing. R3's task documentation for showers, dated 12/9/24, documents R3 is to have a shower twice weekly and as needed. R3's task documentation for oral care and bathing, dated 12/9/24, has no documentation for R3 for the last 28 days. 3.) R4's undated diagnosis sheet documents diagnoses that include: amyotrophic lateral sclerosis, low back pain, depression, weakness, dysphagia, speech disturbance, and need for personal care. R4's Minimum Data Set, dated dated [DATE], documents R4 is cognitively intact. On 12/4/24 at 11:23AM, R4 was sitting in a wheelchair in her private resident room. R4's hair appeared greasy (surrounding the edges) while wearing a hat. R4's teeth appeared to have a layer of mucus covering them. On 12/9/24 at 2:45PM, R4's teeth appeared to have mucous covering them. R4 stated she had not had her teeth brushed that day, and she does not always get a shower every week. R4's Minimum Data Set, dated dated [DATE], documents R4 is dependent for oral care and requires maximum assistance for showering/bathing. R4's task documentation for oral care, dated 12/9/24, does not document any oral care for the past 28 days. R4's task documentation for bathing, dated 12/9/24, documents R4 is to get showers twice weekly and as needed. The facility provided shower sheets documenting that R4 received a shower on 11/27/24 and then again on 12/8/24, eleven days later. On 12/9/24 at 3:10PM, V2, Corporate Director of Nursing, stated dependent residents should be assisted with bathing and nail care as often as scheduled or requested, and oral care should be provided at the beginning and end of each day.

Based on observation, interview, and record review, the facility failed to honor repeated requests of a resident's (R263) choice of living arrangements. This failure affects one (R263) of six residents reviewed for self-determination in a sample list of 34. This failure resulted in R263 becoming anxious, angry, refusing to eat, drink, and receive care from staff. Findings Include: R263's admission progress note, dated 11/15/24, documents, (R263) arrived from (hospital) at approximately 5pm. Nurse to nurse report indicates advanced Amyotrophic Lateral Sclerosis, with Benign Prostatic Hypertrophy, and Osteoporosis cited as the only comorbidities. Resident is non-verbal. Resident is a Do Not Resuscitate. Regular diet with a Gluten Intolerance; requires maximum assistance. Resident takes pills crushed in applesauce/pudding/yogurt. Ambulance service stated the resident traveled to the area via plane from New York, and his family promptly admitted him to (hospital), where he's been since 11/7/24 awaiting placement. Skin check reveals some redness on the posterior, which was communicated by (hospital) who had been using a Zinc barrier cream. CNAs (Certified Nursing Assistants) advised to do the same. Resident would not permit writer to take vitals. Resident uses a sheet with letters to communicate but struggles significantly. An electronic tablet is available in his belongings, but he preferred to use the paper. Resident was also aggressive with CNAs when they were changing him. R263's Progress note, dated 11/15/24 at 11:00PM, by V23, Nurse Practitioner, documents, Reported by nurse that resident is not satisfied with cares that has been provided in facility and wants to go back to hospital. Stable condition. No acute medical issue at this time. Nurse will contact family members and social worker to talk to the (R263) and monitor. On 11/17/24 at 9:00AM, R263 was observed lying in bed leaning to the right side. R263 had severe contractures to all extremities and was unable to speak. R263 had a communication board and was able to express himself by pointing to letters or responses on the board. When asked if R263 was being cared for by facility staff, R263 laboriously spelled out No. I want to go to the hospital. I am afraid. I will die. I want to get up in my wheelchair. When asked if staff took time to listen to R263's wants or needs, R263 pointed to No on the board. R263 spelled out I need help. R263's full breakfast was on the over the bed tray untouched. When asked if R263 can feed self, R263 pointed to no. When asked if staff had offered to help, R263 pointed to no. There was a full cup of water on R263's over the bed tray. When asked if staff offer R263 drinks, R263 pointed to no. When asked if R263 refused care, R263 spelled out I don't trust. I am afraid. Nobody comes. On 11/20/24 at 11:00AM, V20, Licensed Practical Nurse (LPN), stated, I wanted to send (R263) to the hospital when he insisted. He is cognitively intact and can make his own decisions. He can communicate with the board, but it takes a very long time. We really do not have enough staff to meet (R263's) needs. (R263) is physically dependent and has contractures of both arms and legs. I know (R263) was very scared and frustrated because we do not have the staff to spend the time with (R263) that (R263) needs. On 11/20/24 at 2:30PM, V21, Registered Nurse (RN), stated, I was the nurse who admitted (R263). (R263) is completely physically dependent and has contractures to both lower and upper extremities. (R263) in alert, oriented, and fully functional cognitively. (R263) is nonverbal but can communicate using the stroke board. (R263) makes his own decisions. (R263) wanted to go to the hospital. I contacted the Nurse Practitioner who advised me not to send (R263) to the hospital. This facility can not meet (R263's) needs. We have one CNA (Certified Nurse's Aide) for a hall and two nurses in the entire facility. There is not staff time even to effectively communicate with (R263). I knew he was angry and very fearful and honestly, I could see why. Several attempts were made to contact V23, Nurse Practitioner (who refused to send (R263) to the hospital). V1, Administrator, and other corporate staff reached out to V23, but V23 did not contact surveyor. V15, Corporate Nurse, denies the facility has a specific policy addressing resident self-determination.

Based on interview and record review, the facility failed to develop quality based performance improvement projects including collecting and measuring data. This failure has the potential to affect all 54 residents in the facility. Findings include: The facility provided Long-Term Care Facility Application for Medicare and Medicaid, dated 11/18/24, documents 54 residents reside in the facility. The facility provided Quality Assurance Performance Improvement (QAPI) policy dated January 2024 documents that the QAPI Program takes a systematic, comprehensive, and data-driven approach to maintaining and providing safety and quality while involving all caregivers in practical and creative problem solving. The community QAPI Program achieves the following: monitor quality/performance, find opportunities for improvement, improve performance, achieve resident/family desired outcomes, meet regulatory requirement, understand the CNA survey process and regulations, provide a QAPI path to correcting issues. The QAPI Program consist of monthly/quarterly meeetings, daily quality assurance activities, quality tasks and performance improvement plans. On 11/19/24 at 12:15PM, V1, Administrator, and V17, Licensed Practical Nurse (LPN), were interviewed. V17, LPN, stated she had been an employee of the facility for several years, and she was unaware of any performance improvement projects or of quality measures being implemented by the facility. On 11/19/24 at 12:20PM, V1, Administrator, stated she was unable to locate any documentation of any performance improvement projects over the past year, and that moving forward quality improvement/performance improvement activities would be implemented.

Based on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on two of sixteen days reviewed for RN staffing. This failure has the potential to affect all 54 residents in the facility. Findings include: The facility Nursing Schedule (January 8, 2025 through January 18, 2025) documents on Wednesday 1/8/25, Thursday 1/9/25, Sunday 1/12/25, Monday 1/13/25 and Tuesday 1/14/25, the facility scheduled zero (0) hours of RN coverage for a 24 hour period. On 1/27/25 at 1:45 PM, V16, Regional Consultant Administrator, provided a time card for V2 that documents V2 is employed as the Director of Nursing and is employed in supervisory role. The facility Resident Midnight Census, dated 1/21/25, documents 54 residents reside in the facility.

Based on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on two of sixteen days reviewed for RN staffing. This failure has the potential to affect all 54 residents in the facility. Findings include: The facility Nursing Schedule (January 8, 2025 through January 18, 2025) documents on Wednesday 1/8/25, Thursday 1/9/25, Sunday 1/12/25, Monday 1/13/25 and Tuesday 1/14/25, the facility scheduled zero (0) hours of RN coverage for a 24 hour period. On 1/27/25 at 1:45 PM, V16, Regional Consultant Administrator, provided a time card for V2 that documents V2 is employed as the Director of Nursing and is employed in supervisory role. The facility Resident Midnight Census, dated 1/21/25, documents 54 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services, and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 54 residents in the facility. Findings include: On 11/17/2024 at 9:58AM, V5 (Dietary Manager) was actively supervising Dietary operations in the facility kitchen. V5 reported being the full-time manager of the facility Food Service, and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V5 denied meeting the State of Illinois standards to be a Food Service Manager or Dietary Manager. V5 also denied being a certified Food Protection Manager, as required, for every person in charge of a food service. On 11/18/2024 at 12:43PM, V5 (Dietary Manager) reported being unaware if the facilty employed a Dietician. V5 reported never seeing or hearing of any Dietician working in the facility in the past several months. V5 denied: -being a Dietician; -being a Certified Dietary Manager; -having an associate's or higher degree in food service management or in hospitality; -having 2 or more years of experience in the position of Director of Food and Nutrition Services in a nursing facility setting; -being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition; -being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician; -or having completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course. The Food and Drug Administration Food Code (2022) documents a dietary service Person in Charge (PIC) shall be a Certified Food Protection Manager. Throughout the duration of the survey, from 11/17/2024-11/20/2024, the facility failed to effectively sanitize dishes, failed to prevent direct cross-contamination of ice, failed to prevent the potential for biological cross-contamination of stored food, failed to prevent the potential for physical cross-contamination of food, failed to date and label TCS (time/temperature control for safety) food, failed to maintain sanitation test equipment supplies, and failed to maintain sanitary food service flooring areas. The following dietary service conditions were noted: 1. On 11/17/2024 at 8:39AM, V3 (Cook) was working in the facility kitchen. When asked if the kitchen had dishwasher sanitizer test strips, V3 reported not being aware and stated, I have not been shown that yet, how to do that (how to use sanitizer test strips to test the dishwasher for adequate sanitizer concentration). On 11/17/2024 at 9:10AM, V4 (Dietary Aide) was washing resident dishes in the facility mechanical chlorine sanitizing dishwasher. When asked if the kitchen had sanitizer test strips to test the facility dishwasher to ensure the dishwasher was effectively sanitizing dishes, V4 proceeded to walk from the dishwashing room to the adjacent main kitchen area where the three-basin sink was located. V4 returned with a container of sanitizer test strips labeled to test quaternary ammonia sanitizer and not chlorine based sanitizer solutions. On 11/18/2024 at 12:45PM, V9 (Dietary Aide) was washing resident dishes in the above mechanical dishwasher. The dishwasher sanitizer solution concentration measured zero parts per million as measured by Illinois Department of Public Health chlorine sanitizer test strip. V9 observed the test strip and stated yes (the concentration of sanitizer in the dishwasher was zero parts per million). V9 reported thinking previously in the day something was wrong with the dishwasher because V9 had recently changed out the dishwasher's empty container of chlorine sanitizer for a full container and then tested the chlorine level with a sanitizer test strip from above, but still measured zero chlorine present in the dishwasher. V9 reported telling V5 (Dietary Manager) about the dishwasher problem, but V5 didn't respond to V9's concerns. A dishwasher log sheet (October 2024) was located on the wall beside the dishwasher, and did not have any log entries past October 3, 2024 documenting routine testing of the dishwasher sanitizer level to ensure effective dish sanitation. On 11/18/2024 at 12:38PM, the kitchen three-basin sink was in use with all three basins filled with solutions. The sanitize basin contained cooking pans and tested 100 parts per million sanitizer concentration by both a facility sanitizer test strip and Illinois Department of Public Health test strip. The container of sanitizer located immediately above the sanitize basin was empty. The manufacturer's label on the container documented a sanitizer concentration of 200-400 parts per million is required to effectively sanitize dishes. 2. On 11/17/2024 at 9:00AM, the kitchen ice machine was not operational and not producing ice. The storage bin on the machine was nearly empty, containing a layer of ice on the bottom of the bin appearing 3-4 in depth. V1 (Administrator) entered the kitchen and placed seven intact plastic bags of commercially prepared ice into the bin. The bags were randomly resting in direct contact with the existing ice located at the bottom of the bin. The exterior of several of the bags was visibly soiled with black-colored dirt and debris. V3 (Cook) was present and when asked if the ice in the bags would be emptied into the storage bin with the existing ice and then used for resident drinks, V3 stated yeah. On 11/17/2024 at 9:59AM, the above ice machine was operational and imminently ready to release ice into the storage bin. V3 was present and reported V3 was going to wait until the first batch of ice dropped down into the bin and then V3 was planning to empty the above bagged ice on top of the newly produced ice (effectively mixing together the ice in contact with the soiled plastic bags with newly formed ice). 3. On 11/17/2024 at 8:50AM, the reach-in cooler located by the kitchen two-basin sink had an open 48 ounce container of apple juice, an open 48 ounce container of orange juice, and an eight inch pie pan of quiche. None of the food items were labeled with the date opened or prepared or a use-by date. On 11/17/2024 at 8:52AM, the reach-in coolers located near the kitchen three-basin sink contained one-half of a deli ham roll wrapped in plastic, a gallon ziploc bag half full of hot dogs, a two liter plastic container full of a red liquid, a three liter plastic container filled with tuna salad, a gallon ziploc bag half full of ready to eat roast beef deli meat, a metal pan of cooked potatoes nested into a metal pan of cooked pasta (the bottom of the potato pan was in direct contact with the pasta), and a gallon ziploc bag half full of raw bacon. The exterior of the bacon bag was greasy when touched. None of the food packages were labeled with date opened or a use-by date. The raw bacon package was stored directly on top of the other stored food items, including the ready-to-eat deli meat. An adjacent reach-in cooler contained one-half of a sliced tomato wrapped in plastic, and two slices of tomato partially immersed in a white-colored opaque liquid in a ziploc bag. None of the packages were labeled with a use-by date. 4. On 11/172024 at 8:45AM, bulk sugar was stored in the manufacturer's bag in the kitchen pantry. A disposable plastic cup was located inside of the bag and all portions were in direct contact with the sugar. On 11/17/2024 at 8:52AM, the kitchen table-mounted can opener was soiled with sticky food accumulations and metal shavings. On 11/18/2024 at 12:38PM, the can opener remained in the same condition as above. 5. On 11/17/2024 at 8:45AM, floor surfaces throughout the kitchen, dishwashing room, and pantry areas were excessively soiled with accumulations of decomposing food debris, condiment packets, discarded hair nets, disposable utensils, drinking straws, and cardboard. On 11/18/2024 at 12:38PM, the floors remained as above. The Facility Assessment (undated) documents the facility will employ a Dietician and Certified Dietary Manager to provide care to residents in the facilty. On 11/17/2024 at 9:58AM, V5 reported food from the facility kitchen is available for all residents in the facility to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (11/17/2024) documents 54 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to effectively sanitize dishes, failed to prevent direct cross-contamination of ice, failed to prevent the potential for biological cross-contamination of stored food, failed to prevent the potential for physical cross-contamination of food, failed to date and label TCS (time/temperature control for safety) food, failed to maintain sanitation test equipment supplies, and failed to maintain sanitary food service flooring areas. These failures have the potential to affect all 54 residents residing in the facility. Findings include: 1. On 11/17/2024 at 8:39AM, V3 (Cook) was working in the facility kitchen. When asked if the kitchen had dishwasher sanitizer test strips, V3 reported not being aware and stated, I have not been shown that yet, how to do that (how to use sanitizer test strips to test the dishwasher for adequate sanitizer concentration). On 11/17/2024 at 9:10AM, V4 (Dietary Aide) was washing resident dishes in the facility mechanical chlorine sanitizing dishwasher. When asked if the kitchen had sanitizer test strips to test the facility dishwasher to ensure the dishwasher was effectively sanitizing dishes, V4 proceeded to walk from the dishwashing room to the adjacent main kitchen area where the three-basin sink was located. V4 returned with a container of sanitizer test strips labeled to test quaternary ammonia sanitizer and not chlorine based sanitizer solutions. On 11/18/2024 at 12:45PM, V9 (Dietary Aide) was washing resident dishes in the above mechanical dishwasher. The dishwasher sanitizer solution concentration measured zero parts per million as measured by Illinois Department of Public Health chlorine sanitizer test strip. V9 observed the test strip and stated yes (the concentration of sanitizer in the dishwasher was zero parts per million). V9 reported thinking previously in the day something was wrong with the dishwasher because V9 had recently changed out the dishwasher's empty container of chlorine sanitizer for a full container and then tested the chlorine level with a sanitizer test strip from above, but still measured zero chlorine present in the dishwasher. V9 reported telling V5 (Dietary Manager) about the dishwasher problem, but V5 didn't respond to V9's concerns. A dishwasher log sheet (October 2024) was located on the wall beside the dishwasher, and did not have any log entries past October 3, 2024 documenting routine testing of the dishwasher sanitizer level to ensure effective dish sanitation. On 11/18/2024 at 12:38PM, the kitchen three-basin sink was in use with all three basins filled with solutions. The sanitize basin contained cooking pans and tested 100 parts per million sanitizer concentration by both a facility sanitizer test strip and Illinois Department of Public Health test strip. The container of sanitizer located immediately above the sanitize basin was empty. The manufacturer's label on the container documented a sanitizer concentration of 200-400 parts per million is required to effectively sanitize dishes. 2. On 11/17/2024 at 9:00AM, the kitchen ice machine was not operational and not producing ice. The storage bin on the machine was nearly empty, containing a layer of ice on the bottom of the bin appearing 3-4 in depth. V1 (Administrator) entered the kitchen and placed seven intact plastic bags of commercially prepared ice into the bin. The bags were randomly resting in direct contact with the existing ice located at the bottom of the bin. The exterior of several of the bags was visibly soiled with black-colored dirt and debris. V3 (Cook) was present and when asked if the ice in the bags would be emptied into the storage bin with the existing ice and then used for resident drinks, V3 stated yeah. On 11/17/2024 at 9:59AM, the above ice machine was operational and imminently ready to release ice into the storage bin. V3 was present and reported V3 was going to wait until the first batch of ice dropped down into the bin and then V3 was planning to empty the above bagged ice on top of the newly produced ice (effectively mixing together the ice in contact with the soiled plastic bags with newly formed ice). 3. On 11/17/2024 at 8:50AM, the reach-in cooler located by the kitchen two-basin sink had an open 48 ounce container of apple juice, an open 48 ounce container of orange juice, and an eight inch pie pan of quiche. None of the food items were labeled with the date opened or prepared or a use-by date. On 11/17/2024 at 8:52AM, the reach-in coolers located near the kitchen three-basin sink contained one-half of a deli ham roll wrapped in plastic, a gallon ziploc bag half full of hot dogs, a two liter plastic container full of a red liquid, a three liter plastic container filled with tuna salad, a gallon ziploc bag half full of ready to eat roast beef deli meat, a metal pan of cooked potatoes nested into a metal pan of cooked pasta (the bottom of the potato pan was in direct contact with the pasta), and a gallon ziploc bag half full of raw bacon. The exterior of the bacon bag was greasy when touched. None of the food packages were labeled with date opened or a use-by date. The raw bacon package was stored directly on top of the other stored food items, including the ready-to-eat deli meat. An adjacent reach-in cooler contained one-half of a sliced tomato wrapped in plastic, and two slices of tomato partially immersed in a white-colored opaque liquid in a ziploc bag. None of the packages were labeled with a use-by date. 4. On 11/172024 at 8:45AM, bulk sugar was stored in the manufacturer's bag in the kitchen pantry. A disposable plastic cup was located inside of the bag and all portions were in direct contact with the sugar. On 11/17/2024 at 8:52AM, the kitchen table-mounted can opener was soiled with sticky food accumulations and metal shavings. On 11/18/2024 at 12:38PM, the can opener remained in the same condition as above. 5. On 11/17/2024 at 8:45AM, floor surfaces throughout the kitchen, dishwashing room, and pantry areas were excessively soiled with accumulations of decomposing food debris, condiment packets, discarded hair nets, disposable utensils, drinking straws, and cardboard. On 11/18/2024 at 12:38PM, the floors remained as above. On 11/17/2024 at 9:58AM, V5 (Dietary Manager) reported food from the facility kitchen is available for all residents in the facility to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (11/17/2024) documents 54 residents reside in the facility.

Based on interview and record review, the facility failed to implement a comprehensive quality program. This failure has the potential to affect all 54 residents who reside in the facility. Findings include: The facility provided Long-Term Care Facility Application for Medicare and Medicaid, dated 11/18/24, documents 54 residents reside in the facility. The facility provided Quality Assurance Performance Improvement (QAPI) policy, dated January 2024, documents that the QAPI Program takes a systematic, comprehensive, and data-driven approach to maintaining and providing safety and quality while involving all caregivers in practical and creative problem solving. The community QAPI Program achieves the following: monitor quality/performance, find opportunities for improvement, improve performance, achieve resident/family desired outcomes, meet regulatory requirement, understand the CNA survey process and regulations, provide a QAPI path to correcting issues. The QAPI Program consist of monthly/quarterly meeetings, daily quality assurance activities, quality tasks and performance improvement plans. On 11/19/24 at 12:15PM, V1, Administrator, stated she was unaware of an active quality program functioning in the facility at this time, and that moving forward, she would be directing a comprehensive quality program.

Based on interview and record review, the facility failed to hold quarterly quality improvement committee meetings, and failed to include the required members at these meetings. This failure has the potential to affect all 54 residents in the facility. Findings include: The facility provided Long-Term Care Facility Application for Medicare and Medicaid, dated 11/18/24, documents 54 residents reside in the facility. The facility provided Quality Assurance Performance Improvement (QAPI) policy, dated January 2024, documents that the QAPI Program takes a systematic, comprehensive, and data-driven approach to maintaining and providing safety and quality while involving all caregivers in practical and creative problem solving. The community QAPI Program achieves the following: monitor quality/performance, find opportunities for improvement, improve performance, achieve resident/family desired outcomes, meet regulatory requirement, understand the CNA survey process and regulations, provide a QAPI path to correcting issues. The QAPI Program consist of monthly/quarterly meeetings, daily quality assurance activities, quality tasks and performance improvement plans. The facility provided one of four required sign in sheets for the last four quarterly quality meetings that did not include an Infection Preventionist in attendance. On 11/19/24 at 12:20PM, V1, Administrator, stated she would expect quarterly quality meetings to be held and that all required members of the quality committee should be in attendance including the Medical Director, Administrator, Director of Nursing, Infection Preventionist, and Pharmacist. At next year's annual, they will be done.

Based upon observation, interview, and record review, the facility failed to to ensure the resident's menus and/or the individual resident's food plan met her/his nutritional needs and preferences for four (R14, R16, R19, R43) of four residents reviewed from a total sample list of 34. 1.) R19's physician order, dated 2/5/24, documents diet order of regular diet mechanical soft texture with nectar thick fluids. On 11/17/24 at 1:10 PM, R19's plate of food includes carrots sliced, plain. [NAME] colored rice with brown orange cubes and green peas; fried breading piece mixed in; 1/2 cup red paste looking puree on side of plate. Side small plate has crumbled yellow cake substance with white frosting. Bowl contains plain macaroni noodles and brown lentil beans with clear liquid and thin red liquid as drink. V6, Resident family member, demonstrated carrots hard and unable to cut as well as cold when served. R19's Dietary slip, with meal dated 11/17/24 Lunch, documents diet as general, mechanical soft and nectar thick liquids. Meal to be served, pasta faggioli soup, white rice, grilled fried shrimp, glazed carrots and frosted yellow cake. 2.) On 11/17/24 at 9:45 AM, R43 stated her meals haven't been right since last week. They are not following menu, did not receive requested meal; specifically no biscuits gravy sausage, got eggs and oatmeal. When I don't like what is served for a meal, I'm only offered peanut butter and jam alternative. On 11/17/24 at 9:50 AM, R43's breakfast plate on bedside table untouched. Meal ticket with plate documents biscuits and gravy and oatmeal circled as breakfast choices. Egg choice was scratched off ticket. Breakfast plate has scrambled eggs only, and small bowl contains oatmeal. 35347 3. The facility Diet Report (11/18/2024) documents R14 receives a pureed diet. R14's Physician Orders (printed 11/20/2024) document R14 is ordered a pureed diet. The facility menu (11/17/2024) documents residents receiving a pureed diet will receive pureed frosted cake during the lunch meal. On 11/17/2024 at 1:50PM, R14 was eating lunch in the facility dining room. R14's meal slip was present, with R14's menu selections circled including pureed frosted cake. No cake was present with R14's lunch meal. On 11/20/2024 at 9:17AM, V19 (Registered Dietician) reported the facility should be serving therapeutic diets as ordered. 42702 4. R16's physician order, dated 5/10/24, documents an order for a regular diet with pureed texture including nectar thick fluids and low concentrated sweets with added fortified pudding with lunch and supper. R16's breakfast menu sheet, dated 11/19/24, documents pureed western scramble, oatmeal, wheat toast, sausage links, and crushed pineapple. On 11/19/24 at 9:15AM, R16 received pureed western scramble, sausage, and oatmeal. No pineapple or toast was provided as ordered. On 11/19/24 at 9:16AM, V11, Certified Nursing Assistant, stated R16 should have received pureed pineapple and toast.

Based on observation, interview, and record review, the facility failed to serve timely and palatable meals to residents. These failures affect seven residents (R18, R19, R21, R25, R30, R31, R43) of 15 reviewed for meals in the sample list of 34. Findings include: On 11/17/2024 at 8:39AM, V3 (Cook) reported facility meal times are 7:30AM, 12:00PM, and 5:30PM. On 11/19/2024 at 12:46PM, facility meal times were posted in the hallway outside of the dining room. The meals times posted were: breakfast at 7:30AM, lunch at 12:00PM, and supper at 5:30PM. The facility grievance log (January-November 18, 2024) documents 47 formal resident complaints related food. Facility Grievance Forms document the following recent grievances made during Resident Council meetings: --9/18/24: Cold food and Food is tasteless. --9/23/24: Food is cold and bad. Coffee is bad. --10/9/24: Cold food on hall trays and dining room. --10/9/24: Meals are not being served on time. --11/4/24: Breakfast on the hall 9:00/9:30AM Lunch on the hall 1:00/1:30PM. 1. On 11/17/2024 at 10:20AM, R30 reported supper meals have been late the last two weeks and should be served at 5:30-6PM, but have been served at late as 7:00PM. R30 stated it (the late meals) sucks, because I am hungry. 2. On 11/17/2024 at 11:09AM, R21 reported eating all meals in R21's room, and the meals are always late and cold. 3. On 11/19/2024 at 12:52PM, R31 reported hall meal trays do not arrive for breakfast until 9:15AM and lunch trays between 1:30-1:45PM and supper trays between 6:30-6:45PM. R31 reported the kitchen staff often get into verbal fights screaming at each other and have to shut the doors between the resident dining room and kitchen. She reported the staff fights make her feel not good. 4. On 11/19/2024 at the noon meal service, R18 did not receive lunch until 12:55PM. 5. On 11/19/2024 at 12:58PM, R25 was eating lunch in the facility dining room. R25 held up the dinner roll staff served for lunch and stated what do you think about that? The dinner roll was entirely black in coloration on the bottom and extremely hard when touched. 6. On 11/17/2024 at 12:45PM at the dining room designated for residents requiring feeding assistance, no lunch meals were present for residents. V8 (Certified Nurse Aide) was present and reported facility staff transport residents to the dining room at noon and meals are late every day, and don't usually arrive until around 12:45PM, and hall trays don't arrive until 1:45PM. V8 reported lunch is supposed to be served to residents at 12:00PM. R19 was seated at the dining table waiting for lunch with V6, R19's family member. V6 reported being at the facility daily at noon with R19, and meals are always late and cold. Lunch meals were served at 12:55PM, and R19's meal temperature measured 90 degrees Fahrenheit by Illinois Department of Public Health thermometer. V6 stated, that's (R19's lunch meal) cold. 50322 On 11/17/24 at 10:55 AM, V6, R19's family member states she comes to feed R19 lunch everyday at noon scheduled time, but lunch is being served late everyday between 1:00pm and 2:00pm. On 11/17/24 at 12:04 PM resident in dining room, served red liquid in cup. No food in dining room. On 11/17/24 at 1:10 PM, R19 was served a plate. V6, family member, demonstrated carrots hard and unable to cut, as well as cold when served. On 11/18/24 at 1:25 PM, R19 was served a plate in dining room, V6, family member, stated the puree was ice cold. On 11/19/24 at 1:10 PM, R19 was served a lunch plate. Chicken temp was 98.2 degrees farenheit (F), soup temp 102.0 degrees F. 7. On 11/17/24 at 9:45 AM, R43 stated, Most of the time my food is cold and they never serve it on time. Sometimes I don't get lunch until 2:00 PM.

Based on interview and record review, the facility failed to resolve grievances for four (R31, R33, R48 and R49) of five residents reviewed for grievances from a total sample list of 34 residents. Findings include: The facility provided Resident Grievance Policy and Procedure, dated May 2018, documents it is the intent of the facility to encourage residents, their residents, or representatives to communicate any concerns, suggestions, complaints or opportunities for improvement in care or services. Each grievance will be investigated and addressed with a response. The Administrator/Executive Director will ensure grievances are addressed and resolved within a five-day time frame and final outcome communicated to the person originating the grievance. The resident council minutes, dated 1/3/24, document concerns including call lights taking too long and the food being cold. The facility resident council minutes, dated 11/4/24, document a grievance of late breakfast and late lunch was noted along with call lights not being address. The response to the grievance was that low staffing and missing ingredients cause the kitchen staff to be behind which causes late meals. The facility provided grievances, dated 9/23/24, document it took three hours for a call light to be answered when a catheter was leaking and that the food is cold. The facility provided grievances, dated 9/26/24, document staff did not provide timely care causing a resident to go in her pants. On 11/18/24 at 10:09AM, R31 stated, We have on going issue with staffing and food. The dining room is served is first. If you get a special order it is hot, but the regular food is cold. On 11/18/24 at 10:13AM, R33 stated, I didn't get my breakfast this morning until after 9:00AM. On 11/18/24 at 10:15AM, R48 stated she didn't' get her breakfast until after 9:00AM this morning, and that she often gets medications late. I have medicines that need to be given with food and lunch time is running into smoke time.We are not fed for an hour to two hours after. They need a plate warmer and more people to pass trays. On 11/18/24 at 10:20AM, R49 stated the hall trays are set out and left for hours to be given. On 11/18/24 at 10:22AM, R31 stated, Your insulin isn't given until after you eat and our medications that need to be given are given after we eat.

Based on observation, interview, and record review, the facility failed to provide fingernail care, bathing, and timely toileting/incontinence cares for three (R16, R21, R30) of 16 residents reviewed for Activities of Daily Living (ADLs) in the sample list of 34 residents. Findings include: 1. The facility grievance log (January-November 18, 2024) documents 19 formal resident complaints related to call light response times. Facility Grievance Forms document the following recent grievances made during Resident Council meetings: -8/7/24: 3rd shift not cleaning up residents letting the resident in urine and not cleaning up the resident and Call lights aren't being answered in a timely manner -9/23/24: Took 3 hours for call light to be answered when (urinary) catheter was leaking -9/26/24: staff member didn't provide timely care resulting in her to go in her pants -10/9/24: Call lights not being answered in a timely manner. -11/4/24: Call lights not being answered in a timely manner. R30's diagnosis list (printed 11/19/2024) documents R30's diagnoses include: Hemiplegia/Hemiparesis (partial or total paralysis on one side of the body), Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements), Anxiety Disorder, Major Depressive Disorder, and Muscle Weakness. R30's quarterly assessment (8/5/2024) documents R30 requires substantial or maximal assistance from facility staff for all activities of daily living. The same record documents R30 is frequently incontinent of bladder and always incontinent of bowel. R30's Care Plan (9/20/2024) documents R30 is incontinent of bladder and at risk of septicemia (life-threatening infection that occurs when bacteria, viruses, or fungi enter the bloodstream and spread) from urinary tract infections. The same record documents facility staff should check R30 every two hours for incontinence and also as-needed per R30's request. On 11/17/2024 at 10:23AM, R30 was in bed and reported facility staff do not answer call lights timely, and R30 has waited over an hour before to get an incontinence brief changed. R30 reported getting uncomfortable waiting on staff for care. 2. R21's diagnosis list (printed 11/20/2024) documents R21's diagnoses include: Multiple Sclerosis (chronic neurological disorder resulting in muscle weakness/spasms in the arms and legs, problems with walking/standing, tremors, dizziness, and speech problems), Feeding Difficulties, Muscle Weakness, Abnormal Posture, Lack of Coordination, and Muscle Wasting/Atrophy. R21's quarterly assessment (8/8/2024) documents R21 has both upper and lower extremity range of motion impairment and requires substantial/maximal staff assistance for eating. R21's Care Plan (11/9/2024) documents R21 has difficulty feeding R21's self and needs staff assistance. The same record documents R21 requires 1:1 staff assistance for meals. On 11/17/2024 at 11:09AM, R21 reported eating meals in R21's room, and staff routinely drop a meal tray off in his room, but don't return for an hour to assist R21 with eating. R21 reported being the first resident to receive a hall tray, so staff pass all other trays before returning to help R21 eat R21's meals. 42702 3. On 11/19/24 at 1:27PM, R16 was eating chicken with her fingers. R16's fingernails had copious quantities of feces (dark brown substance) between the nail and fingertip. On 11/19/24 at 1:28PM, V11, Certified Nursing Assistant, confirmed R16 had feces under her nails and that they would take care of it. On 11/20/24 at 10:56AM, V2 Director of Nursing, stated nail care should be provided on shower days to all dependent residents, especially anytime feces is found under the nails.

Based on interview and record review, the facility failed to follow physicians orders for treatment of a nonpressure wound for one resident (R54) of two residents reviewed for nonpressure wounds in a sample list of 34. Findings Include: R54's Minimum Data Set (MDS), dated [DATE], documents R54 is cognitively intact. R54's Treatment Administration Record (TAR) for November documents a current physician's order to Change wound vac dressing day shift every day shift every Monday, Wednesday,and Friday. R54's Hospital discharge orders, dated 10/10/24, document, Left Medial Calf- Negative pressure therapy to be changed three times per week. Vac (vacuum) is continuous at 125mmHg. R54's TAR for November documents that treatment was not completed Monday 11/4/24, Friday 11/8/24, Monday 11/11/24, or Friday 11/15/24. On 11/17/24 at 10:00AM, R54 stated, I fell here (at the facility) and my surgical incision busted open and I bled all over the floor. That was when I got the wound vacuum. The nurse don't bother to change the dressing like the doctor ordered. On 11/19/24 at 12:30PM, V2, Director of Nursing, stated, I wasn't aware these treatments have been missed, but I do see that they were not signed off as ordered. On 11/20/24 at 10:00AM, V15, Corporate Nurse, stated the facility does not have a policy specific to wound vacuums.

Based on observation, interview, and record review, the facility failed to allow the right to refuse a laboratory blood draw for one (R5) of two residents reviewed for abuse on the sample list of five. This failure resulted in R5 having a negative reaction to the situation, in which R5 sustained skin tears to the left hand and arm. This failure also resulted in R5 having psychosocial harm in which R5 was afraid to sleep at night. Findings include: The facility's Final Report, dated 11/6/23, documents on 10/30/23, V1, Administrator, was notified R5 stated V9, Phlebotomist (Laboratory staff), held him down this morning. R5's undated witness statement documents, Told many times didn't want blood drawn. I told them over and over I have bad blood. They said they would call the Fire department and they kept grabbing me and had their claws coming out. They grabbed and grabbed, and I said no, no, no. There was 3 or 4 of them. On 11/27/23 at 11:30 AM, R5 stated in regards to the incident on 10/30/23, R5 told them R5 didn't want his blood drawn, but they held R5 down, and made him do it. R5 stated R5 told them over and over he didn't want it done, but they treated him like a pig and did it anyway. R5 then started to cry and stated, I can't sleep at night, I am so worried she will come back in here. I just shake terrible thinking about it. At that time V12 (R5's family member) stated R5 has PTSD (Post Traumatic Stress Disorder) from serving in the Army. V12 stated R5 becomes very upset about the situation. V12 stated he hasn't had any problems with his PTSD for many years until this occurred. V12 then lifted the right sleeve of his shirt, and R5 had several healed scars. V12 pointed to 3 areas on the arm, and stated these are from the lab draw. V12 stated these areas can heal, but the mental damage will be forever. On 11/27/23 at 12:25 PM, V9 stated she came in to the facility on [DATE] to draw labs. V9 stated it was time to draw R5's labs, and he was roaming the halls. V9 stated she got an (unknown) Certified Nurse's Assistant (CNA) to help her. V9 stated she was trying to get him to go to his room and he was confused, and was going in the wrong direction. V9 stated R5 was being argumentative and finally got him turned around. V9 stated, We were heading in the right direction and the CNA left, and I yelled back 'what room is his' and she said third on the right. We got in the room and I shut the door. V9 stated V9 got R5 situated and had the lab supplies ready. V9 stated after she put the tourniquet on R5, he became combative and was heading to the door. V9 stated she was trying to get the tourniquet off and he had his hand on the door and wouldn't let go, so neither of them could get out. V9 stated V9 attempted to take his hand off the door knob. V9 stated she didn't realize how sensitive his skin was. V9 stated she finally got the door opened and got the tourniquet off, and he had two or three skin tears from taking his hand off the door, and one on his arm from taking the tourniquet off. V9 stated she wrapped his arm with gauze. V9 stated V9 was able to finish the blood draws after that. V9 stated, Thinking back on the incident; when he was agitated in the hall, I should have not even tried to obtain the lab. On 11/27/23 at 12:43 PM, V10, CNA, stated, (V9) came in to draw (R5's) blood, and (V9) couldn't get it, so she hollered down the hall, and he kept saying he didn't want it, and he had bad blood. After the nurse explained the procedure he let us draw it (the blood). I held his hand while she drew it, and he was fine. I was holding his left hand and he was squeezing my other hand with his right hand. At that point he let us. After the fact, he kept coming up to the nurse's station and stated he doesn't want blood drawn any longer, and stated he has bad blood and he didn't want it drawn. V10 stated R5 did have skin tears from pulling away from the lab lady. On 11/27/23 at 2:22 PM, V1, Administrator, stated, (V9) was already upset when he was going down the hall to his room to have his blood drawn. At that point, since he was already agitated, they should have waited. V1 stated they should have just quit attempting when he said he didn't want it done. On 11/27/23 at 2:22 PM, V1 stated all CNAs are provided with a copy of Resident Rights. V1 then provided a paper copy of the Resident Rights which documents residents have the right to choose a physician and treatment, and participate in decisions and care planning. The Resident Rights documents also states, Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will make every effort to assist each resident in exercising his or her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on observation, interview, and record review, the facility failed to provide safe cares for one (R5) of two residents reviewed for abuse on the sample list of five. This failure resulted in R5 sustaining skin tears to the right hand, wrist, and elbow. Findings include: The facility's final investigation report, dated 11/6/23, documents on 10/30/23, R5 became combative when the laboratory technician was completing a blood draw and sustained skin tears. On 11/27/23 at 11:30 AM, R5 stated, I told them I didn't want my blood drawn but they held me down and made me do it. I told them over and over I didn't want it done but they treated me like a pig and did it anyway. At that time, V12 (R5's family member) lifted the right sleeve of R5's shirt. R5 had several healed scars. V12 pointed to 3 areas on the arm and wrist and stated this is where his skin had been torn from the lab draw. R5's skin assessment, dated 10/30/23, documents a skin tear to the right hand measuring 1.5 centimeters in length, a skin tear to the right hand measuring 1 centimeter by 0.1 centimeter, a skin tear to the right hand measuring 1.2 centimeters by 0.2 centimeters, a skin tear to the right elbow measuring 2.2 centimeters by 0.5 centimeters, and a skin tear to the right wrist measuring 4 centimeters by 0.5 centimeters. On 11/27/23 at 12:25 PM, V9, Laboratory Technician, stated on 10/30/23, V9 came into the facility to do blood draws. V9 stated when she got to R5's blood draw, R5 was roaming the hallways. V9 stated R5 was going the wrong way to his room and became argumentative with the staff. V9 stated when R5 got into the room, V9 closed the door and applied the tourniquet. V9 stated she was about to draw R5's blood when R5 became argumentative and combative, and wheeled over by the door and grabbed the door knob. V9 stated there was no way out of the room except through the door. V9 stated R5 would not let go of the door knob and was upset and yelling. V9 stated she had to grab R5's hand and pull it off of the door, which caused skin tears to his hand. V9 stated R5 sustained a skin tear to the arm when she was trying to remove the tourniquet. V9 stated when R5 was combative and argumentative in the hallway, she should have not tried to do the blood draw. On 11/27/23 at 2:22 PM, V1, Administrator, stated V9 could have done something other than grab R5's hand, like wait for him to calm down, go to the other side of the room, or use her cell phone to call. V1 stated R5 was already upset when he was going down the hall. V1 stated, At that point, since he was already agitated, they should have waited. V1 stated they should have just quit attempting when he said he didn't want it done.

Based on interview and record review, the facility failed to operationalize guiding policies on the provision of resident care by neglecting to: provide cardiac medications (for 18 days) and notify the physician when cardiac medications were continuously held; obtain residents weights, monitor oral intake, determine the reason for inability to chew foods, and notify the physician of R1's refusal of meals; and assess or provide interventions as a significant decline in residents function from baseline occurred. These failures affect one (R1) of three residents reviewed for death on the sample list of 6. These failures resulted in serious harm and danger to R1's health contributing to R1's death. These failures also resulted in severe weight loss in which R1 lost 30 pounds in a five-week time frame (11.65 % of his body weight). These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 while the facility continues to educate nursing staff to ensure that: medications are given and weights are obtained per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R1's Careplan, dated with a review date of [DATE], documents R1 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's [MEDICATION(S)] was not administered on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. And R1's [MEDICATION(S)] was held on ,d+[DATE] (am dose), ,d+[DATE] (am dose), ,d+[DATE] (both doses), ,d+[DATE] (both doses), ,d+[DATE] (am dose), ,d+[DATE] (am dose), ,d+[DATE] (am dose), [DATE] (am dose), [DATE] (am dose), [DATE] (am dose), [DATE] (am dose), ,d+[DATE] (both doses), ,d+[DATE] (am dose), ,d+[DATE] (am dose), ,d+[DATE] (am dose), ,d+[DATE] (am dose), ,d+[DATE] (both doses), and ,d+[DATE] (am dose). V9's Physician Order's sheet signed by V9 on [DATE] documents under the heading [CONDITION(S)] states, Hold blood pressure (B/P) medication if B/P is below ,d+[DATE]. The facility's Administration of Medications, with a review date of ,d+[DATE], documents, 1. If for any reason a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A notation shall be made on the nurse's progress notes in the patient's clinical record. R1's hospital discharge orders, dated [DATE], documented an order to weigh resident daily. R1's weight summary record documents R1's weight as 259.2 pounds on [DATE], this weight summary record does not document any other weights. R1's Health Status Note, dated [DATE] at 11:24 AM, documents staff concerned with lack of appetite and only wanting to eat ice cream. R1's meal intake sheet documents R1 refused supper on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. This sheet documents R1 ate less than 25 percent on [DATE]. There is no documentation of what R1 ate for breakfast or lunch from [DATE] through [DATE]. R1's medical record does not document R1's intakes were monitored, or that the physician was notified of R1's meal refusals, with the exception of [DATE], after R1 was seen by V8, Nurse Practitioner. This medical record does not document R1's meal intakes were monitored, or the physician was notified after R1 was seen by the physician on [DATE]. R1's medical record does not document the physician was notified R1's cardiac medications were being held. On [DATE] at 10:30 AM, V6, Licensed Practical Nurse (LPN), stated R1's blood pressure fluctuated quite a bit. V6 stated she held R1's cardiac medications multiple times, and did not notify the physician these medications were being held. On [DATE] at 8:40 AM, V11, LPN, stated on [DATE] ,she held R1's cardiac medications and did not notify the physician. V11 stated she has never notified the physician about R1 losing weight or not eating. On [DATE] at 9:01 AM, V12, LPN, stated V12 held R1's cardiac medications and did not call the physician. V12 stated she was never informed he wasn't eating. V12 stated, The CNAs(Certified Nursing Assistants) do the weights. I wouldn't know about someone's food intake unless the CNAs tell me. On [DATE] at 1:37 PM, V13, Power of Attorney/Former Home Care Aide, stated R1 was admitted to the facility for therapy and his goal was to return to home. V13 stated R1 could walk with a walker and had a good appetite. V13 stated V8 (Nurse Practitioner) was R1's primary physician prior to admitting to the facility. V13 stated she wasn't impressed with the facility physician (V9), so she requested he be seen by V8. V13 stated she was very concerned with his condition, and all he was eating was ice cream. We had concerns about him not standing. I was confused why he wasn't participating in therapy. He went to see (V8) on [DATE]. She was really concerned about him when she seen him. We set up a care plan meeting with the facility because he wasn't eating. He didn't like the food and they thought it would be easier to eat the food if it was pureed. He said he couldn't chew the food. R1's physician visit summary, dated [DATE], documented by V8, Nurse Practitioner, documents R1's weight as 229 pounds. This visit summary documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During interviews on [DATE] at 10:27 AM and [DATE] at 2:33 PM, V8, Nurse Practitioner, stated: R1 has been a patient of hers since 2017. He was admitted to the facility for therapy and he was seen by the facility's physician (V9) while at the facility. Prior to his admission to the facility he could walk with a walker. V13 reached out to her due to V13's concern for his declining condition. When (R1) was seen in the office, it took three staff members to transfer him. (R1) looked like a completely different man as he had lost so much weight. He weighed 229 pounds. (V8) was shocked when she saw him and his decline was very concerning. V8 stated, The facility should have called the physician about his intakes, him only eating ice cream, and should have weighed him. This could have caused an electrolyte balance and killed him. (R1's) cardiac medications were not only for Hypertension, but worked together to decrease his cardiac workload and to protect his heart and kidneys. The physician should have been notified before holding these medications. It is an issue that they didn't notify anyone. R1's Plan of Care Note, dated [DATE] at 10:52 AM, documents, care meeting held today. (R1) agrees to see speech therapy and requested to have food (consistancy) down graded to puree to see if this helps him eat more. (V13) would like to see if appropriate for nutritional drinks. On [DATE] at 9:23 AM, V14, Care Plan Coordinator, stated, We had a care plan meeting with the family (V13) due to his deterioration with therapy. They also had a huge concern that he wasn't eating. He was only wanting to eat ice cream. Sometimes he would eat a cheeseburger. (R1) stated he ate ice cream because it was easier to chew it. The CNAs chart his intakes and if his intake is below 50 percent it should come up on the dashboard. V14 stated, Weekly weights should be done for four weeks after being admitted to the facility. The Dietary Manager or the Director of Nursing should be monitoring his weights. They haven't been having weight meetings lately. On [DATE] at 3:00 PM, V2, Director of Nursing (DON), stated she started working at the facility at the end of September. V2 stated she was out of the building from [DATE] through [DATE]. V2 stated she was not able to monitor R1's intakes or ensure weights were obtained. On [DATE] at 9:29 AM, V1, Administrator, stated, New admits should be weighed weekly times four weeks. The CNAs would obtain the weights. The nurses should ensure the weights are obtained. I am losing my managers and bringing in new managers so there is a transition. The DON would be responsible for the admission review. CNAs will track intakes. I knew (R1) was only wanting ice cream. I worked in the kitchen the last week (R1) was here, and all his (meal) tickets said ice cream. V1 stated she was not aware that he couldn't chew or that he had significant weight loss. V1 stated, I guess maybe they didn't weight him. I wasn't aware the nurses were holding (R1's) medications. I am aware that they were holding them now. Not sure what the policy was. I would think it would pop up on the clinical screen. I would expect them (nurse managers) to look into it and see why it was being held and notify the physician. On [DATE] at 10:39 AM, V10 (V9's nurse) stated V9 (R1's physician) stated he expects the nursing staff to call after holding medications the first time that they are held, and not giving R1's cardiac medications as scheduled put R1 at the risk for significant harm and danger. V9 felt the facility not monitoring R1's weight, food intake, and assessing the reason for eating only ice cream, put R1 at risk for significant harm and danger. On [DATE] at 9:50 AM, V7, County Coroner, stated R1 had a heart attack due to Carotid Artery Disease. V7 stated he thinks R1 not getting his cardiac medications could have contributed to his death. V7 stated, In my eyes, it is a significant failure. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy situation was identified to have begun on [DATE] when the facility failed to monitor R1's weights per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 2:30 PM, V1, Administrator, was notified of the Immediate Jeopardy Situation. On [DATE] between 7:45 AM and 4:00 PM, the surveyor confirmed through observation, interview, and record review, the facility took the following action to remove the Immediate Jeopardy: 1.) The Director of Nursing & Assistant Director of Nursing were educated on [DATE] by the Administrator that weights should be obtained per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents should be assessed when a significant decline in functioning from baseline is present and interventions put in place to address needs. Residents' medical record should be reviewed to ensure that medications are being provided as ordered and weights are being monitored. Additionally, they were educated on the Pharmacy Medication Administration policy and it should be followed to ensure medications are given per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2.) An AD HOC(needed) QAPI (Quality Assurance Performance Improvement) was held with the Medical Director to discuss the identified issue and immediate plan to address. The Administrator, Director of Nursing, Assistant Director of Nursing held this meeting with him on [DATE] 3.) A chart audit was started [DATE] to review missing weights, medications not given, weight loss, and orders not transcribed. This was completed by V4, Interim DON, on [DATE]. 4.) Education with Licensed staff educated by the Assistant Director of Nursing started on [DATE], regarding on the Pharmacy Medication Administration policy to ensure medications are given per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . That weights should be obtained per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents should be assessed when a significant decline in functioning from baseline is present and interventions put in place to address needs. Residents' medical record should be reviewed to ensure that medications are being provided as ordered and weights are being monitored. 5.) Education with the Certified Staff by the Assistant Director of Nursing started on [DATE] to ensure that weights should be obtained per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 6.) The Administrator educated Nurse Managers on [DATE] that they should hold a daily clinical QA meeting to discuss resident's medical condition and review pertinent medical records. V4, Interim Director of Nursing, and V3, Assistant Director of Nursing, held meetings on [DATE] and [DATE].

Based on interview and record review, the facility failed to prevent severe weight loss by failing to: monitor residents nutritional intake, obtain weights per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures affect one of three residents (R1) reviewed for death on the sample list of six. These failures resulted in R1 having a severe weight loss in which R1 lost 30 pounds, which was 11.65 percent of R1's body weight in a five week time period. Findings include: R1's Nurse's note, dated [DATE] at 6:17 PM, documents R1 was admitted to the facility. R1's hospital discharge orders, dated [DATE], documents an order to weigh R1 daily. R1's weight summary record documents R1's weight as 259.2 pounds on [DATE]; this weight summary record does not document any other weights. R1's Health Status Note, dated [DATE] at 11:24 AM, documents staff concerned with lack of appetite and only wanting to eat ice cream. R1's meal intake sheet documents R1 ate refused supper on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. This sheet documents R1 ate less than 25 percent on [DATE]. There is no documentation of what R1 ate for breakfast or lunch from [DATE] through [DATE]. R1's medical record does not document R1's intakes were monitored or that the physician was notified of R1's meal refusals, with the exception of [DATE], after R1 was seen by V8, Nurse Practitioner. This medical record does not document R1's meal intakes were monitored, or that the physician was notified after R1 was seen by the physician on [DATE]. On [DATE] at 8:40 AM, V11, Licensed Practical Nurse (LPN), stated R1 only ate ice cream. V11 stated she isn't sure why he only ate ice cream. V11 stated the Certified Nursing Assistants (CNAs) document meal intakes. V11 stated she has never notified the physician about R1 losing weight or not eating. On [DATE] at 9:01 AM, V12, LPN, stated R1 was on a regular diet when he came, but he switched to a pureed diet. V12 stated she was never informed he wasn't eating. V12 stated, The CNAs do the weights. I wouldn't know about someone's food intake unless the CNAs tell me. On [DATE] at 1:37 PM, V13, Power of Attorney/Former Home Care Aide, stated R1 was admitted to the facility for therapy and his goal was to return to home. V13 stated V8 (Nurse Practitioner) was R1's primary physician prior to admitting to the facility. V13 stated she wasn't impressed with the facility physician (V9) so she requested he be seen by V8. V13 stated she was very concerned with his condition and all he was eating was ice cream. We had concerns about him not standing. I was confused why he wasn't participating in therapy. He went to see (V8) on [DATE]. She was really concerned about him when she seen him. We set up a care plan meeting with the facility because he wasn't eating. He didn't like the food, and they thought it would be easier to eat the food if it was pureed. He said he couldn't chew the food. R1's physician visit summary, dated [DATE], documented by V8, Nurse Practitioner, documents R1's weight as 229 pounds. This visit summary documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 10:27 AM, V8, Nurse Practitioner, stated, (R1) was discharged from the hospital on [DATE] and was admitted to the facility for therapy. His family reached out so he came to (V8's) office on [DATE]. He weighed 229 pounds. V8 stated his weight loss was very concerning to her. He was only eating ice cream while at the facility. The facility brought him to her office. (R1) has been my patient since 2017. I (V8) called the facility because I was concerned about his (R1) weight loss. His decline was very concerning. Didn't think he was being monitored. He was a completely different man. R1's Plan of Care Note, dated [DATE] at 10:52 AM, documents, care meeting held today. (R1) only eating ice cream for all meals. (V13) concerned with the weight loss due to lack of appetite as well. (R1) agrees to see speech therapy and requested to have food down graded to puree to see if this helps him eat more. (V13) would like to see if appropriate for nutritional drinks. All parties agree to revisit discharge plans at a later date to give (R1) time to work on appetite and gain strength. On [DATE] at 9:23 AM, V14, Care Plan Coordinator, stated, We had a care plan meeting with the family (V13) due to his deterioration with therapy. They also had a huge concern that he wasn't eating. He was only wanting to eat ice cream. Sometimes he would eat a cheeseburger. (R1) stated he ate ice cream because it was easier to chew it. The CNAs chart his intakes, and if his intake is below 50 percent it should come up on the dashboard. V14 stated weekly weights should be done for four weeks after being admitted to the facility. The Dietary Manager or the Director of Nursing should be monitoring his weights. They haven't been having weight meetings lately. On [DATE] at 3:00 PM, V2, Director of Nursing (DON), stated she started working at the facility at the end of September. V2 stated she was out of the building from [DATE] through [DATE]. V2 stated she was not able to monitor R1's intakes or ensure weights were obtained. On [DATE] at 9:29 AM, V1, Administrator, stated, New admits should be weighed weekly times four weeks. The CNAs would obtain the weights. The nurses should ensure the weights are obtained. I am losing my managers and bringing in new managers so there is a transition. The DON would be responsible for the admission review. CNAs will track intakes. I knew (R1) was only wanting ice cream. I worked in the kitchen the last week (R10 was here, and all his ( meal) tickets said ice cream. V1 stated she was not aware he couldn't chew or that he had significant weight loss. V1 stated, I guess maybe they didn't weight him. On [DATE] at 2:33 PM, V8, Nurse Practitioner, stated, The facility should have called the physician about R1's intakes, him only eating ice cream, and should have weighed him. This could have caused an electrolyte balance and killed him. On [DATE] at 10:39 AM, V10 (V9's nurse) stated V9 (R1's physician) felt the facility not monitoring R1's weight, food intake, and assessing the reason for eating only ice cream, put R1 at risk for significant harm and danger.

Based on interview and record review, the facility failed to ensure cardiac medications were given per physician's orders, and failed to call the physician after the medications were held on 18 separate days for one (R1) of three residents reviewed for death on the sample list of six. These failures resulted in the risk for significant harm and danger to R1's health who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R1's Careplan, dated with a review date of [DATE], documents R1 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Physician's Orders documents orders, dated [DATE], for [MEDICATION(S)] (Calcium Channel Blocker) 81 milligram (mg) once a day, [MEDICATION(S)] (Ace Inhibitors) 20 mg 1 tab by mouth one time a day, and [MEDICATION(S)] (Alpha Beta Blocker) 25 mg 1 tab by mouth twice a day. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's [MEDICATION(S)] was not administered on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. And R1's [MEDICATION(S)] was held on ,d+[DATE] (am dose), ,d+[DATE] (am dose), ,d+[DATE] (both doses), ,d+[DATE] (both doses), ,d+[DATE] (am dose), ,d+[DATE] (am dose), ,d+[DATE] (am dose), [DATE] (am dose), [DATE] (am dose), [DATE] (am dose), [DATE] (am dose), ,d+[DATE] (both doses), ,d+[DATE] (am dose), ,d+[DATE] (am dose), ,d+[DATE] (am dose), ,d+[DATE] (am dose), ,d+[DATE] (both doses), and ,d+[DATE] (am dose). On [DATE] at 10:30 AM, V6, Licensed Practical Nurse (LPN), stated, (R1's) blood pressure fluctuated quite a bit. On the days that (R1) was low, we (nurses) would hold his cardiac medications if he was lower than ,d+[DATE]. We have standing orders from (V9, Physician) to hold them. V6 stated [MEDICATION(S)] 10 milligrams was held by V6 on [DATE] and [DATE]. V6 stated the [MEDICATION(S)] was held by V6 on [DATE], [DATE], and [DATE]. V6 stated the [MEDICATION(S)] was held by V6 on [DATE], [DATE], and [DATE]. V6 stated on [DATE] his blood pressure was ,d+[DATE], on [DATE] it was ,d+[DATE], on [DATE] it was ,d+[DATE], and on [DATE] it was ,d+[DATE]. V6 stated she did not notify V9 (Physician) she was holding the medications. V6 stated she held medications that she felt affected his blood pressure. On [DATE], V6 stated, I didn't give the [MEDICATION(S)] or [MEDICATION(S)] because his blood pressure was ,d+[DATE]. On [DATE] at 8:40 AM, V11, LPN, stated on [DATE] she held R1's doses of [MEDICATION(S)] 10 mg, his morning dose of [MEDICATION(S)], and his [MEDICATION(S)]. V11 stated she held them because of his blood pressure being ,d+[DATE]. V11 stated she didn't notify V9 about holding his medications or his low blood pressure. V11 stated she doesn't know the facility's policy about holding the medications. On [DATE] at 9:01 AM, V12, LPN, stated, I would hold his cardiac medications when his blood pressure was low. I took his B/P every time before giving his medications. When I was being trained, they taught me to do that. I wasn't trained which cardiac medications should be held for low blood pressure. V12 stated she didn't ever notify the physician she was holding his medications. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . V9's Physician Order's sheet signed by V9 on [DATE] documents under the heading [CONDITION(S)] states, Hold blood pressure (B/P) medication if B/P is below ,d+[DATE]. The facility's Administration of Medications with a review date of ,d+[DATE] documents, 1. If for any reason a physician's order cannot be followed, the physician shall be notified as soon as is reasonable. A notation shall be made on the nurse's progress notes in the patient's clinical record. On [DATE] at 2:33 PM, V8, Nurse Practitioner, stated R1 has been a patient of hers since 2017. V8 stated R1 was receiving the cardiac medications for [CONDITION(S)], Heart Failure, and Hypertension. V8 stated the facility should have notified the physician before holding R1's medications. V8 stated all three medications worked together for R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V8 stated the [MEDICATION(S)] helps with Hypertension, but also helps protect his kidneys and his heart. V8 stated, (R1) had chronic kidney disease. It is an issue that they didn't notify anyone. On [DATE] at 10:39 AM, V10 (V9's nurse) stated V9 (R1's physician) stated he expects the nursing staff to call after holding medications the first time that they are held, and not giving R1's cardiac medications as scheduled put R1 at the risk for significant harm and danger. On [DATE] at 9:50 AM, V7, County Coroner, stated R1 had a heart attack due to Carotid Artery Disease. V7 stated he thinks R1 not getting his cardiac medications could have contributed to his death. V7 stated, In my eyes it is a significant failure.

Based on observation, interview, and record review, the facility failed to prevent falls by failing to provide supervision; failing to ensure a safe room environment; and failing to maintain wheelchair brakes in working condition for three (R197, R10, R20) of five residents reviewed for falls on the sample list of 37. This failure caused R197 to fall sustaining a laceration to his left eye brow which required medical intervention to close. Findings Include: 1. R197's admission record, printed 9/29/22, lists the following diagnoses: Dementia with Behavioral Disturbance, Type II Diabetes with [CONDITION(S)], Cognitive Communication Deficit, Muscle Weakness, Unsteadiness on Feet, [CONDITION(S)], Altered Mental Status, and [CONDITION(S)] Disease. R197's Minimum Data Set (MDS), dated [DATE], documents R197 is severely cognitively impaired, experiences hallucinations and Delusions, displays physical, verbal, and other behavioral symptoms directed at others, and wanders. R197's Care Plan, reviewed 9/20/22, documents (R197) is at risk for falls (related to) Deconditioning. (R197) will be free of falls through the review date. Call Don't Fall sign. Assess clothing for proper fit. Be sure (R197) call light is within reach and encourage (R197) to use it. Encourage (R197) to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure personal items are within reach. R197's progress note, dated 9/24/2022 at 4:15 PM, documents, (R197) was wandering in the hallways and staff found him exiting through the Assisted Living Facility doorway. CNA (Certified Nurse's Assistant) noticed his face was bleeding and he stated he had stubbed his toe and fell to the floor hitting his head and left side of his face. Writer administered first aid, started neurochecks, vital signs, and evaluated his range of motion. (R197) was sent to emergency room for evaluation. R197's Progress note, dated 9/24/22 at 8:22 PM, documents, (hospital) called to report (R197's) CT (computerized tomography) scan was negative and the laceration to his eyebrow was (closed with wound adhesive). He is ready to return to facility. On 9/25/22 at 11:11 AM, (R197) was laying across unoccupied bed in his room feet on the floor and his upper body across bed. R197 had a laceration approximately 3 inches long above his left eye brow. Transparent wound adhesive is visible on the laceration. There was also a purple bruise surrounding R197's eye. R197 was struggling to upright himself. There were no staff visible in room or surrounding corridor. When asked if (R197) is able to get back up, (R197) mumbled and shook his head to indicate he was not. As R197 struggled, he moved his upper body closer to the edge of the bed. On 9/26/22 at 2:20 PM, V26, Certified Nursing Assistant, (CNA) stated, I was working (9/24/22) when (R197) fell . (R197) wanders a lot and tries to get out the door. He thinks he's going home. The kitchen is close to the double doors into the assisted living area. The doors are alarmed, but the kitchen staff help out by putting in the code and turning off the alarms when they sound because people like maintenance staff go in and out that door a lot. Another staff (V32, Certified Nursing Assistant) came to the nurse's station to find the nurse. She said she found (R197) all the way through the double doors into the assisted living area and he was bloody. I went up to the hall by the kitchen and found bloody foot prints in the hall and (R197) was on the floor in the front hall of assisted living. The nurse came and we got (R197) back to his room. The nurse called the ambulance and (R197) went to the emergency room . The facility's Fall investigation report does not include the witness as described by V26. On 9/26/22 at 3:00 PM, V1, Administrator, stated, That was (V32, Certified Nursing Assistant). V1 provided a copy of a hand written statement by (V32). The statement documents, I (V32) heard the alarm go off at the assisted living area and I saw (R197) walking and bleeding. I did not witness the fall. V32 could not be reached for interview. On 9/27/22 at 11:00 AM, V2, Director of Nursing, stated, (R197) does wander a lot. He should not have made it all the way over to Assisted Living. We have a lot of challenges when it comes to staffing. The kitchen staff should not be shutting off the door alarms unless they check why it is alarming. 2. On 9/25/22 at 9:11 AM, R10 stated, I tripped over a (mechanical lift) leg, the staff left in the room a couple weeks ago, my hip is sore from it. I am able to walk around with my cane. R10's medical record documents on 9/9/2022 at 10:53 AM, Resident stated that (R10) was moving the machine out of her room (mechanical lift) and tripped over it as (R10) was pushing it out of the door way. An area of redness was noted to resident's left deltoid area from when she slid through the doorway and bumped arm on the doorway as she fell . Resident landed on left side of buttocks before laying back to her left side. The facility's Fall Details report documents, R10, type: fall, location: residents room, witness: V7 LPN, Environmental conditions: Obstacles in path- (Mechanical Lift). Conclusion: resident was going into her room after breakfast and moved the lift out of the way and tripped over it. Education completed with staff to move equipment out of room when care is completed. On 9/26/22 at 9:36 AM, V2, Director Of Nursing, stated, The (mechanical lift) had been used by staff for (R10's) roommate, staff had left it in the room, R10 tripped over it. On 9/28/22 at 11:40 AM, V7, Licensed Practical Nurse, stated, I was on the hallway passing medications and I saw the (mechanical lift) come out or R10's room and then R10 fall out the doorway beside the (mechanical lift). Staff had left the mechanical lift in (R10's) room, (R10) stated (R10) was trying to push the mechanical lift out of (R10's) room. (R10) had redness to her left arm that later turned into a bruise. I educated staff to not keep medical equipment in resident rooms. 3. On 9/25/2022 at 10:30 AM, R20 reported R20's right wheelchair brake does not work; it will not effectively engage. R20's right wheelchair brake was observed immediately disengaging after any force was applied to R20's wheelchair. R20's wheelchair was unable to remain in a stationary position with the dysfunctional right brake. R20 reported telling facility staff several days ago about the failed wheelchair brake, but no staff had yet responded to R20. R20 reported requiring the use of a mechanical lift for transferring from R20's bed to R20's wheelchair, and using the wheelchair brakes engaged during those transfers, and also while seated at the dining room table. On 9/28/2022 at 11:10 AM, R20 was seated in the above wheelchair, and again reported telling maintenance about five days ago about R20's right wheelchair brake not working, but maintenance staff have not fixed the brake yet. R20 reported direct care staff sometimes complain about the non-functioning wheelchair brake when transferring R20 to R20's wheelchair. R20 then demonstrated the right brake not being able to remain engaged. R20 reported liking to have the brakes engages while at the dining room table to keep from rolling backwards. Resident Council minutes (5/6/2022) documents, (R20) needs (R20's) brakes fixed on her chair. The same record documents on 9/6/2022, (R20) needs wheelchair fixed. The facility's Fall Prevention Policy, revised 2021, states, Following any falls the facility completes an occurrence report. Details of the fall will be reported and potential casual factors identified and investigated. Interventions will be immediately implemented following each fall and added to the resident's plan of care.

Based on observation, interview, and record review, the facility failed to prevent the development and worsening of pressure ulcers by failing to: ensure a residents brace was in proper position and monitored, monitor skin condition underneath a brace, implement turning and positioning programs, assess a pressure ulcer upon admission, provide pressure ulcer treatments and interventions, and routinely assess, monitor, and provide pressure relieving interventions for residents. These failures affect four (R33, R26, R246, R27) of five residents reviewed for pressure ulcer on the sample list of 37. This failure resulted in R33 developing an unstageable pressure ulcer to the right lower leg exposing muscle and ligaments, a unstageable pressure ulcer to the heel, and three stage two pressure ulcers to the right, left hip, and sacrum, and resulting in R26 developing an unstageable pressure ulcer to the sacrum. Findings include: 1. R33's Admission assessment, dated 8/12/22 at 12:31 PM, documents R33 does not have pressure ulcers, and is at mild risk for pressure ulcer. R33's Nurse's note, dated 8/12/2022 at 2:44 PM, documents R33 has a black immobilizer to the right leg that R33 is to wear at all times. R33's medical record does not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R33's Pressure Ulcer Risk Assessment, dated 8/19/22 with a lock date of 9/8/22, documents R33 is a moderate risk for pressure ulcers. R33's Admission Minimum Data Set assessment, dated 8/25/22, documents R33 is totally dependent with two person assist for turning and positioning. R33's Skin/Wound Note dated 8/27/2022 at 11:11 AM documents, New pressure wound noted to inner (right) ankle. (10.5 centimeter (cm) X 4 cm). Severe pain to the area. Foul odor noted (with) moderate drainage. Wound was noted after removing the leg brace off her lower R leg/ Indentation from the brace noted to the R (right) ankle. Although, brace is to be on her Upper thigh for the healing femur (fracture). Also, eschar noted to R heel. R33's Skin and Wound Evaluation, dated 9/20/22, documents a new, in house acquired open lesion to the left buttock measuring 2.9 cm by 2.7 cm by 1.6 cm wound. R33's Skin and Wound Evaluation, dated 9/20/22, documents a new, in house acquired open lesion to the right buttock measuring 2.8 cm by 2.1 cm by 1.8 cm wound. R33's Skin and Wound Evaluation, dated 9/20/22, documents Moisture Associated Skin Damage to the Sacrum measuring 10.5 cm by 6.1 cm by 2.8 cm. On 9/27/22 at 1:38 PM, V21, Registered Nurse, and V3, Licensed Practical Nurse/Wound Nurse, changed the dressing to R33's wounds. The wound to R33's right lower leg was 8 centimeters (cm) by 3.5 cm with a depth of 0.9 cm. The wound was 90 percent covered with dark yellow gray slough. The outer edge of the wound exposed muscle and ligaments. There was a unstageable pressure ulcer to R33's right heel that measured 1.1 cm by 1.9 cm. This wound was covered with black eschar. There was a stage two circular pressure ulcer to the sacrum measuring 1.2 cm in diameter. There was scarring to R33's left and right buttocks. V3 stated these areas were healed facility acquired stage two pressure ulcers. On 9/27/22 at 9:45 AM, V17, Licensed Practical Nurse (LPN), stated when she assessed the area, she noticed that the brace was in the wrong spot; it was supposed to be on the upper leg. The brace was an immobilizer and was supposed to be positioned so the she could not bend at the knee. It should not have been positioned as low as it was. The (unknown) Certified Nurse's Assistants came and got me because they noticed blood on her leg around her ankle. V17 stated she ended up taking it off because she didn't have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V17 stated the wound to the inner ankle had a lot of drainage, and she could tell it was caused from pressure, because there was an indentation where the brace was sitting. V17 stated, It was an irregular shaped ulcer with an indentation and that the wound bed was green. V17 stated her right heel was also black. Review of R33's medical record does not document R33 was on a turning and positioning program or that R33 received turning or positioning. On 9/28/22 at 12:56 PM, V22 (Physician's Nurse) stated V9 (R33's physician) would have expected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V22 stated V9 would have expected a turning and positioning program to be implemented to prevent the development of pressure ulcers On 9/26/22 at 4:02 PM, V2 Director of Nursing confirmed a turning and positioning program was not implemented for R33. V2 confirmed R33's medical record did not document the receipt of turning and positioning. V2 also confirmed R33's medical record did not contain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's pressure ulcer pressure injury prevention policy, dated 4/2018, documents for residents at moderate risk for pressure ulcer the facility will implement, Individualized turning and repositioning (utilizing a 30-degree rule). 2. R26's medical record documents R26 was admitted to facility on 7/24/22, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's Hospital discharge instructions, dated 7/24/22, documents, Wound care per facility protocol. R26's Admission Skin Integrity assessment, dated 7/24/22, documents, Open area to lower back. No measurements or a wound description is documented. R26's Nurses Notes documented on 7/24/22, by V18, Licensed Practical Nurse, Resident has an open area on lower back. V18 LPN stated, On 7/24/22, (R26) admitted with a stage 2, open area to the sacrum, there was no drainage to the wound, the wound bed was pink, there was no slough or eschar to the wound. I don't know exact measurements, it was bigger than a dime but smaller than a quarter. R26's Braden skin risk assessment, dated 7/24/22, documents a score of 16, indicating at risk for skin breakdown. R26's medical record does not document a physician ordered treatment to R26's open area to lower back from admitted [DATE] through hospital admitted [DATE]. R26's medical record documents on 8/4/22, R26 was sent to the emergency room and admitted to the hospital with a Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] R26's hospital records document, Hospitalist Admission History and Physical, date of service: 8/4/22, Physical Exam: Stage two thoracic pressure ulcer. R26's Hospital Wound Clinic Consult notes, signed by V23 (Hospital Wound Nurse) documents, Wound 8-5-22 Sacrum open, black wound bed, Unstageable. Wound on 8-11-22, wound bed: full thickness, eschar full coverage, brown, black fragile red, wound length: 1.6 centimeters, wound width: 3.6 centimeters, wound depth: 0.2 centimeters, wound surface area: 5.76 centimeters squared. R26 readmitted back to the facility on [DATE]. R26's hospital discharge orders dated 8/17/22, Wound care instructions: Wound care: cleanse sacral wound with normal saline and pat dry edges apply Santyl nickel thickness to necrotic wound bed pack with saline moistened gauze cover with [MEDICATION(S)] (foam dressing), change twice a day and as needed. R26's Readmission skin integrity assessment, dated 8/17/22, documents, skin integrity: does resident have impaired skin integrity: yes, Resident was readmitted with the following skin issues: assessment is blank. R26's medical record does not document a description, type of wound or wound measurements for R26's sacral wound from readmitted [DATE] through 8/22/22. R26's medical record does not document the hospital wound care instructions, dated 8/17/22, were implemented by the facility until 8/22/22. R26's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's Skin Wound Evaluation form, completed by V2, Director of Nursing, dated 8/22/22, documents, Pressure, Unstageable, Slough/Eschar, location: is blank, acquired: present on admission, how long present: Unknown, Wound Measurements: (surface area: 6.72 centimeters squared), wound length: 3.2 centimeters, width: 2.1 centimeters, depth: not applicable. Treatment- dressing appearance: Missing is checked. Notes: readmitted to facility on 8/17/22 from hospital with sacral wound. Treatment orders in place. Wound care to see on next visit. R26's Skin Wound Evaluation form, dated 9/2/22, documents, Pressure, Unstageable, Location: is blank, Wound measurements: blank, slough, increased drainage. No notes, no measurements documented. R26's Skin Wound Evaluation form, dated 9/7/22, documents, Pressure, Unstageable, Location: is blank, Wound measurements: 4.5-centimeter length, 1.9 cm width by 2.9 cm depth. (Surface area: 8.55 cm2.) R26's Skin Wound evaluation form, dated 9/13/22 documents, Pressure, Unstageable, Location: is blank, Wound measurements: 4.9 centimeters length, 1.5 centimeter width, depth: not applicable. (Surface area: 9.31 cm2). R26's Skin Wound Evaluation, form dated 9/20/22, documents, Pressure, Unstageable, Location: is blank, Wound measurements: 4.1 centimeters length, 2.3 centimeters width, depth: not applicable. (Surface area: 9.43 cm2). R26's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . May substitute [MEDICATION(S)] [MEDICATION(S)] if out of Calcium Alginate. two times a day for Wound care, start date: 9/9/2022 end date: 9/16/2022. R26's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . May substitute [MEDICATION(S)] [MEDICATION(S)] if out of Calcium Alginate, two times a day for Wound care, start date: 9/17/2022. R26's Treatment Administration Records (TAR) do not document the completion of physician ordered treatment to R26's sacral wound: at 8:00 AM on 8/26/22, 8/27/22, 8/28/22, 8/30/22, 8/31/22, 9/3/22, 9/4/22, 9/6/22, 9/10/22, 9/11/22, 9/14/22, at 7:00 PM on 8/23/22, 8/25/22, 8/26/22, 9/1/22, 9/3/22, 9/4/22, 9/7/22, 9/12/22, 9/13/22, 9/15/22, or at 1:00 AM on 9/23/22 and 1:00 PM on 9/18/22, 9/19/22, 9/20/22, 9/24/22 and 9/25/22. On 09/26/22 at 11:29 AM, R26 states, Sometimes they do the treatment once a day and sometimes it is twice a day, just depends on if they have time or not. R26's Minimum Data Set assessment, dated 8/24/22, documents R26 as cognitively intact. On 9/27/22 at 2:15 PM, V2, DON, stated, The nurse that does the admission on hallway is responsible to assess and measure wounds. Normally, if a resident admits with a wound, they have Physician orders, if not we have a protocol the nurse can follow and call and get physician orders. If the staff do not feel comfortable they can notify (V3 Wound Nurse) and (V3) will do the assessment and obtain and write orders. Wounds should be measured weekly and the description documented. Nurses are to sign out treatments on the TARs after they are completed, if a resident refuses it is to be documented on the TAR's, if it is blank that can mean they forgot to sign it out or they did not do it. Wound care observations were completed on 9/27/22 at 3:02 PM with V21, Registered Nurse, and V3, Wound Nurse. V3 measured R26's sacral wound, R26's wound depth was: 0.7 cm, width was 3.4 cm and length was 3.4 cm (wound surface area: 11.56 cm2), V3 stated, the wound is unstageable. no undermining, no tunneling is present. R26's wound bed appeared red with minimal scattered spots of slough present. On 9/28/22 at 10:10 AM, V22 (Physician's nurse) stated, (V9, R26's Physician) expects the facility to assess a residents wound on admission, contact the physician or wound care provider in house for a treatment order, apply the physician ordered treatment, and monitor the wounds weekly. On 9/28/22 at 3:00 PM, V3, Wound Nurse, confirmed there was no assessment, measurement, or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 also confirmed no assessment was completed for R26's sacral wound after readmission from hospital on 8/17/22 until 8/22/22, and a treatment was not initiated to R26's sacral wound ulcer until 8/22/22. V3 confirmed R26's TAR's do not document the completion of R26's physician ordered treatment twice a day as ordered. 3. R246's medical record documents an admitted [DATE]. R246's Admission Skin integrity assessment, dated 9-16-22, documents a Stage 1 pressure ulcer to sacrum (admitted with) and a Stage 2 pressure ulcer to ischium (admitted with). No measurements or wound description is documented on this assessment. R246's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R246's progress notes, dated 9/16/22, document Has one ([MEDICATION(S)] dressing) covering coccyx area. (no measurements or wound description is documented). R246's Pressure Ulcer Risk Assessment, dated 9/16,22 score of 10, indicating at high risk for skin breakdown. R246's Careplan, initiated on 9/19/22, documents, (R246) has potential/actual impairment to skin integrity related to stage I pressure ulcer to sacrum ad stage II pressure ulcer to ischium. Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, [CONDITION(S)], granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated. R246's medical record does not document the measurements or a wound assessment for R246's wounds from admission on 9/16/22 through 9/28/22. On 9/28/22 at 12:45 PM, V3, Wound Nurse, confirmed R246 did not have measurements or wound description documented in R246's medical record. 4) R27's Care Plan (8/19/2022) documents R27 has impaired skin integrity and a coccyx wound. The same record documents staff are to keep R27 off of R27's back while in bed and to respond immediately to any complaints of pain. R27's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R27's Minimum Data Set (8/7/2022) documents R27 is at risk for developing pressure ulcers/injuries and has one or more unhealed pressure ulcers. On 9/25/2022 at 11:11 AM, R27 was laying on R27's back in bed on top of a mechanical lift sling, and reported having pain on R27's left back area. R27 reported telling staff thirty minutes ago about having pain, and they replied they would come back in five minutes to help R27, but R27 reported nobody returned to R27's room. V28 (Certified Nurse Aide) was present in the hallway outside of R27's room, and reported R27 had a wrinkle in the fabric mechanical lift sling he was laying on, and V28 was not going to fix the wrinkle for R27 until R27 was transferred from the bed for lunch, which was not until 12:00 PM.

Based on record review and interview, the facility failed to supervise two residents (R4 and R6) with known histories of repeated falls. These failures resulted in R4 falling from the commode while left unattended and sustaining a humerus fracture, and R6 falling multiple times when left unsupervised. R4 and R6 are two of three residents reviewed for falls in the sample list of three. Findings include: 1. R4's Diagnosis Sheet (current) includes the following diagnoses: Dementia, Repeated Falls, Unsteady on Feet, Reduced Mobility and Convulsions. R4's Minimum Data Set (MDS), dated [DATE], documents R4 as being severely cognitively impaired, and not steady, only able to stabilize with assistance when moving from a seated to standing position. R4 is also documented on this same MDS as needing the assistance of one person when toileting. R4's Plan of Care (current) documents a focus area of Falls with a directive for Nursing staff: Do not leave (R4) in the bathroom unattended, with initiation dated 9/30/21. The facility's Fall Log dated March through September 2022, documents R4 with the following falls: 3/27/22 x 2 falls, 7/31/22, 8/17/22 and 8/28/22. A Facility Incident Report, dated 8/28/22, for R4 documents the following: fall in bathroom, (V3 Licensed Practical Nurse) left the room to find a clean brief as resident (R4) was incontinent. I (V3) heard (R4) scream from the hallway--When (V3) and CNA (Certified Nursing Assistant) entered the room (R4) was lying on (R4's) back, with (R4's) w/c (wheelchair) on top of (R4) in the next door neighbor's room. (R4) was in no distress on visual assessment, but upon ROM (Range of Motion) to upper extremities, (R4) screamed in pain when attempted to (Left) shoulder. Upon palpation (V3) felt 2 separate bones and visually on the verge of protruding through the skin. (V3) contacted (Emergency Services) for immediate transfer. On 9/7/22 at 10:15 am, V3 confirmed V3 had placed R4 on the commode in a shared bathroom, and left R4 unattended on the commode to retrieve a clean incontinence brief. V3 stated V3 was in the hall and heard R4 scream, and upon returning to the bathroom found R4 on the floor of the doorway leading to another resident's room. V3 stated the wheelchair was on top of R4, and confirmed the above assessment on R4's Left Arm/Shoulder area. V3 also confirmed at this time V3 had not read R4's Plan of Care. R4's Hospital Notes on 8/28/22 document the following: Fall with pain and deformity of Left Shoulder. X-ray - Three views of the left shoulder performed. Separate Anterior, Posterior and Lateral views left humerus also obtained. Impression: 1. Oblique fracture of the proximal humerus involving the humeral neck. There is displacement and angulation present with some impaction or overriding present. No dislocation. 2. [CONDITION(S)] changes. The X-ray findings are Electronically signed by V10, Radiologist. On 9/7/22 at 10:30 am, V1, Administrator, confirmed R4 should not have been left on the commode unattended, and R4's fractured Left arm was due to falling while unsupervised in the bathroom on 8/28/22. V1 also confirmed V3 should have had all necessary supplies with V3 when delivering care to R4. 2. R6's Diagnosis Sheet (current) includes the following diagnoses: Dementia with Behavioral Disturbances, Repeated Falls, Muscle Weakness, [CONDITION(S)], and Unsteady on Feet. R6's MDS, dated [DATE], documents R6 as being Moderately Cognitively Impaired with Behaviors. This same MDS documents R6 needing extensive assist in transfers. R6's Plan of Care (current) documents a focused area on Falls, with a directive to Nursing staff: (R6) is to be in supervised areas when up, with an initiation date of 3/03/22. The facility's Fall Log, dated April through September 2022, documents R6 with the following falls: 4/23/22, 4/29/22, 8/11/22. The facility's Incident Reports on the above falls document the following: 4/23/22 at 9:20 am - R6 found on the floor in the common area by the dining room. R6's wheelchair was positioned by the arm of the couch and R6 stated I was trying to get over there to the couch. R4 was positioned between the wheelchair and the couch facing the dining room. Unwitnessed fall. 4/29/22 at 1:10 pm - R6 found sitting on the floor in another resident's room. Confused. Unwitnessed fall. 8/11/22 at 8:00 pm - R6 in dining room and fell out of wheelchair. Unwitnessed fall. On 9/7/22 at 1:00 pm, V1 confirmed R6's above falls occurred when R6 was unsupervised. V1 also confirmed at this time, due to R6's history of repeated falls, R6's Plan of Care includes R6 is not to be left unsupervised in common areas when up.

Based on interview and record review, the facility failed to ensure R2 was not sexually assaulted by R1, and R3 was not subjected to physical, verbal, and mental abuse by an employee. This failure resulted in R2 experiencing ongoing emotional distress and fearfulness as a result of being assaulted by R1. These failures affected two (R2, R3) of five residents reviewed for abuse on the sample list of eight. Findings include: 1.) The facility's Abuse Investigation report, dated January 9, 2022, written by V1, Administrator, documents R1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This report documents R2 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This report documents, It was reported to (V1, Administrator) that (R1) was making inappropriate comments to (R2). (R1) asked (R2) if (R2) wants a kiss or wants to come to (R1's) room and play. (R2) reported this made (R2) feel uncomfortable. Interview with (R2) who stated that (R1) did not touch (R2) but (R1) kept asking (R2) if (R2) wanted to kiss or hug (R1) or go to (R1's) room to play. (R2) stated that (R2) didn't like (R1) doing this and doesn't want (R1) to do this again. Interview with (R1) who stated that (R1) was just talking to (R2). (R1) denies that what (R1) said to (R2) was inappropriate. (V1) explained to (R1) that this made (R2) feel uncomfortable and that (R1) is not to ask (R2) to do these things again. (R1) agreed (R1) would not talk to any of the (residents) at the facility this way. In conclusion, I (V1, Administrator) do agree that the statements that (R1) made to (R2) were inappropriate and (V6) Social Services will follow up with both parties weekly for the next 2 weeks for psychosocial well-being. On 1/24/22 at 2:25 PM, R2 stated R2 recalls the incident on 1/9/22, and stated, (R1) tried to hug me and then tried to kiss me and I told (R1) no, then (R1) said will you play with me and I told (R1) no, so (R1) was following me back to my room and I was trying to get away and (R1) kept going faster and faster and I kept trying to get away but (R1) grabbed my chair and then (R1) tried to kiss me and kept asking me to go to (R1's) room. I kept telling (R1) no and (R1) would ask me again and I told (R1) I wanted to go to my room. I don't think (R1) takes no for an answer. I was scared about what (R1) would do to me. One of the other CNAs, (V11, Certified Nurse's Assistant) saw (R1) and came and got me and took me to my room. R2 stated, (V11) told (V4, Licensed Practical Nurse) about me and (R8). I am still scared and now I have to watch my back. I'm scared that (R1) would do again. I watch out my door to see if (R1) is out of (R1's) room. On 1/25/22 at 12:37 PM, V11 CNA stated, I was helping a resident and seen (R1) hugging (R2) from the side. I asked if there was a problem. (R2) said (R2) didn't like (R1) hugging (R2). I asked (R1) to go to (R1's) room and pushed (R2) to (R2's) room. V11 stated after ensuring R1 went back to R1's room, I then went back into (R2's) room and (R2) was crying and said (R2) felt assaulted. When I asked what happened (R2) said (R1) asked if (R1)could give (R2) a kiss and (R2) said no and then (R1) asked if (R2) wanted to come to (R1's) room to play and (R2) said no. Then (R1) hugged (R2). I seen (R1) hug (R2) but that was all. I reported it immediately. On 1/25/22 at 2:27 PM, V1, Administrator, stated the encounter between R1 and R2 did not meet definition of sexual abuse but maybe harassment, and R1's comments to R2 were inappropriate. 2.) The facility's Abuse Investigation report, dated January 18, 2022, documents R3 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This investigation also documents, It was reported to (V1, Administrator) that a CNA (V5, Certified Nurse's Assistant) reported to her nurse (V4, Licensed Practical Nurse) that another CNA (V6) was rough with (R3) while transferring (R3) from the (mechanical lift). (V5) stated (V6) was trying to remove the sling from under (R3) and it caused (R3) to bump the wall. V5's written statement, dated 1/11/22 at 4:30 PM, documents, On 1/11/22 right before supper. I was standing near the nurse's station when I heard (R3) scream. I immediately jogged down the hall to (R3's) room. I saw (V6, CNA) attaching the sling to the (mechanical lift), ignoring (R3's) screams. I quickly told (V6) to stop and I asked (R3) what was wrong. (R3) replied don't' want up. (R3) looked scared. I said okay let me ask the nurse. As I went to walk out (V6) started to hook (R3) up to the (mechanical lift) again so I told (V6) do not move (R3) until I ask (V4, LPN). I asked if (R3) could stay in bed and (V4) said (R3) could so I went back and said that (R3) was staying in bed and that (V6) would take the sling from under (R3). I went to walk out but I decided to turn around and help. (V6) grabbed the edge of the sling and flung (R3) into the wall and (R3) screamed ow (V6) disregarded the scream, grabbed (R3) from the back of (R3's) knee and shoved it into the wall to hold (R3) on (R3's) side. (R3) was clearly screaming My leg, My leg! I had to tell (V6) twice I have (R3's) (backside), you can let go of (R3's) leg. Let go of (R3's) leg you're hurting (R3). At that point (V6) did. (V6) yanked the (mechanical lift) sling from under (R3). (V6) did not use the roll tuck, roll pull sling method. I kinda looked at (V6) and said ok and (V6) ignored it. At some point in all of this (V6) was cussing saying (R3) done scratched my (expletive) face. I immediately reported this to (V4). On 1/25/22 at 9:53 AM, V5, CNA, stated on 1/11/22, I was at the nurse's station. I heard (R3) scream. So I went down to (R3's) room quickly and went in. (V6, CNA) was attaching the sling to the (mechanical) lift. I said hold on because (R3) doesn't scream like that. I asked (R3) what was wrong and (R3) told me (R3) didn't want to get up. I told (V6) that I was going to go ask (V4, LPN) if (R3) could stay in bed. I told (V4) not to do anything until I got back. (V4) told me (R3) could stay in bed. I went back into the room and told (R3) that (R3) didn't have to get up, and that (V6) would get the sling out from under (R3). I went to walk out, then I decided to turn around and help. (V6) grabs the sling from underneath (R3) and lifts it very forcefully and (R3) hit the wall and screamed, Ow! I heard something hit the wall it sounded like it made a thud sound, I thought it was probably a elbow or knee. At this time, (R3) is lying on (R3's) right side facing the wall. Then (V6) grabbed the back of (R3's) left knee and pushed it into the wall to hold (R3) over onto the side. Then (V6) ripped the sling out from underneath (R3) without doing two rolls and we are taught not to do this because it could easily cause a skin tear. Then the drawsheet needed repositioned, so (V6) started tucking the drawsheet underneath (R3). Then (R3) said Ow my leg. Then I put my leg on (R3's) bottom, but (V6) did not let go of (R3's) knee. (R3) screamed, Oh, my leg again. Then I said let go of (R3's) leg you are hurting (R3). Then V6 let go of (R3's) leg. Then we rolled (R3) to get the drawsheet from under (R3). Then I told (V6) just to leave it for now. Then (V6) left the room. Sometime during this incident (V6) stated, (R3) scratched my (expletive) eye. I then finished cares, and immediately walked out and told (V4, LPN.) I felt like (V6) was physically abusive to (R3). (V6) was perfectly fine right before (V6) went in there. I felt like (R3) was screaming because (R3) didn't want to get up. I felt like the reason (V6) acted like that towards (R3) was because (R3) had scratched (V6) or because (V6) was frustrated because I said (R3) didn't have to get up. On 1/25/22 at 11:30 AM, V4, Licensed Practical Nurse, stated on 1/11/22, V5 came to me and told me they were changing (R3) and (R3) didn't want to get up. So then a few minutes later (V5) came to me and reported that (V6) was rough with (R3) during cares. I walked (V6) up to the time clock and told (V6) that we had received an allegation and (V6) began to yell and cuss. In the breakroom she was like f that and then said (V6) would clock out and not be back. I would consider (V5) a reliable witness (V5) never complains about co-workers.

Based on interview and record review, the facility failed to ensure an investigation for a resident's fall was investigated, failed to ensure resident's falls were thoroughly investigated, failed to identify the root cause of falls, and failed to ensure fall prevention interventions and post fall interventions were implemented. These failures affect 3 residents (R1, R2 and R3) reviewed for falls in the sample of three. These failures resulted in R1 falling twice resulting in a [CONDITION(S)] and an injury to the lung that required a chest drainage tube to be placed. Findings include: 1. R1's Fall Risk Data Collection assessment, dated 9/30/21, documents R1 is a high risk for falls. R1's Minimum Data Set, dated dated [DATE], documents R1 requires extensive staff assistance for toileting and transferring. R1's Occurrence Report documents R1 had a fall on 9/30/21 at 2:20pm. This report documents R1 was found sitting on the floor in the bathroom with R1's pants and briefs down around the bottom of R1's ankles. The conclusion documents R1 slid to the floor on buttocks, and documents the root cause of the fall as due to resident action or internal risk factors but no resident specific details/reason. There is no documentation why R1 was in the bathroom, when R1 was last toileted, or when R1 was last observed prior to the fall. R1's Occurrence Report documents R1 had a fall on 10/1/21 at 7:00am. This report documents R1 was found on the floor on R1's left side laying in front of the sink in R1's room, and internal rotation of the left leg was noted and a full head to toe assessment was performed, with no details of what the head to toe assessment consisted of/showed. This report does not document the last time R1 had been assisted to the toilet. The conclusion for this fall documents R1 was assisted off the floor and requested to be taken to the bathroom. R1 noted hip pain, and V6, Licensed Practical Nurse (LPN), came to re-assess R1 due to the hip pain. R1 requested to go to the dining room and was having trouble breathing. R1 was then taken to the nurse's station where staff applied oxygen and transferred R1 to the hospital. The root cause is documented as due to resident action or internal risk factors but does not identify a specific identified root cause related to the fall. This report documents fall interventions were in place at the time of the fall, but the investigation does not document what fall interventions were in place. This report also documents R1 was admitted to the hospital with a diagnosis of a Left [CONDITION(S)] and Pneumothorax. R1's Hospitalist Admission History and Physical Exam, dated 10/1/21, documents R1's medical history including a history of [CONDITION(S)] (DVT) and Pulmonary Embolism (PE) with R1 taking [MEDICATION(S)] (Anticoagulant) and Aspirin (NonSteroidal Anti-[CONDITION(S)]) medication, [CONDITION(S)] which caused [CONDITION(S)] and Anxiety. This report documents R1 presented to the hospital with Dyspnea and no breath sounds on the right side. A Computed Tomography (CT) of the chest revealed a moderate right Pneumothorax and a non-displaced Left Acetabular Fracture. This report documents R1 was admitted to the hospital for Acute Hypoxemic [CONDITION(S)] secondary to Traumatic Right Pneumothorax after fall today. On 10/19/21 at 2:10pm, V2, Director of Nursing (DON), stated R1 was in the bathroom trying to pull up R1's pants and lost R1's balance. R1 requires assist and refuses to use call light at times. There is no documentation of how R1 got in to the bathroom. Staff placed a sign in the bathroom to call, not fall, as a reminder, but staff are to be taking R1. V2 stated R1 had gone from R1's bed to the chair to the bathroom, but it is not documented and there is no supporting documentation. That is just where (R1) goes. There is no documentation of where R1 was prior to the fall. There is no documentation of investigation into when R1 was last toileted. V2 stated the root cause was R1 is unaware of safety limitations and transfers without asking for assistance, but the investigation is incomplete. V2 stated R1 was found on the floor on 10/1/21 at 7:00am. V2 stated staff reported R1 needed to go to the bathroom, so staff assisted R1 and that is when R1 reported the hip pain. R1 wanted to go to dining room. V2 stated when a head to toe assessment is completed, staff do a skin check, and check for range of motion and shortening, etc of leg and vital signs. V2 stated V2 didn't know for sure if R1 had always had the shortening of the left leg. 2. R2's Face Sheet, dated 10/19/21, documents R1's diagnoses including Alcoholic [CONDITION(S)], Cognitive Communication Deficit, Muscle Weakness, Degeneration of Nervous System, [CONDITION(S)], Hallucinations, Unspecified [CONDITION(S)], Anxiety and Chronic Pain Syndrome. R2's Minimum Data Set (MDS), dated [DATE], documents R2 was dependent on staff for bed mobility and toileting. This MDS also documents R2 has a history of multiple falls. R2's Fall Risk Data Collection assessment, dated 7/17/21, documents R2 is at a high risk for falls. R2's Occurrence Reports document R2's fall incident investigations as follows: 8/28/21 at 10:01am- R2 attempted to stand up from the shower chair in the shower room. V12, Certified Nursing Assistant (CNA), reported R2 got up and the shower chair slid out from under R2. There is no documentation the facility evaluated the shower chair to ensure proper functioning. There is no documentation regarding if the shower chair was being used properly, such as positioning and use of brakes on shower chair. The root cause is documented as due to resident action or internal risk factors with no identification of specific root cause of why R2 fell . 8/28/21 at 9:15pm- R2 was found on the floor after an unidentified family adjoining R2's room heard R2 hit the wall. R2 had a bruise to the left temple area of R2's head. This report documents R2 stated R2 was getting ready for work. This report documents R2 lost R2's balance and fell , but does not identify why R2 may have lost his balance and fell . There is no documentation of a post fall intervention placed in regards to this fall within the investigation. R2's Occurrence Report, dated 8/29/21 at 1:12am, documents R2 was found laying on the floor. This investigation documents R2 rolled out of bed while trying to get up unassisted, but does not identify why R2 was attempting to get out of bed. There is no documentation of staff interviews related to this fall. There is no documentation in this investigation of a post fall intervention being placed for this fall. R2's Occurrence Report, dated 8/29/21 at 6:25am, documents V9, Licensed Practical Nurse (LPN), heard a loud thump while at the nurse's station, and V9 went down the hall and found R2 lying in the hallway on R2's right side wearing only a brief. R2 was moaning and stated (R2) just fell . There is no documentation in the investigation as to when R2 had last been toileted. This investigation also documents V14, Certified Nursing Assistant (CNA), reported R2 was lying on R2's left side on the ground and includes environmental conditions present including obstacles in path of isolation bins, bedside table, and that R2 has a recliner in R2's room along with a bedside table. This report documents R2 lost R2's balance while ambulating unassisted, and is unaware of R2's safety limitations. R2 is encouraged to use R2's call light and wait for assistance. There is no root cause identified as to why R2 had got up unassisted, or what may have actually caused R2 to fall. R2's Occurrence Report, dated 9/6/21 at 7:15pm, documents R2's position when found as right side witnessed fall. There is no documentation as to when R2 last received toileting, repositioning, or had food and fluids. There is no documentation of interviews with staff for this investigation. This report documents the conclusion of the investigation including R2 attempted to self transfer, but due to R2's weakness, R2 was unable to complete the transfer. There is no root cause identified as to why R2 attempted to self transfer. R2's Occurrence Report, dated 9/9/21, documents V15, R2's family, was visiting with R2 and left to get something to drink. V15 found R2 on the floor upon returning to R2's room. This report does not document when R2 had last been toileted, repositioned, or given food or fluids. This investigation documents R2 was last observed 9/9/21 at 4:08pm, but this was by R2's wife, and does not identify when R2 was last seen/observed by staff. The root cause is documented as due to resident action or internal risk factors with no identification of specific root cause of why R2 fell . R2's Progress Notes, dated 9/12/21 at 1:50pm, documents R2 experienced a fall that was unwitnessed. This note documents R1's alarm was sounding but staff were unable to respond in time before R2 rolled off the bed. This note documents V2, Director of Nursing (DON), and V3, Assistant Director of Nursing (ADON), were notified and the facility was to start the process of moving R2 closer to the nurses station and to place a louder alarm on R2. There is no documentation R2 was moved closer to the nurse's station, or that a louder alarm was put in place for R2. There is no investigation documented for this fall. On 10/19/21 at 4:00pm, V2, Director of Nursing (DON), stated R2 had [CONDITION(S)] of the liver and would get agitated, and the facility had sent R2 out multiple times to try to get R2 help. In regards to R2's fall while in the shower with a shower chair in use, V2 stated V2 doesn't know if the shower chair was working properly or not, and the shower chair that had been used has been replaced. V2 stated V2 doesn't know if the shower chair wheels were locked because that was not investigated. V2 also stated V2 is unaware of which family had notified staff of R1's fall on 8/28/21 at 9:15pm, and V2 did not interview the family. V2 stated R2 was getting up to get ready for work and staff gave R2 a positioning pillow to help R2 from rolling out of bed, but there is no documentation R2 rolled out of bed, or documentation of interviews with staff regarding this fall on 8/28/21 at 9:15pm. 3. R3's Admission Record, dated 10/20/21, documents R3's diagnoses including [CONDITION(S)], Metabolic [CONDITION(S)], Heart Failure, Chronic [CONDITION(S)], History of [CONDITION(S)] (TIA), Repeated Falls, Sick [MEDICATION(S)] Syndrome, Ischemic [CONDITION(S)], Unsteadiness on Feet, Lack of Coordination and Cognitive Communication Deficit. R3's Minimum Data Set (MDS), dated [DATE], documents R3 requires extensive staff assistance for bed mobility, transfers and toileting. This MDS also documents R3 has a history of falls. R3's Fall Risk Data Collection assessment, dated 9/29/21, documents R3 is a risk for falls. R3's Occurrence Report documents R3 fell on [DATE] at 9:15am. This report/investigation documents R3 stated R3 was trying to get into bed when (R3's) feet started to slide, and R3 slipped down to R3's buttocks to the floor. There is no documentation in this investigation as to when R3 was assisted to the toilet, was visually observed, given fluids or food, repositioned or given medications. There is no documentation if R3's call light was within reach. This investigation documents R3 was wearing poorly fitting shoes and slipper socks. This investigation documents the root cause due to resident action or internal risk factors, but does not document details regarding the root cause of R3's fall. There is no documentation of witness statements from staff working that day or responsible for R3's care that day. R3's Occurrence Report documents R3 fell on [DATE] at 7:51pm. This report documents R3 had swelling/small localized bump to R3's right shin. R3 was found holding on to the rail in the bathroom when R3's knees started to buckle and R3's shin hit the wheelchair and V16, Licensed Practical Nurse (LPN) assisted R3 to the floor. R3 stated R3's knees buckled. This report documents a conclusion including R3 reported R3 was trying to go to the bathroom and R3's knees buckled. R3 was encouraged to use R3's call light and wait for assistance, with a root cause due to resident action or internal risk factors, with no specific root cause identified. On 10/20/21 at 1:00pm, V2, Director of Nursing (DON), stated R3's fall investigations are incomplete and do not identify a root cause specific to each fall, due to details of each fall not being investigated. The facility's Fall Prevention Policy (S.A.F.E.), dated February 2014, documents the definition as the S.A.F.E program promotes Safety Assessment, Fall prevention and Education of both staff and residents. This policy documents residents found to be at high risk for falls are placed on the S.A.F.E. program and specific interventions are implemented to meet individual needs. This policy documents following any falls, the facility staff completes an Occurrence Report. Details of the fall will be reported and potential causal factors identified and investigated. Interventions will be immediately implemented following each fall and the resident's care plan will be updated. All Occurrence Reports are reviewed at the daily meeting to ensure an intervention was immediately implemented, added to the plan of care and that the current intervention is appropriate. This policy also documents occurrences will be reviewed weekly at the facility's care management meeting to ensure the occurrence report is completely finished and closed and that interventions were implemented timely and to evaluate the outcome of the interventions. Revisions to the plan of care will be done if indicated.

Based on interview and record review, the facility failed to demonstrate timely effective actions to prevent and address a resident's significant change in condition for one of three residents (R1) reviewed for competent nursing staff in a sample of five. This failure resulted in R1 not receiving timely medical interventions or physician ordered laboratory work following symptoms of dehydration which included lethargy, not eating or drinking, and muscle twitching. These failures also resulted in R1 being sent emergently to the hospital where she was diagnosed with [REDACTED]. Findings include: A Significant Change Condition & Notification policy (undated) states that a significant change in a resident's condition includes change in level of consciousness such as lethargy, other abnormal findings, or a need to significantly alter treatment. According to an article from the National Institute of Health (Kim, 2006), [MEDICAL CONDITION] reflects a net water loss. This article further states, Severe symptoms are usually evident only with acute and large increases in plasma concentrations above ,[DATE] mmol/L (millimoles per liter). Importantly, the sensation of intense thirst that protects against severe [MEDICAL CONDITION] in health may be absent in patients with altered mental status, or in elderly people. This article also states that more serious signs of [MEDICAL CONDITION] include altered mental status and lethargy. R1's meal intake log, dated [DATE] to [DATE], documents R1 had no meal intake, which includes fluids, for 34 out of 43 meals. Of the remaining nine meals, R1 consumed ,[DATE]% (percent of a meal) five times, and ,[DATE]% of a meal four times. R1's Vital Signs Monitoring, dated [DATE] to [DATE], documents R1's blood pressure had usually ranged from ,[DATE] mmHg (millimeters of mercury) to ,[DATE]mmHg, however, on [DATE] to [DATE] R1's blood pressure was lower than usual and was documented as ,[DATE] mmHg, ,[DATE] mmHg, and ,[DATE] mmHg on those days. R1's nurse's note, dated [DATE], documented by V6 (Licensed Practical Nurse/LPN), documents R1 was noted to have, green discharge from vagina along with dark color urine with foul odor. This nurse's note also indicates R1's physician (V11) was notified regarding R1's urine with no new treatment orders received and that nursing staff will continue to monitor R1's dark colored and foul-smelling urine. R1's nurses' notes, dated [DATE] to [DATE], do not document any additional assessment of R1's urine or vaginal discharge until [DATE]. R1's nurse's note, dated [DATE] at 4:28p.m., and entered by V5 (LPN), documents, Writer faxed MD (V11) regarding lethargy and twitching on ,[DATE] and suggested labs and to run IV (Intravenous) fluids d/t (due to) s/s (signs and symptoms) of dehydration and MD only agreed to CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel). They will be drawn on [DATE]. A Non-Urgent Nursing Home Correspondence Fax sheet, dated [DATE], shows V5 sent a fax to V11's office on [DATE] at 10:21a.m., stating R1 was, lethargic and twitching often. She (R1) is not drinking much the past couple of days or eating d/t (Due to) lethargy. The section on the fax sheet where R1's vital signs could have been entered was blank. On this fax under nurse recommendations V5 wrote she recommended, labs and possible IV fluids. This fax further documents V11's office faxed back orders for R1 to have CBC and CMP lab work completed. R1's nurse's note, dated [DATE] at 7:30a.m., and entered by V5, documents, Res (R1) lethargic and unable to swallow medications. At 11:59p.m., R1's nurse's note documents, Resident (R1) remained lethargic and unable to wake up. No intake including meds (medications) given. MD aware, POA (Power of Attorney) aware. Labs being drawn in AM (morning). Awaiting results for orders. R1's medical record does not include a fax indicating R1's physician was notified that R1's symptoms of lethargy persisted, or R1 was unable to swallow medications and was unable to wake up. R1's nurse's note, dated [DATE] at 9:11a.m., entered by V6, documents, Aides told nurse resident (R1) felt warm and when nurse took res (R1) temp it was 101.5 (degrees Fahrenheit), res was very lethargic and still having green vaginal discharge along with (altered mental status). MD notified UA (urinalysis) ordered and CBC/CMP done this AM awaiting results. At 11:28a.m., V6 documented, (V12, V11's nurse) called from (V11) office, wanted to know what was going on with resident, nurse let her know that she (R1) had a fever of 101.5 (F) and was very lethargic. V12 asked nurse to get blood sugar of resident, bs (blood sugar) was 181-V12 then asked if resident had been voiding and nurse let her know she (R1) has been dry since she (V6) got on shift today, V12 informed nurse that she has results from labs and resident had high sodium levels and was [MEDICAL CONDITION] and to go ahead and send her out. On [DATE] at 10:06a.m. and at 2:00p.m., V5 (LPN) stated she was R1's nurse on the 6:00a.m to 6:00p.m. shift on [DATE]. V5 stated R1 had a significant change in her condition. V5 stated on that date, R1 was lethargic and was having muscle twitching. V5 stated R1's lethargy and muscle twitching can be the result of dehydration. V5 stated, It was obvious she was dehydrated because of the lethargy and twitching. V5 stated the nursing staff tried to get R1 to drink fluids but R1 refused. V5 stated R1's condition change was serious enough that she notified V11, R1's physician. V5 stated she did not call V11 but instead notified V11's office by fax. V5 stated V11's office sent a return fax with orders to have the lab draw a complete blood count and a comprehensive metabolic panel for R1. V5 stated she didn't think the orders meant the labs needed to be drawn immediately so she entered them into the computer for the next scheduled lab technician visit which was for [DATE]. V5 stated the fax she sent to V1's office on [DATE] was the only communication V5 had with V11's office. On [DATE] at 10:31a.m., V6 stated she starts work at 6:00a.m. for the day shift. V6 stated she was R1's nurse on [DATE] when she noted R1 had a green discharge from her vaginal area and that her urine appeared darker than usual and with a foul odor. V6 stated since R1 did not have other symptoms of a Urinary Tract Infection such as a fever, V11 did not order a Urinalysis, but instead, instructed V6 to encourage R1 to drink more fluids. V6 stated on [DATE], V6 worked the day shift as R1's nurse after having been off work for several days. V6 stated when she began her shift, R1's condition was different than usual. V5 stated normally R1 did not stay in bed and was more active, however, on [DATE], R1 was in bed, lethargic, had a temperature, and the CNA staff reported to her R1 had not had any urine output in her incontinence brief. V6 stated she knew R1 was scheduled for labs that morning plus she sent a fax to V11's office detailing R1's symptoms. V6 stated she also knew she needed to send R1 to the hospital, but waited for V11's office to respond. V6 stated V11's office responded they had received R1's lab results and R1's sodium was abnormal, and she should be sent to the emergency room for evaluation and treatment. R1's laboratory (lab) report, dated [DATE], documents that R1's White Blood Cell Count (WBC) was 23/mcL (microliters). This same lab report documents a normal WBC is no greater than 11mcL. This report also documents that R1's Sodium was 177 mmol/L (millimoles per liter) which is categorized as High Panic. This report indicates the normal range for sodium is ,[DATE]mmol/L. In addition, R1's BUN (Blood Urea Nitrogen) was 94ml/dl (milligrams per deciliter) with normal range being ,[DATE]mg/dl, blood creatinine was 2.30mg/dl with the normal range being 0XXX,[DATE].10 mg/dl. R1's hospital Physician's progress notes, dated [DATE], documents R1 presented to the hospital on [DATE] with altered mental status, severe [MEDICAL CONDITION], acute kidney injury, and severe dehydration which required IV fluids and IV antibiotics. This same progress note documents R1's prognoses was considered poor. R1's hospital physician discharge summary note, dated [DATE], documents R1 was admitted to the hospital for altered mental status. This same progress note documents that R1, was severely dehydrated on presentation with [MEDICAL CONDITION]. In addition, this progress note documents R1 was also admitted with right lower lobe Pneumonia, a small Subarachnoid Hemorrhage, and Acute Kidney Failure. This progress note further documents R1 was placed on hospice comfort care and was deceased on [DATE]. R1's death certificate, dated [DATE], documents R1 was deceased on [DATE] from a Cardiopulmonary Arrest due to Pneumonia, [MEDICAL CONDITION], Intracranial Bleed, and Severe Dementia. On [DATE] at 11:16a.m., 12:17p.m., 1:50p.m., 2:30p.m., V2 (Director of Nurses) stated V5 did not notify her on [DATE] that R1 had a change in condition with symptoms of lethargy, muscle twitching, and was not drinking any fluids. V2 stated this was a serious situation. V2 stated V5 should have asked V11 if R1's CBC and CMP should be ordered stat instead of V5 placing the order for R1's lab draw on the next schedule lab day, which was [DATE]. V2 stated if she had been R1's nurse on [DATE] when R1 developed lethargy and muscle twitching, she would have called V11 to ask for stat labs and she would have also called 911 to send R1 to the emergency room because R1's symptoms could have indicated severe dehydration. On [DATE] at 10:05a.m., V11 stated he was R1's physician. V11 stated he expects the facility to call him when residents have a change in condition instead of sending a non-urgent fax. V11 stated when his office ordered for R1 to have the CBC and CMP to be drawn when R1 was exhibiting the symptoms of lethargy and twitching, he would have expected V5 to order those labs for that day and not for two days later. V11 stated when R1's symptoms persisted into the next day, [DATE], he would have expected the facility to notify him that R1's symptoms had not improved. V11 stated he would have expected nursing staff to report R1's abnormal blood pressures such as those on [DATE]-[DATE]. V11 stated facility nursing staff should monitor residents for changes in blood pressure, poor food and fluid intake, over what time frame and then report those details when reporting changes in residents' condition. V11 stated if R1's labs had been drawn as ordered on [DATE], or if R1's persistent symptoms had been reported on [DATE], R1's significant change in condition could have been treated sooner.

Failures identified required more than one deficient practice statement. A.) Based on observation, interview, and record review, the facility failed to follow facility policy and local health department guidance to designate staff to work on the COVID-19 (human coronavirus infection) unit, and restrict employees with COVID-19 symptoms from working and exposing residents to infection. This failure resulted in all 39 residents residing in the facility being unnecessarily exposed to an infectious disease. The facility failed to follow facility policy and local health department guidance to promptly separate COVID-19 symptomatic residents away from non-infected residents for two of 40 residents (R1 and R4) reviewed for infection control in the sample of 41 residents. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 10/24/20 , the facility remained out of compliance at a severity level two. The facility is in the process of re-educating key management personnel and direct care staff regarding appropriate COVID-19 infection control measures. Findings include: The facility's Action Plan - Covid-19 policy, dated 9/24/20, documents the transition (isolation) unit is utilized for residents who are: newly admitted or readmitted to the facility; who have new onset of fever greater than 100 degrees Fahrenheit or respiratory/COVID-19 symptoms but have not tested positive for COVID-19; or had roommates that were transferred to the transition or recovery units. This policy documents the facility's recovery unit will be utilized for residents who have tested positive for COVID-19. This policy documents residents who have a new onset of fever of greater than 100 degrees Fahrenheit or respiratory COVID-19 symptoms who have not tested positive for COVID-19, will be immediately transferred to the transition unit, immediately tested for COVID-19, placed on droplet precautions with isolation setup including gowns, face masks, face shield or goggles, and recommends the use of an N95 mask or higher level respirator. This policy documents residents who reside on the transition and recovery units should have vital signs taken every shift and oxygen saturations taken every 4 hours. This policy documents the facility will have a plan to designate consistent staffing on the transition and recovery units. This policy documents employees should stay home if they are feeling ill and employees will be screened for symptoms prior to each shift. This policy documents, If an employee experiences any of the following symptoms, then they are to notify their supervisor, immediately leave the community and obtain onsite COVID-19 testing if resources are available. 1. Fever (Greater than 100 degrees Fahrenheit) or chills 2. Cough 3. Shortness of breath or difficulty breathing 4. Fatigue 5. Muscle or body aches 6. Headache 7. New loss of taste or smell 8. Sore throat 9. Congestion or runny nose 10. Nausea or vomiting 11. Diarrhea. a.)1.) On 10/19/20 at 12:47 PM, V5, Certified Nursing Assistant (CNA), was working the 100 and Lotus units. V5 stated V5 is currently assigned to work the Lotus and 100 units, and V5 has also worked on the 200 unit (where COVID-19 positive residents reside.) On 10/19/20 at 1:30 PM, V7, Licensed Practical Nurse (LPN), stated a nurse is assigned to work on the 200 unit, but that nurse has to come out of the unit to the nurses' station (located between Lotus and 100 units) to use the phone and fax machine. V7 stated the facility does not have designated staff to work on the 200 unit. V7 stated last week V5, CNA, worked on the 200 unit, and today V5 is working the Lotus and 100 units. On 10/19/20 at 2:00 PM, V10, Licensed Practical Nurse (LPN), was working the 200 unit. V10 stated V10 was tested for COVID-19 and V10 had symptoms of a cough and sore throat on 10/9/20. V10 stated V10 worked at the facility on 10/9, and V10 had reported V10's symptoms on the employee symptom screening form and to V1, Administrator. V10 stated V1 told V10 since V10 did not have a fever V10 could continue to work. V10 stated V10 continued to work until V10 received V10's COVID-19 positive test results 6 days later. V10 stated V10 had worked on all 3 of the units within the facility, providing direct resident care (for COVID-19 positive and susceptible residents), after V10 developed symptoms on 10/9. The facility's Census, dated 10/9/20, documents COVID-19 positive residents R3, R8-R17, R31, and COVID-19 negative resident R32 resided on the 200 unit. The facility's Census, dated 10/10/20, documents COVID-19 negative residents R1, R2, R4-R7, R19, R21-R30, R34-R41 resided on the 100 and Lotus units. The facility's Census, dated 10/10/20 and 10/13/20, document R3, R8-R18, R20, R31, and R32 resided on the 200 unit. The facility's Census, dated 10/15/20, documents COVID-19 positive residents R3, R6, R8-R18, and R20-R23 resided on the 200 unit. V10, LPN's Employee Screening Tool/Health Assessment,, dated 10/9/20 documents V10 answered yes to experiencing a new onset of cough and sore throat. This assessment documents a handwritten note that V2, Director of Nursing (DON), found V10 appropriate to work and V10 should contact V2 if V10's symptom's worsened. V10's COVID-19 test, with a collection date 10/9/20 and test date 10/14/20, documents V10 tested positive for COVID-19. V5's COVID-19 test, with a collection date 10/19/20 and test date 10/20/20, documents V5 tested positive for COVID-19. The facility's Nursing and CNA schedules document V10, LPN, worked on 10/9 on the 200 unit and 10/10/20. The schedules document V5, CNA, worked on 10/10 6:00 AM to 2:00 PM on the 200 unit, 2:00 PM to 6:00 PM on the 100/Lotus units, 10/11, 10/16, 10/19, and 10/20 on the 100/Lotus units, 10/13, and 10/15 on the 200 unit. R38's COVID-19 Daily Resident Screening, dated 10/10/20 at 6:28 PM, documents the screening was completed by V10, LPN, (indicating V10 worked on the 100 and Lotus units on 10/10/20.) The facility's October 2020 Infection Control Logs document 18 residents and 7 employees have tested positive for COVID-19. These logs document V5, CNA, had symptoms of nausea/vomiting, cough, and body aches on 10/20/20, and V10, LPN, had symptoms of cough and sore throat on 10/9/20. R18's COVID-19 test, dated 10/5/20, documents R18 tested positive for COVID-19. R11-R17's COVID-19 tests, with a collection date of 10/6 and test date of 10/8/20, document R11-R17 tested positive for COVID-19. R3, R6, R8-R10's, and R19's COVID-19 tests, with a collection date of 10/6 and test date of 10/7/20, document R3, and R8-R10 tested positive, and R6, R19, and R24 tested negative for COVID-19. R21-R23's COVID-19 tests, with a collection date 10/6 and test date of 10/8/20, document R21-R23 were negative for COVID-19. R4's, R6's, R19-R22's, R24's, and R32's COVID-19 tests, with a collection date 10/12 and test date 10/14/20, document R6, R19-R22 tested positive, and R4, and R24 tested negative for COVID-19. R32's COVID-19 test collected on 10/8 documents R32 was negative for COVID-19. R24's COVID-19 test, dated 10/18/20, documents R24 tested positive for COVID-19. R32's and R4's COVID-19 tests, with a collection date 10/19 and report date 10/20/20, document R32 and R4 tested positive for COVID-19. On 10/19/20 at 12:28 PM, V1, Administrator, stated the facility currently has 17 residents residing in the facility who have tested positive for COVID-19, and R24 had went to the hospital on [DATE] and tested positive for COVID-19. On 10/20/20 at 2:35 PM, V3, Corporate Registered Nurse, stated all residents were tested on ,[DATE] and by 10/8 the facility received positive COVID-19 test results for R3 and R8-R17. V3 stated R18 had tested positive after being sent to the hospital on [DATE], and on 10/14/20 R6 and R19-R23 tested positive for COVID-19. V3 confirmed V10, LPN, and V5, CNA, have worked on all units in the facility, providing direct resident care, and stated the facility has had to utilize staff to cover call offs. V3 stated V5, CNA, worked day shift on 10/20/20 and developed COVID-19 symptoms after the start of V5's shift and was sent home. On 10/20/20 at 3:18 PM V1, Administrator, stated V2, Director of Nursing (DON), had approved V10, LPN, to work on 10/9/20 with a cough and sore throat. V1 stated at that time we were all wearing full PPE (Personal Protective Equipment) and if V10 had a fever we would have sent V10 home. V2 told V10 to report back to V2 if V10's symptoms worsened. V1 confirmed V10 worked in the facility on 10/10/20, providing direct resident care. On 10/21/20 at 3:46 PM, V2, DON, stated it was reported to V2 that V10 had a new onset of cough and sore throat at the beginning of V10's shift on 10/9/20. V2 stated V10 did not have a fever, so V2 told V10 to wear full PPE and report back to V2 if V10's symptoms worsened. V2 confirmed V10 also worked on 10/10/20. V2 stated staff are not allowed to work if they have a fever or their symptoms are bad, and it is cold season. On 10/21/20 at 8:06 AM, V14, Supervising Nurse County Health Departmen,t stated V14 has been providing CDC (Centers for Disease Control and Prevention) and IDPH (Illinois Department of Public Health) written guidance updates on COVID-19 to the facility regularly. V14 stated the facility should not allow a staff person who has a cough and sore throat to work, since those symptoms can be symptoms of COVID-19. V14 stated the facility should have designated staff who work only on the COVID-19 positive units, and they should not have staff working on the positive unit and then later caring for residents who are asymptomatic. On 10/21/20 at 11:12 AM, V1 stated rooms [ROOM NUMBERS] were the designated COVID-19 positive rooms, and Lotus Unit and the first 6 rooms of 200: 201, 202, 203, 213, 214, and 215 were the transition rooms until 10/7/20. V1 stated on 10/14/20 the facility extended the entire 200 unit to be the designated unit for COVID-19 positive residents, and Lotus unit (rooms 143-148) and rooms 105-111 became the transition rooms. V1 stated V1 received COVID-19 positive test results on 10/20/20 for R32, R4, V6, Maintenance Supervisor, V5, CNA, and V15, Housekeeper. V1 stated the facility tries to have the same staff stay on the Lotus unit, but they do cross over to help on the 100 unit if needed. V1 stated V10, LPN, had came in to cover a call off on 10/10/20, and confirmed V10 worked on the 100 and Lotus units after working with COVID-19 symptoms on the 200 unit on 10/9/20. V1 confirmed the facility's schedule documents V5, CNA, worked 10/10 6:00 AM to 2:00 PM on the 200 unit, 2:00 PM to 6:00 PM on the 100/Lotus units, 10/11, 10/16, 10/19, and 10/20 on the 100/Lotus units, 10/13, and 10/15 on the 200 unit. V1 stated, Ideally we want staff to work on the recovery unit, but we have had call offs and have needed to fill the shifts on the other units. a.)2.) On 10/19/20 at 1:44 PM, R1 and R4 were sharing a room. Their room was not located on the transition unit, but located in an area of the building where non-infected susceptible residents reside. R4's COVID-19 Daily Resident Screening ,dated 10/19/20 at 9:38 AM, documents R4 had a runny nose and R4 complained of congestion. R4's COVID-19 Daily Resident Screening, dated 10/18/20 at 9:59 AM, documents R4 had a cough. R4's Progress Note, dated 10/16/20 at 3:02 AM, by V16, Registered Nurse, documents R4 had complaints of mild shortness of breath and V16 noted crackles to R4's left lower lung. R4's COVID-19 test, with a collection date of 10/12 and test date 10/14/20, documents R4 tested negative for COVID-19. R4's COVID-19 test, with a collection date 10/19 and report date 10/20/20, document R4 tested positive for COVID-19. R1's Census, dated 10/20/20, and R4's Census, dated 10/21/20, documents R1 and R4 resided in the same room from 10/1 until 10/20/20. R1's Admission Record, dated 10/20/20, documents R1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's medical record documents R1 had no observed or reported respiratory during this period of time. R1's COVID-19 test wi,th a collection date 10/14 and test date 10/17/20, documents R1 was negative for COVID-19. On 10/20/20 at 2:35 PM, V3, Corporate Registered Nurse, stated if a resident has respiratory symptoms or COVID-19 symptoms, the resident should be moved to the transition unit. On 10/21/20 at 3:46 PM, V2, DON, stated resident COVID-19 symptom monitoring and vital signs should be done every shift, and if a resident has any respiratory or COVID-19 symptoms they should be moved to the transition unit. V2 stated V2 was not aware that R4 was having symptoms of a runny nose, cough, or shortness of breath. V2 confirmed R4 should have been moved to the transition unit when R4 began having respiratory symptoms. On 10/21/20 at 8:06 AM, V14, Supervising Nurse County Health Department ,stated V14 has been providing CDC (Centers for Disease Control and Prevention) and IDPH (Illinois Department of Public Health) written guidance updates on COVID-19 to the facility regularly. V14 stated if a resident has symptoms of COVID-19 such as a cough, runny nose, or shortness of breath, the resident should be transferred to the transition unit and placed on Transmission Based Precautions. On 10/21/20 at 11:12 AM, V1 confirmed R4 (R2's roommate) was not moved to the transition unit until 10/20/20 when the facility received R4's COVID-19 positive test result. When V1 was asked why R4 was not moved to the transition unit prior to 10/2020, V1 stated V1 was not aware that R4 was having respiratory symptoms prior to receiving R4's test results. The facility's Resident List Report, dated 10/19/20, documents 39 residents reside in the facility. An Immediate Jeopardy situation was identified on 10/21/20. The Immediate Jeopardy was identified to have begun on 10/9/20 when the facility allowed V10, LPN, to work in the facility with symptoms of COVID-19 infection thereby exposing multiple staff and residents on multiple units to COVID-19 infection. On 10/23/20 at 11:58 AM, V1 was notified of the Immediate Jeopardy situation. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: 1.) On 10/26/20 at 12:30 PM, V11, Regional Corporate Nurse, confirmed the facility held a Quality Assurance Performance Improvement meeting and developed a Performance Improvement Plan on 10/20 and 10/23/20 to develop an abatement plan. 2.) On 10/26/20 at 12:15 PM, V1 confirmed licensed nurses and department managers were re-educated on 10/20 through 10/24-20 on the screening questionnaire tool sheet, notifying V1 and V2 of any symptomatic screening tool findings, and staff with possible symptoms will not be allowed to work. 3.) On 10/26/20 at 12:15 PM, V1 confirmed facility staff have received re-education on 10/20 to 10/24/20 to report any symptomatic screening concerns to V1 and V2 immediately prior to or during their shift, the facility will not allow any staff member or visitor to enter the building with a fever greater than 100.0 degrees Fahrenheit or with other reported infectious symptoms. 4.) On 10/26/20 at 12:15 PM, V1 confirmed licensed staff have been re-educated on 10/20 to 10/24-20 to notify the physician, V1, and V2 when possible COVID-19 symptoms are present, and the symptomatic resident should be moved to the transition unit. The remaining 7 staff who had not received training were removed from the work schedule and would not return to work until they have received the education and training. 5.) On 10/26/20 at 10:53 AM, ,V1 confirmed V1 and V2 received education from V11 on 10/23/20 that the facility will designate staff to the COVID-19 unit. 6.) On 10/26/20 at 12:10 PM, V11 confirmed V11 audits of staff screening tools were completed from 10/24 to 10/26/20 to ensure staff were being appropriately screened and appropriate protocols were followed. 7.) On 10/26/20 at 12:15 PM, V1 confirmed V1 completed reviews of the staff schedule from 10/24 to 10/25/20 to ensure designated staff are assigned to work on the COVID-19 unit. 8.) On 10/26/20 at 1:58 PM, V11 confirmed audits of resident COVID-19 screenings were conducted daily from 10/20 to 10/26/20 to review if COVID-19 symptoms were present, and ensure the physician, V1, and V2 were notified, and the resident was moved to the transition unit and tested per facility policy. V11 stated R35's COVID-19 assessment on 10/23/20 documented R35 had a cough. V11 stated R35's symptoms were not identified until the audit on 10/24/20 due to R35's COVID-19 assessment on 10/23/20 was not uploaded into R35's medical record at the time of the audit on 10/23/20. V11 stated R35 was not moved to the transition unit until 10/24/20. B. Based on observation, interview, and record review, the facility staff failed to wear appropriate Personal Protective Equipment (PPE) and remove PPE, failed to complete COVID-19 symptom monitoring and obtain vital signs per facility policy, and update Care Plans to include Transmission Based Precautions for five of 41 residents (R1-R5) reviewed for infection control in the sample of 41. Findings include: The facility's Action Plan - Covid-19 policy, dated 9/24/20, documents the transition (isolation) unit is utilized for residents who are: newly admitted or readmitted to the facility; who have new onset of fever greater than 100 degrees Fahrenheit or respiratory/COVID-19 symptoms but have not tested positive for COVID-19; or had roommates that were transferred to the transition or recovery units. This policy documents the facility's recovery unit will be utilized for residents who have tested positive for COVID-19. This policy documents residents who have a new onset of fever of greater than 100 degrees Fahrenheit or respiratory COVID-19 symptoms who have not tested positive for COVID-19, will be immediately transferred to the transition unit, immediately tested for COVID-19, placed on droplet precautions with isolation setup including gowns, face masks, face shield or goggles, and recommends the use of an N95 mask or higher level respirator. This policy documents residents who reside on the transition and recovery units should have vital signs taken every shift and oxygen saturations taken every 4 hours. b.)1.) On 10/19/20 at 12:47 PM, V5, Certified Nursing Assistant (CNA) was working on the Lotus and 100 units. V5 stated an N95 mask, face shield, and isolation gown are worn into non-isolation resident rooms, and V5 stated isolation gowns are not changed between entering and leaving the rooms. V5 stated the residents who reside on the transition unit (Lotus) have an isolation gown hanging in their room for staff to wear upon entering the isolation room. V5 stated the gown is shared between staff and it is applied over top of the gown V5 was currently wearing. V5 stated the gown should be hung back up in the isolation room upon leaving the room. On 10/19/20 at 1:05 PM, V8, Housekeeping Supervisor, was working on the 100 and Lotus units. V8 was wearing goggles and a cloth mask. V8 stated V8 had tested positive for COVID-19 on 10/8 and had been off of work for ten days. On 10/19/20 at 1:08 PM, V9, CNA, was working the 100 and Lotus units. V9 was wearing a surgical mask, face shield, and isolation gown. V9 stated V9 is not able to wear an N95 mask since V9 has Asthma. V9 stated V9 wears a face shield, surgical mask, and isolation gown to enter rooms on the 100 and Lotus units. V9 stated gowns are changed at the end of the shift, and isolation rooms have gowns hanging in the room to put over top of the gowns we are wearing in the hallway. V9 stated gloves and gowns should be removed prior to leaving isolation rooms. On 10/19/20 at 1:16 PM, Isolation carts were located outside of rooms 143-148 on the Lotus unit. There were signs posted on the doorways to the resident rooms documenting droplet precautions. On 10/19/20 between 12:47 PM and 1:44 PM, V5, V9, CNAs, and V7, Licensed Practical Nurse (LPN) were observed entering resident rooms located on the 100 and Lotus units. On 10/19/20 at 1:19 PM, R5 was lying on the floor in R5's room. V5 and V7 entered R5's room. V7 was wearing a gown (that was worn in the hallway), surgical mask, and goggles. V7 was wearing a face shield, N95 and surgical mask, and gown (that was worn in the hallway.) V7 did not apply gloves, and neither V5 nor V7 applied a clean gown to enter R5's room. There is a sign on R5's door documenting R5 is on droplet precautions. At 1:28 PM, V5 and V7 were observed leaving R5's room. V5 and V7 did not remove their gowns upon leaving R5's room. At 1:30 PM, V7 was sitting at the nurses' station wearing the same gown that was worn into R5's room. V7 stated a gown, N95 and surgical mask, face shield and gloves are to be worn when entering resident rooms on the Lotus unit, and gloves and gowns should be changed between each resident room. V7 confirmed V5 and V7 did not apply a clean gown when V5 and V7 entered R5's room, or remove their gowns when V5 and V7 left R5's room. V7 confirmed V7 did not wear gloves in R5's room, and R5's room did not contain an isolation gown or gloves. V7 stated, The gown I'm wearing now is the same one I wore into (R5's) room. On 10/19/20 at 2:00 PM, V10, LPN, was working on the 200 unit of the facility. V10 was wearing a surgical mask (not an N95 mask), goggles, and an isolation gown. V10 stated staff are to wear N95 masks and surgical masks overtop of the N95 when entering COVID-19 positive rooms. V10 stated V10 is wearing a surgical mask since V10 had previously tested positive for COVID-19. On 10/19/20, between 1:57 PM and 2:40 PM, V10 was observed entering resident rooms on the 200 unit. On 10/20/20 at 2:35 PM, V3, Corporate Registered Nurse, stated staff should wear N95 masks, face shield/goggles, gloves, and gown into resident rooms on the transition unit. V3 stated gowns should be changed upon leaving the transition unit. V3 stated there are hooks located in the isolation rooms for staff to hang their gowns on upon leaving the room. V3 stated surgical masks should be worn by all non-direct care staff, and N95 masks by direct care staff when there are COVID-19 positive cases in the building. V3 stated V3 saw that V8 was wearing a cloth mask and reported V8 to V1. V3 stated staff working on the COVID-19 positive unit (200 unit) should be wearing N95 masks. On 10/21/20 at 8:06 AM, V14, Supervising Nurse County Health Department, stated V14 has provided written COVID-19 guidance and updates from the CDC and IDPH to the facility regularly. V14 stated the facility's staff should not be working and providing direct care on both the transition unit and asymptomatic unit unless they are changing their PPE prior to leaving the transition unit (Lotus) and caring for residents on the asymptomatic (100) unit. V14 stated gown and gloves should be changed upon leaving the isolation rooms. V14 stated all staff should be wearing a surgical mask while in the building, and if staff are caring for residents the staff should be wearing an N95 mask. The facility's Resident Roster, dated 10/19/20, documents 39 residents reside in the facility. b.)2.) On 10/19/20 at 1:44 PM, R1 and R4 were sharing a room on the 100 unit. On 10/19/20 between 1:16 PM and 1:19 PM, R2 was in R2's room located on the Lotus (transition) unit. There was a sign on R2's door indicating R2 was on droplet precautions. R2 was wearing oxygen. On 10/19/20 at 2:15 PM, R3 was in R3's room located on the 200 unit. R1-R4's Order Summary Reports, dated 10/21/20, document R1-R4 have an order to obtain vital signs every shift for COVID-19 screening There is no documentation in R1's medical record that R1's vital signs and pulse oximetry were obtained on 10/14 first shift, 10/4, 10/6, 10/7, 10/8, 10/11, 10/13 second and third shifts, 10/10 first and third shifts, and all three shifts on 9/30-10/3, 10/5, and 10/9. There is no documentation in R1's medical record that R1 was assessed for COVID-19 symptoms on first shift on 10/1-10/3, 10/5, 10/7-10/11, 10/16; second shift on 9/30-10/9, and 10/16; and third shift on 9/29-10/10 and 10/13/20. There is no documentation in R2's medical record that R2's vitals signs and pulse oximetry were obtained on all three shifts on 9/29, 9/30, 10/5, 10/7, and 10/9; second and third shifts on 10/1, 10/2, 10/4, 10/6, 10/8, 10/11, 10/13; first and third shifts on 10/10; and first shift on 10/14. There is no documentation in R2's medical record that R2 was assess for COVID-19 symptoms on first shift on 9/29, 9/30, 10/3, and 10/5-10/11; second shift on 9/29-10/9, 10/13, and 10/16; and third shift on 9/29-10/10, 10/13, and 10/18/20. There is no documentation in R3's medical record that R3's vital signs and pulse oximetry were obtained on third shift on 10/13, 10/14; second and third shifts on 10/2, 10/6, 10/8, 10/10, 10/11, 10/12; and all three shifts on 9/29, 9/30, 10/1, 10/3, 10/7, and 10/9/20. There is no documentation in R3's medical record that R3 was assessed for COVID-19 symptoms on first shift on 10/3, 10/5, 10/7-10/9, and 10/12; second shift 10/2-10/12; third shift on 10/2-10/13/20; and all three shifts from 9/4-10/1/20. There is no documentation in R4's medical record that R4's vital signs and pulse oximetry were obtained on second and third shifts on 10/2, 10/4-10/9, 10/11, 10/13; first and third shift on 10/10; and 9/29 first shift through third shift on 9/30. There is no documentation in R4's medical record that R4 was assessed for COVID-19 symptoms on first shift 9/29, 9/30, 10/3, 10/5, 10/7-10/11; second shift on 9/29-10/9, 10/13, 10/16; third shift 9/29-10/10 and 10/13/20. On 10/19/20 at 1:30 PM V7, LPN, stated resident COVID-19 symptom monitoring and vital signs, including temperature and pulse oximetry, are completed once per shift. On 10/20/20 at 3:46 PM, V2, Director of Nursing, stated residents should have COVID-19 symptom screening and vital signs completed every shift. On 10/22/20 at 10:05 AM, V1, Administrator, confirmed R1-R4 were missing documentation of vital signs and COVID-19 symptom monitoring. V1 stated V1 had no additional documentation of vital signs or COVID-19 symptom monitoring for R1-R4 to provide. b.)3.) On 10/19/20 between 1:16 PM and 1:19 PM, R2 and R5's rooms were located on the Lotus (transition) unit. There were signs on R2's and R5's doors indicating R2 and R5 were on droplet precautions. R2's Census, dated 10/20/20, documents R2 has resided on the transition unit since 10/8/20. There is no documentation in R2's Care Plan, with a revision date of 9/8/20, that R2 is on transmission based precautions. R5's Census, dated 10/20/20, documents R5 has resided on the transition unit since 10/8/20. There is no documentation in R5's Care Plan, with a revision date of 10/20/20, that R5 is on transmission based precautions. On 10/20/20 at 3:18 PM, V1 stated care plans should be updated to include transmission based precautions. V1 confirmed R2's and R5's care plans did not include transmission based precautions.

Based on interview and record review, the facility failed to assess an existing Stage III pressure ulcer and failed to implement individualized, resident specific interventions for one resident (R1) of three residents reviewed for wounds in a sample of 15 residents. As a result of this failure, R1's existing Stage III pressure ulcer became significantly worse (Stage IV with visible muscle and bone), and R1 developed a new, facility acquired, unstageable pressure ulcer on his left heel. Findings include: R1's Care Plan, last updated 6/7/20, includes the following Diagnoses: [REDACTED]. R1's wound Care Plan, last updated 6/7/20, documents The resident has potential/actual impairment to skin integrity related to debridement of coccyx wound, immobility, dependent on staff for repositioning. A problem is documented on 6/7/2020: Stage 1 blister left heel. This description includes a blister which would indicate at least a Stage II as per current standard of practice. Wound clinic documentation, dated 6/17/20, documents this wound as unstageable. R1's Care Plan includes the following generic interventions: Wound clinic as ordered. Date Initiated: 06/09/2020 Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Date Initiated: 03/04/2020 Follow facility protocols for treatment of [REDACTED]. to MD (medical doctor). Date Initiated: 03/04/2020 The resident needs pressure relieving/reducing mattress, pillows to protect the skin while in bed. Date Initiated: 03/04/2020 The resident needs pressure relieving/reducing cushion to protect the skin while up in chair. Date Initiated: 03/04/2020 Revision on: 06/07/2020 The resident needs protective heel boots Date Initiated: 06/07/2020 Wound vac (vacuum) as ordered Date Initiated: 06/09/2020. R1's Care Plan includes no additional interventions. R1's progress note, dated 3/3/20 at 4:02pm, documents that R1 was admitted on [DATE]. At that time, R1's skin assessment documents R1 as high risk for breakdown. The facility's Nursing Admission/Readmission Data Collection, dated 3/3/20, documents R1 was admitted with a stage III Pressure Ulcer measuring 6x3x3.5 centimeters (Length x Width x Depth) to his sacrum. There is no assessment of the appearance of the wound or whether there is any drainage from the wound or any odor. No wound assessment is documented until 3/5/20 at 2:08pm. No wound treatment is documented on Treatment Administration Sheet as completed until evening shift on 3/5/20. Wound Assessment on 3/5/20 at 2:08 pm, documents the measurements of R1's pressure ulcer on Sacrum as 6x4x1.5 centimeters (cm.) (length x Width x Depth). At that time a treatment order is received from physician and initiated for: Cleanse wound with normal saline, apply alginate to wound bed, and cover with foam border dressing. On 3/31/20, the wound assessment states the wound measures 3x2.5x2.5cm. A dressing is signed off the treatment sheet as done daily beginning 3/5/20. The wound is not assessed except for weekly wound sheets. On 4/21/20, even though the wound was improving at this point, the wound care order is changed to: Cleanse wound, apply Santyl ointment to wound bed, cover with Dakin's solution and dry dressing. Although the wound treatment is signed off on the treatment sheet as done daily, no assessment of the wound is completed except for the weekly wound tracking. On 5/20/20, R1 was seen by the local hospital wound clinic. The wound clinic documents the sacral wound measurements are 10 x 8 x 5.5 centimeters with 34%to 66% necrosis (eschar) and exposed muscle. At that visit, a [DEVICE] was ordered. The [DEVICE] is documented as placed on 5/21/20, at 125 millimeters of suction. At that time, the wound clinic ordered Low air loss mattress, inflatable cushion for wheelchair, turn and position every two hours, and float heels off bed and chair. However, R1's care plan was not personalized to include these interventions, and it is not documented whether they were initiated or not. From the time the [DEVICE] was placed, until 6/12/20 when R1 went for a surgical debridement of the sacral wound, there is no documentation of the appearance of the wound, how much drainage the [DEVICE] is collecting, or whether the wound vac is even functioning. On 6/7/20, the heel wound was documented on R1's progress notes. On 6/10/20, the wound clinic documented the wound on R1's Coccyx measured 10 x 9. x 5.9 centimeters, with exposed muscle and bone, had foul odor and 67-100% necrosis . On 6/10/20, the wound clinic documented the facility acquired heel wound had progressed to 4.5 x 5.5 x 0.1 and was documented at unstageable. On 6/17/20, the wound clinic documents the wound to R1's sacrum has increased to 11 x 14 x 5 centimeters following surgical debridement. On 8/5/20 V2, Director of Nursing (DON), verbalized R22, Registered Nurse (RN) former wound nurse, had been responsible for wound care until he ended his employment with the facility recently. The facility did not know how to contact R22. V2 stated, I thought he was doing a good job of wound care and documentation until I discovered his documentation was not up to my standards. I agree that there should have been better wound documentation. I realize our care plans aren't what they should be, and I am working with corporate to improve that. R1 was hospitalized during the onsite portion of this survey. On 8/5/20 at 12:45am, V20, Wound Care Nurse Manager at the wound clinic caring for R1's wound, verbalized that in her opinion R1 was not being off loaded as recommended related to the rapid deterioration of the sacral wound and the development of the unstageable heel wound. V20 stated, It's really sad. (R1) was positive and kidded around with us when he first came to us. But the last few times I've seen him, he just hangs his head and cries. I think there was some issue at the facility with the function of the [DEVICE]. I remember (V22) the wound nurse talking to us about having to get a replacement pump. On 8/5/20, V21, Wound Care Medical Doctor, stated, They (the facility) didn't take very good care of (R1). I can say that if (the facility) had followed the wound care recommendation that I made (R1's) sacral (Coccyx) wound would not have deteriorated as rapidly as it did, and if (the facility) had floated (R1's) heels on a low air loss mattress he would not have developed the second pressure area on his heel.

Based on interview and record review the facility failed to provide incontinence care to meet the needs of one of three residents (R1) reviewed for incontinence care on the sample of seven residents. This failure resulted in R1 expressing feelings of shame, sorow, embarrassment and abandonment. Findings include: R1's Physician order [REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] documents R1 is cognitively intact and requires the extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. The MDS documents that R1 is at risk for pressure ulcers and is continent of bowel and occasionally incontinent of urine. R1's Pressure Ulcer Wound Evaluation dated 8/8/16 documented an acquired pinpoint Stage I pressure ulcer on R1's Sacrum measuring 0.1 centimeters (cm, Length) x 0.1 cm (width) x 0.0 cm (depth) with [MEDICATION NAME] Tissue Present (pink). The wound evaluation documents 8/8/16 as the date of clinician notification. On 8/8/16 at 9:00 am R1 stated R1 had not received toileting one night (8/5/16) and that R1 was wet and clothes were wet. R1 stated R1 had not received care until the night shift came on. R1 stated that E22, Certified Nursing Assistant (CNA), had helped R1. R1 stated R1 had been wet for a long time. On 8/10/16 at 3:36 pm E22, CNA, stated that E22 works the night shift. E22 stated on 8/5/16 E22 came on duty at 10:00 pm with E23, CNA. E22 stated R1's call light was on and R1 crying. E22 stated E22 could hear R1 crying in R1's room from the nurse's station. E22 stated E24 (CNA) and E25 (CNA) were the evening shift CNAs and were sitting at the nurse's station with E21, Registered Nurse, and not responding to R1's call light and crying. E22 stated that made me so mad that (R1) was crying and (E21, E24 and E25) were just sitting at the nurse's station and not responding to (R1's) call light. E22 stated E22 and E23 went directly into R1's room and R1 was sitting in the wheelchair and was soaked (in urine). E22 stated R1 said that R1 had the call light on for a long time and needed to go to the bathroom and needed to be changed. E22 stated R1 is continent of bladder and uses the bed pan. E22 stated that E22 and E23 transferred R1 from the wheelchair to the bed and provided incontinence care. E22 stated the incontinence undergarment was completely wet (with urine). E22 stated E22 wrote a note to E2, Interim Director of Nursing, and put the note under E2's office door on 8/8/16. On 8/11/16 at 8:30 am E23 stated that E23 clocked in on 8/5/16 at 9:55 pm. E23 stated R1's call light was on and R1 was crying and yelling R1 was wet. E23 stated she is not sure how long R1's call light was on. E23 stated R1 said the call light had been on since 9:30 pm. E23 stated E23 with E22 then provided R1's incontinence care. E23 stated R1's incontinent undergarment was heavy, saturated with urine, and had a strong urine odor. E23 stated R1 is not usually incontinent and knows when R1 needs to use the bed pan. On 8/11/16 at 11:40 pm R1 stated that on the night of 8/5/16 R1 had the call light on and a CNA (unknown) answered it and then turned the call light off. R1 stated that R1 told the CNA (unknown) that R1 wanted to lay down and that I was wet. R1 stated the CNA (unknown) told R1 that CNA would be back with help. R1 stated No one even came. Don't know if they couldn't find anybody. I was already wet and I kept having to urinate in the undergarment. I couldn't get to the bed pan. The urologist said the more you use the undergarment it can make you more incontinent because its just easier to go into the undergarment. R1 stated My call light was on and I heard people talking at the nurse's station. I called out 'I'm wet.' R1 stated I was crying because no one was coming. Made me feel sad and unloved. I was upset. Nobody was coming when I called out. Made me feel abandoned. Made me wonder why. Maybe they don't like me. Maybe I did something wrong. Made me feel like I'm a big bother. I feel like I need to apologize because I have to go to the bathroom. I feel like I'm a big bother. I shouldn't feel that way but I do. R1 stated then E22 came in and the (mechanical lift) sling was wet, my pants were wet, and the pad on my wheelchair was wet. Everything was wet and smelled of urine, which made me feel gross because I stunk and all I could smell was urine. On 8/8/16 at 11:40 am E18 and E20 provided incontinence care for R1. R1 had a pin point open area on the sacrum. On 8/8/16 at 11:45 am E2, Director of Nursing, stated R1 has a Stage II open area on the coccyx. E2 stated R1 returned from the hospital on [DATE] with the pressure ulcer that healed last week and Yes, it's open again. E2 stated the open area measures 0.2 cm x 0.2 cm x 0.0 cm. The Pressure Ulcer Prevention policy dated August 2015 documents .Individualized . toileting, incontinent care and hydration per individual resident needs .

Based on interview and record review the facility failed to ensure residents are free of misappropriation of resident property for seven of seven residents (R2,R4,R5,R6,R7,R8,R3) reviewed for theft, on the sample of 25. A facility staff member failed to immediately notify the Administrator of being asked by another staff member to assist with cashing a resident's check as potential theft (misappropriation of property). This staff member failed to recognize this action as misappropriation of resident's property as defined in facility policy. These failures resulted in the deliberate forgery and cashing of R2's personal check without her consent. R2 experienced anxiety and financial harm by the forgery and cashing of her personal check by staff. The facility also failed to have a policy-driven operating system in place to prevent the diversion of narcotics, resulting in the theft by staff of narcotic medications belonging to residents (R4,R5,R6,R7,R8). In addition facility staff failed to recognize and identify misappropriation of resident property by failing to immediately report the theft of a lottery ticket belonging to R3, as directed by facility policy. Findings include: 1. The physician progress notes [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] states R2 has no cognitive impairment or behaviors. The Admission Face Sheet dated 11/28/14 documents that R2 was admitted to the skilled unit from the attached independent living apartments on 11/28/14. The physician's orders [REDACTED]. On 2/4/15 at 1:15pm R2 stated she received her bank statement on Saturday (1/24/15) and was going over the statement on Saturday night. R2 stated there were five checks listed on the statement and "when I got to the last one (check)-I thought it wasn't mine-it was made out to (E3, (CNA) Certified Nurse Aide). I immediately told (E12, Independent Living Supervisor) on Sunday (1/25/15) morning. (E12) made a couple of phone calls and she and (E4, Social Service Director) came and talked to me. The written statement by E12, Independent Living Supervisor states, "On January 23, 2015, (R2) asked me to look at her bank statement....showed me the part of the statement that was a photocopy of the check that had gone through the account. As I looked at the copies, it was very clear that one of the checks had not been signed by (R2), as the signature was completely different. After asking (R2) if she knew the person the check was made out to, (R2) said she wasn't sure, but thought ...this happened because she had left her checkbook on the cabinet in her room on the nursing (skilled) side, when she was staying over there......." The statement documents that E12 immediately reported the issue to E5, Independent Living Director. On 2/4/15 at 1:55pm E5, Independent Living Supervisor stated that E12 reported the problem with R2's check to her on 1/25/15. E5 stated after looking at the bank statement "I knew there was a problem." E5 stated she immediately reported the issue to E1, Administrator and was told to call the police. E5 stated she talked to Z2 (Police Chief) and also called E4, Social Service Director. On 2/4/15 at 2:10pm E4 stated she went in on Sunday (1/25/15) and interviewed R2. E4 stated she interviewed E3 and E6, CNA's (alleged perpetrators) about R2's check and immediately suspended both of them. The Police Department Case Report dated 1/28/15 states, "On 1/25/15....contacted...in regards to a possible theft from a resident (R2).....(R2) ...not aware she had written a check for the amount of $375.00 dollars on 12/14/14....had never written a check out to the name posted on the check (E3, CNA) and never ordered (cosmetic) products which was listed in the Memo area of the check.....(E3)stated she was contacted by (E6, CNA) who asked (E3) if she would cash a check for her (E6) for (cosmetic) products.....on arrival at...bank...(E6) handed (E3) a check made out for $375.00 dollars, however did not have a name on the check....(E6) told (E3) to write her own name on the check so it would be easier to cash..(E3) complied and then wrote (cosmetic company name) in the memo area so (R2) would remember what the check was for....(E3) then cashed the check and had the teller hand the cash over to (E6)....(E3) was asked if she knew the check to be stolen to which she stated no....(E6) admitted she observed the check laying on the counter top of the nurses station and took it. (E6) admitted to signing (R2's) name on the check and using the money to repair her vehicle....." The report states that E6 was arrested for "Fraud" and "Aggravated Identity Theft....." On 2/4/15 Z2, Police Chief stated he arrested E6, CNA after she fully confessed during the investigation. Z2 stated E3, CNA "truly believed that it was for (cosmetic) product." On 2/5/14 at 12:05pm E3, CNA stated, "(E6) asked for a favor- she got a check from (R2) to purchase (cosmetics)-it was around Christmas-so it made sense to me...asked if I would cash it for her.....Went to bank and (E6) handed the check to me--didn't really look at the amount-saw (R2's) signature...(E6) didn't want to put her name on the check--(E6) said (R2) left the payee part of the check blank so whoever was cashing it could put their name on it-easier. First I told her (E6) to put her name on it and she could endorse it to me...She (E6) said it would be easier for me (E3) to put my name, so I wrote my name in the payee spot of the check and wrote (cosmetic name) in the memo section......I (E3) signed my name on the back of the check..I cashed it and (E6) told the teller how she wanted it(money)..." When asked if she had any suspicions, E3 stated, "(R2) was on our side(skilled unit) from retirement (unit)..didn't think anything of it....I knew we weren't supposed to get money from residents--from abuse training...I asked (E6) if she had permission to do it, she (E6) assured me she had permission to do it (cash R2's check). I did not report it to anyone because I assumed she (E6) had permission. I was not aware it was a problem until I got suspended (1/25/15)." On 2/4/15 at 1:15pm R2 stated that she "made the check out (E3) did it for somebody else (E6, CNA)...she was dismissed. My checkbook was over there on the skilled side-unit the whole time-checkbook was in the drawer with some bills....." R2 stated she called her bank on Monday (1/26/15) and talked to them about the forged check ($375.00). R2 stated she is missing another check besides the one which was "forged." R2 stated she was told by the bank that they "will not reimburse" her for the amount of money the check was forged for, which is three hundred and seventy five dollars. On 2/5/15 at 1:00pm R2 stated that "I have never bought .......cosmetics, did not ask for a book or anything." R2 confirmed that she did not order any cosmetics from E6, CNA. R2 stated she "felt terrible about the loss of the three hundred and seventy five dollars-gone-bank will not reimburse me for this-I have not been reimbursed by anybody at this point. I was saving to get a different car. I never thought I would have to mistrust someone-people are nice here-never dreamed one of the workers would take advantage of anyone-Unbelievable-never had second thoughts-it happened- really bad...Oh my gosh is this going to result in stolen identity-very worried.." 2. The statement dated 10/28/14 signed by E14, CNA stated, "I came into work at 9:30pm on 10/27/14.....About 10:00pm....I went to get (E13, Licensed Practical Nurse, LPN) to tell her she had a phone call..she looked at me like she was lost and didn't understand. so I repeated myself..she put her hands on her head...said she had a bad headache...she went to phone, sat down and wasn't making any sense.....I said (E13) the phone isn't even to your ear...her speech was slurred......(E16, CNA) took (E13's) (blood pressure) at 11:30pm it was 78/54..I called (E15, (Former) Director of Nursing, DON) told her what was going on (E15) said she would be right there....(E16) and I walked (E13) to the couch together and layed her down.....About 12:30pm (E16, CNA, E15, DON) and I done med(medication) count. there was 2 [MEDICATION NAME] (narcotic medication) missing, 4 vials of [MEDICATION NAME] (anxiolytic medication) and 1 pill of [MEDICATION NAME] ambulance came and got (E13)..." On 2/9/15 at 1:40pm E14, CNA confirmed the statement she wrote was accurate to the events which occurred with E13, LPN on 10/27/14. E14 stated E13 "could barely talk on phone...we (E16,E14) told her we were going to call an ambulance-walked her to the couch-(E13) could barely walk-within minutes she was out--called (E15) and she came in...Did a pill count with (E15)-short [MEDICATION NAME] ([MEDICATION NAME]) and vials of [MEDICATION NAME]" E14 stated she thought E13 was the only nurse on that night. The statement dated 10/28/14 signed by E16, CNA states, "I arrived at work at 9:20pm...noticed around 10:00pm (E13) was having slow reaction times...trouble understanding what people were telling her...(E13) was walking slow and half stumbling...sitting at nurse's desk with hands in her face and looked....as though she was falling asleep...(E14)... had to direct (E13) to sit down and talk to person on the phone...left to do some work......returned (E13) was holding the phone to her chest and fell asleep...started drooling...laid her on couch...(E14) called (E15)...came in and called ambulance...we(E14,E16,E15) did med (medication) count.....and noticed error in count..2 pills of [MEDICATION NAME] missing, 4 vials of [MEDICATION NAME] and 1 pill of [MEDICATION NAME] missing." The statement dated 10/28/14 and signed by E15, (Former) DON states, "...received call at 11:47pm (10/27/14) from (E14,CNA) that nurse (E13) was 'slurring her words, b/p(blood pressure) was 78/54.....head hurt'....said I would be right in.....arrived at ....(E13) was sleeping on the couch....did not respond to me calling her name...I called 911....asked ambulance driver for the keys to the med carts....had both (E14, E16) present when I counted narcotics(10/28/14)...I found the following items (individually packaged medications) missing and not signed out: [MEDICATION NAME]/Apap 10/325mg(milligrams)-2 pills missing, count said 102 and only 100 were there(R4); Lorazepan ([MEDICATION NAME]) 0.5mg-1 pill missing, count said 26 and only 25 were there (R5); [MEDICATION NAME] 2mg/ml(milliliter) vials, count said 5 vials, only 3 vials were there (R6); Lorazepan 2mg/ml vials, count said 2.0 vials , (no) vials were there (R7); the refrigerator in the med room did not have the padlock on it when we entered the room to count. I called ....evening nurse(E17,RN) asked if they had done count, he informed me yes they had and it was correct when he left. I asked him who had counted the new bottles, he informed me (E13, LPN) had told him she and (E16,CNA) had counted them. (E17) stated the [MEDICATION NAME] had 23 (R8), the paper written by (E13) says 21.....I called 911 (and) reported the situation to the dispatcher....I received a call from (Z2, Police Chief)..said he would be by in the morning for statements..." R4's Controlled Substance Proof of Use record dated 10/14/14 for [MEDICATION NAME] with APAP ([MEDICATION NAME]) 10mg/325mg take one every 4 hours documents by E17, RN on 10/27/14 at 8:00pm there were 102 tablets left. The entry dated 10/28/14, no time, by E15, DON documents there were 100 tablets present. The Medication Record dated 10/1-10/31/14 documents the [MEDICATION NAME] with APAP was not given at 12:00am because R4 was sleeping. The medication was scheduled to be given at 4:00am, 8:00am, 12:00pm, 4:00pm, 8:00pm and 12:00am. On 2/9/15 at 9:15am E15 confirmed she counted on 10/28/14 with E14 and E16, CNA's and there were medications missing. E15 stated R4 was to get the [MEDICATION NAME]/Apap 10/32mg every 4 hours. E15 stated she spoke with R4 after E13, LPN was gone and R4 said "he never took it at 4:00am." On 2/10/15 at 1:55pm R4 stated there was a time, when depending on what nurse was working, that he was not awakened in the middle of the night for his dose of [MEDICATION NAME]. R4 was unable to identify the name of the nurse, but stated "It's better now." R5's Controlled Substance Proof of Use record dated 9/18/14 for Lorazepan 0.5mg one tablet every 8 hours prn (as needed) documents 26 tablets of [MEDICATION NAME] on 10/25/14. The next entry is dated 10/28/14 by E15, DON and documents only 25 tablets left. The PRN Medication Information documents R5 receiving [MEDICATION NAME] 0.5mg being given last on 10/25/14 at 10:00pm. On 2/9/15 at 9:15am E15, DON confirmed R5 was missing one tablet of [MEDICATION NAME]. R6's Controlled Substances Proof of Use dated 11/5/13 for [MEDICATION NAME] 2mg/ml vial documents 5-5ml vials of [MEDICATION NAME] were sent from the pharmacy on 11/5/13. The record does not document [MEDICATION NAME] being given to R6. The only entry on the record is dated 10/28/14 by E15, DON with there being 3 vials of [MEDICATION NAME] present in the medication refrigerator. On 2/9/15 at 9:15am E15, (Former) DON confirmed R6 was short 2 vials of [MEDICATION NAME] when she counted on 10/28/14 after sending E13, LPN by ambulance to the hospital. E15 confirmed R6's [MEDICATION NAME] was originally sent from the pharmacy on 11/5/13. R7's Controlled Substances Proof of Use dated 10/28/13 for [MEDICATION NAME] 2mg/ml vials documents 6-5ml vials were sent from the pharmacy. The entry on the record dated 4/8/14 documents R7 received [MEDICATION NAME] with 2 vials remaining. The last entry on the record by E15, (Former) DON documents no vials of [MEDICATION NAME] remaining. On 2/9/15 at 9:15am E15, DON confirmed R7 was missing two vials of [MEDICATION NAME]. E15 stated the package with the label was also missing, only the Controlled Substances Proof of Use record was found in the back of the narcotics book. On 2/9/15 at 9:15am E15 stated R8 was admitted with [MEDICATION NAME] XR(extended release) 20mg and E17, RN told her there were 23 pills in the container, when they were counted by E18, LPN. E15 stated that E18 wrote 23 on the label of the bottle of [MEDICATION NAME] XR. E15 stated E13, LPN counted the [MEDICATION NAME] as 21 and made out a "new sheet(controlled substance record)" and placed it in the narcotic book. E15 stated when counted there were only 21 [MEDICATION NAME] XR 20mg. The undated Individual Residents Controlled Substance Record for R8 states [MEDICATION NAME] 20mg po (by mouth) every 12 hours, with amount received documented as 21. There is no [MEDICATION NAME] 20 mg signed out on the record. The Admission Face Sheet dated 10/27/14 documents R8 was admitted to the facility on [DATE]. The label on the bottle documents [MEDICATION NAME] ER 20mg belonging to R8, with 23 written in on the label. On 2/9/15 at 1:55pm E18, LPN stated she counted a new resident's (R8) medication ([MEDICATION NAME] XR) and wrote the amount on the label of the bottle of medication. E18 stated she was standing next to E17, RN when she counted the medication. E18 stated the statement she documented on 10/28/14 is accurate. The statement dated 10/28/14 signed by E18, LPN states, ".....The narcotic count at the end of my shift on 10/27/14 was correct for (Medication) Cart 2. I completed the count with LPN (E13)." The statement dated 10/28/14 signed by E17, RN states, ".....On....10/27/14 I counted narcotics at the end of my shift with LPN (E13). Following the count, keys to the med card were turned over to (E13) as we both agreed the count was correct. On 2/9/15 at 1:45pm E17 confirmed the statement was accurate to what occurred on 10/27/14. On 2/10/15 at 10:45am E1, Administrator stated that staff were not counting the vials of [MEDICATION NAME] kept in the medication refrigerator when they counted narcotics. E1 confirmed since staff were not counting the vials of [MEDICATION NAME], they don't know for sure when they disappeared. The Police Report dated 10/28/14 states, "(E13, LPN) was asked about the incident of her being unresponsive and unable to function the night (10/27/14) that the prescription medications was missing. (E13) stated she knew nothing about the missing prescriptions and stated her pill count should be correct.....(E13) stated she currently has a prescription for [MEDICATION NAME] and [MEDICATION NAME].and ...for [MEDICATION NAME] for 7 days due to a dental issue.....asked when she had ingested the last [MEDICATION NAME] pill to which she stated on 10/27/14 at about 11:00am.....(E13) was then handed over to......Jail for booking on for 2 outstanding in-state warrants for Possession of a controlled substance.." On 2/5/15 at 11:15am Z2, Police Chief stated (E13) is due in court on 3/6/15 and he will be arresting her after he is in possession of all the facts involving the incident with missing prescription drugs which occurred on 10/27/14. 3. The Physician order [REDACTED]. The untitled and unsigned facility form states, "On 1/17/15 at 10:00am, Report made that housekeeper (E8) was cleaning (R3's) resident room when she found a lottery ticket and placed the ticket in her wallet. (E8) was suspended immediately. Abuse investigation initiated." The statement dated 1/19/15 by E11, Housekeeper states, "On Friday the 16th of January, 2015, I observed (E8) putting a (state lottery) ticket in her wallet. (E8) said she found it under (R3's) bed. I did notify my supervisor on Saturday January 17, 2015." On 2/9/15 at 12:50pm E11, Housekeeper stated he went to the custodian' room on 1/16/15 around 12:40pm, and overheard E9, Housekeeper telling E8 to put the lottery ticket back on the counter in R3's room. E11 stated he saw E8 put the lottery ticket in her wallet instead. E11 confirmed that E8 worked the rest of her shift on 1/16/15. E11 stated he reported the incident to E10, Housekeeping Supervisor the next day (1/17/15). The statement dated 1/19/15 by E9, Housekeeper states, "On Friday 1/16/15, I was approached by (E8, Housekeeper) asking how long a (lottery) ticket was still valid. When I asked her why, (E8) said she had found a ticket under (R3's) bed. It was not valid but she folded it up and put it in her wallet.....I did notify my supervisor on Saturday the 17th of January 2015." On 2/9/15 at 1:10pm E9, Housekeeper stated she was told by E8 that she found a lottery ticket under R3's bed. E9 stated she told E8 to put the lottery ticket back (in R3's room), but E8 folded the ticket and put it in her wallet. E9 stated her supervisor (E10) was off that day, so she reported the incident the next day (1/17/15) to E10, Housekeeping Supervisor. The undated and unsigned Final Report states...."(E8) picked up an old lottery ticket when she was cleaning a resident's (R3) room...(E8) stated she put it in her pocket to see if it was good...stated she took the ticket back to the (R3's) room after lunch that day....stated she put it back because she knew that if she left the building with the ticket, it would be theft....the final reporting of this incident resulted in an unfounded accusation of abuse..." On 2/5/15 at 12:30pm E1, Administrator stated that two housekeepers, E9 and E11 saw E8 put the lottery ticket belonging to R3, in her wallet. E1 stated there was a delay in reporting of one day. E1 stated her expectation is for staff to report allegations immediately to the Administrator. The Abuse Prevention Policy dated 11/21/14 states, "Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent."